Every finding on record at Manning Gardens Care Center, Inc

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained free from accidents and hazards by not identifying, repairing, or replacing unsecured, lifted, or damaged floor vents in multiple resident rooms in accordance with the facility policy Safety and Supervision of Residents and Quality of Life- Home like environment for one of three sampled residents (Res 1).This failure resulted in Res 1 experiencing a fall and sustaining facial injuries, and placed other residents and staff at risk of injury due to the hazardous floor vents in 7 of 12 rooms that were observed.During a review of Res 1's History and Physical (H&P), dated 10/28/25, the H&P indicated Res 1 was a [AGE] year-old male with complex medical problems with multiple comorbidities (presence of two or more long term medical conditions leading to reduced quality of life). Res 1 was admitted for short term (around the clock care and therapeutic services to help a patient recover from an illness, surgery, or even an accident with a ultimate goal to help the patient achieve independence and a better quality of life) and long term rehab (ongoing around the clock support to assist with daily living, nursing care and medical management often longer than 90 days) from the acute care hospital following a large Middle Cerebral Artery (MCA) stroke (disruption of blood flow to the brain's largest vessel, often causing severe symptoms like contralateral paralysis ( loss of voluntary movement on one side of the body caused by damage to the opposite side of the brain), facial drooping (sudden or gradual weakness of facial muscles, typically affecting one side) and speech deficits (a condition hindering clear communication, impacting how sounds are produced, words are formed, or fluency is maintained). During a concurrent interview and observation on 3/27/26 at 11 a.m. outside Res 1's room, Res 1 was observed standing outside the room with a bruise under the left eye and an abrasion on the left cheek. Res 1 stated he had fallen in his room and experienced pain. Res 1 stated he got up to use the bathroom, and his socks became caught on the floor vent, causing him to fall forward and hit his face. Res 1 stated blood came from his nose, the area under his eye became bruised, and he felt afraid for his safety and eye. Res 1 stated the floor vent had been lifted prior to his fall and that he had notified maintenance personnel in the past, but no action was taken. Res 1 stated after the fall, [MS] entered the room and repaired the vent. Res 1 stated facility staff did not appear to care about his concerns for his safety when the floor vent lifted up. Res 1 stated facility staff did offer help after the fall, but he refused to go to the hospital. Res 1 stated other rooms at the facility also had vents that were broken and lifted up and could lead to injuries to other residents.During a concurrent interview and record review on 3/27/26 at 12:05 p.m. with the Director of Staff Development (DSD), Res 1's electronic medical record (EMR), undated was reviewed. The DSD stated the nursing note on 3/26/26 at 7:01 a.m. indicated, . Around [1:10 a.m.] writer was entering in room to assess resident [room and bed number] to change resident G-TUBE [plastic tube delivers nutrition, fluids, and medications directly into the stomach] feeding. noted resident was going to use the restroom, as usually he does, noted resident falling and by the time this nurse went to resident, resident was already on the floor laying on face down. Assessed the resident and noted light nose bleed, 0.5 [centimeters (cm-unit of measurement)]x0.5 cm abrasion and bruise noted under left eye on the cheek. Writer immediately tum resident face on the side, cleaned abrasion . Resident denied any pain. Asked the resident what was resident doing at the time of fall, resident stated . was trying to go to the bathroom, my sock got stuck in the vent on the floor. This writer notified the maintenance to check the vent; slip was made and placed in the maintenance box . The DSD stated the nursing documentation showed staff assessed and monitored the resident and applied all appropriate interventions. The DSD stated staff notified all required parties and monitored Res 1 for 72 hours according to the facility policy. The DSD stated staff witnessed the fall and notified maintenance right away, and maintenance repaired the vent in Res 1's room. The DSD stated the Maintenance Supervisor would be the appropriate person to address details regarding the vent issue and the repair in Res 1's room.During a phone interview on 3/27/26 at 1:24 p.m. with the Maintenance Supervisor (MS) and the DSD, the MS stated he became aware of the incident in Resident 1's room and repaired the vent right away. The MS stated the corner piece of the vent had lifted and fallen inside the vent. MS stated he replaced the vent, secured it, and planned to replace and secure vents in other rooms throughout the facility. The MS stated he had been in his role since September 18th of the previous year and had observed that all vents on the floor required replacement. The MS stated Res 1 informed him that he had notified the previous maintenance staff about the vent sticking up and slipping out of place; however, the MS stated he was not aware of, nor did he have any record of previously submitted work orders. The MS stated floor vents in other rooms also had the potential to lift, move, or develop cracks, which could create safety hazards. The MS stated the facility was now replacing all floor vents that posed potential safety hazards to residents. The DSD stated that as far as she was aware, this was the first incident at the facility involving the vents on the floor leading to any safety hazards. The DSD stated as soon as she became aware of the issue, she notified the facility administrator (ADM) and the MS and directed them to evaluate Res 1's concerns and assess any other rooms that might present safety issues. The DSD stated the facility leadership had already started implementing safety precautions and actively working on ensuring resident safety by replacing vents. During a concurrent observation and interview on 3/27/26 at 2 p.m. with the DSD, all rooms were observed in the facility for floor vents and identified seven rooms (Rooms 10, 11, 12, 14, 15, 16, and 17) with floor vents that were lifted, had broken pieces, had sharp corners or edges, and/or were not secured in place. The DSD stated and agreed these vents could potentially pose safety hazards for residents in the rooms and for facility staff entering the rooms when residents were not mobile. The DSD stated to her knowledge, these vents had been in this condition for a long time and no residents or staff had expressed safety concerns. The DSD stated she was unable to explain why rooms [ROOM NUMBERS] had solid, secured vent pieces while the other rooms did not. The DSD stated the facility had already identified this gap and was in the process of correcting it. The DSD stated and agreed the vents should have been replaced or repaired earlier and that doing so might have prevented the incident with Res 1. The DSD stated to her knowledge, this was an isolated incident related to floor vents. During a phone interview on 3/30/26 at 1:29 p.m. with the ADM, the ADM stated he was at the facility on the morning of 3/27/26 prior to the surveyor's arrival. The ADM stated he had already reviewed the incident with Res 1 during the Quality Assurance (QA) meeting on 3/27/26, and the MS was instructed to replace all vents in the facility to ensure residents safety. The ADM stated the facility team had already identified this issue and had begun implementing corrective actions before the surveyor arrived. The ADM stated he had been at the facility for fifteen years and this was the first vent related incident or concern he had been made aware of. The ADM stated his team promptly worked on a solution to ensure resident safety. The ADM stated although he agreed some vents were not in great shape and required repair or replacement, no staff or residents had previously reported or witnessed safety concerns related to the vents.During a review of the facility's policy and procedures (P&P) titled, Safety and Supervision of Residents, dated July 2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Facility-Oriented Approach to Safety . Our facility-oriented approach to safety addresses risks for groups of residents . Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization . Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents . The QAPI Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary . The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents . The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly .During a review of the facility's P&P titled, Quality of Life- Home like environment, dated July 2017, the P&P indicated, . Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident (Res) 1), had a safe, clean, comfortable and homelike environment when staff admitted Res 1 to a room that contained a bed side storage and drawer that were not cleaned and contained personal belongings of the previous resident, the flooring had sticky residue and the staff did not clean the bed prior to use. These failures had the potential to cause cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and potentially expose Res 1, who had undergone recent surgery to infections leading to prolonged recovery time.FINDINGS:During a phone interview on [DATE] at 9:08 a.m. with Res 1, Res 1 stated she had been recently accepted as a resident to the facility. Res 1 stated she had been in an accident in [state name 1] and was admitted to the Trauma Center (a specialized hospital emergency department with around-the-clock staffing and equipment designed to treat severe, life-threatening injuries including immediate surgical care and specialized care) and the Trauma Center tried to find somewhere to transfer her so she could return to [state name 2], close to her home. Res 1 stated the facility accepted her as resident on Tuesday ([DATE]) afternoon and she arrived via medical transport to the facility on Thursday ([DATE]), early morning at 6:20 a.m. Res 1 stated she had over an eight-hour ride in the ambulance and the facility had over 24 hours of notification prior to her arrival. Res 1 stated when she arrived at the facility, staff placed her in a dirty bed with linen and a blanket used by the previous resident was on the bed, a drawer next to the bed had personal used items from the previous resident, the pillow had used and dirty tissues stuffed under it, the closet [bed side storage] still had clothes and personal belonging of the last resident and the floor was dirty with sticky residue. Res 1 stated she had taken pictures and it was very disturbing for her. Res 1 stated she was transferred and left in a dirty bed, with other resident's belonging and it took the facility a couple hours to get her some clean linen and housekeeping to clean her room. Res 1 stated she feared for her safety and was in pain. Res 1 stated the facility staff had to reposition her to change the bed linen, which lead to unnecessary pain and stated her room should have been cleaned prior to her arrival. Res 1 stated she had no storage space in the closet as other residents belongings were left behind, the beside drawer was full of the previous residents belongings as well. Res 1 stated her environment was dirty, unsanitary [dirty and could be spreading illness] and unsafe. During a review of Res 1's History and Physical (H&P), dated [DATE], the H&P indicated Res 1 was a [AGE] year old female who was admitted at the facility for short-term rehabilitation (typically defined as a stay with services that are focused on helping patients recover from an acute illness, injury, or surgery so that they can return home or to a lower level of care) with complex medical comorbidities (presence of two or more chronic or acute health conditions in one person, complicating care and increasing mortality (incidence of death within a population, often expressed as a rate risk)). The H&P indicated Res 1 fell off a vehicle and suffered a ground level fall with multiple fractures (crack or break in a bone). Res 1 had pubic rami fractures (crack or break in the small bones at the very front of the pelvis), comminuted and displaced fractures involving the right superior and inferior pubic rami (indicate a high-energy pelvic injury where the bone is broken into multiple pieces and shifted, often resulting in an unstable pelvic ring ( bowl-shaped bony ring at the base of spine that acts as the anchor point between upper body and legs)), right alae of the sacrum displaced fracture (the wing-shaped bone at the base of the spine (sacrum) on the right side is broken, and the pieces may have shifted out of place often causes severe lower back/buttock pain), associated small soft tissue hematoma (collection of clotted blood outside blood vessels) at the intraperitoneal of retzium (hidden area of lower pelvis, right between bladder and pubic bone (the front of your pelvis)), right L5 (L1 to L5, five large, bones located in the lower back between the rib cage and pelvis) lateral transverse process comminuted displaced fracture (bony projection on the right side of the 5th lumbar vertebra is broken into multiple pieces and shifted from its normal position). The H&P indicated Res 1 underwent percutaneous fixation right posterior pelvis percutaneous reduction and fixation anterior pelvis (a minimally invasive technique to stabilize anterior and posterior pelvic ring disruptions through small incisions, reducing blood loss and infection risk compared to open surgery).During an interview on [DATE] at 12:20 p.m. with Res 1, Res 1 stated she had expressed her concerns to the Director of Social Services (DSS), the Business Manager (BM), and nursing leadership (unable to recall specific name) at the facility. Res 1 showed pictures of the bed side drawer with personal belongings inside, the flooring appeared to be dirty with some black residue and streaks on it and stated she had taken these pictures upon admission to the facility. Res 1 stated she was unable to take a picture of dirty bed as she was already transferred onto the bed. During an interview on [DATE] at 12:55 p.m. with the Director of Staffing Development (DSD), the DSD stated she was familiar with Res 1. The DSD stated Res 1 expressed concerns upon admission about her room and they were all addressed promptly. The DSD stated Res 1 arrived at 6:20 a.m. on [DATE], during the shift change on [DATE]-night shift going into early morning [DATE] day shift. The DSD stated Res 1 had a concern that she was placed in an unclean bed upon arrival to the facility. The DSD stated Res 1 also had concerns that personal belongings and clothes were present in a closet and drawer, and both of the storage spaces were not clean. The DSD stated and validated that the closet and bed side drawer were not empty after the previous resident was discharged , however, she stated she was not aware and was not able to validate whether the bed and bed linens were dirty upon admission of Res 1. The DSD stated Res 1 also had concerns with the floor not being cleaned and it was addressed immediately. The DSD stated Res 1 expressed these concerns to her and the BM and she apologized to Res 1 for her experience. The DSD stated the facility in-serviced the staff and housekeeping about the importance of ensuring the room was ready for the resident upon admission. The DSD was not able to comment on why the room closet and bed side drawer were not cleared of the personal belongings of the last resident [Res 3], who was assigned to the bed prior to Res 1. The DSD stated the facility process was to clean the bed, change the linens immediately after the resident was discharged or sent to hospital. The DSD stated the bed where Res 1 was placed upon admission was on hold until midnight for Res 3. The DSD stated Res 1 arrived at 6:20 a.m. (approximately six hours later after the bed hold had expired for Res 3) and was placed in the bed. The DSD stated per the facility's Certified Nursing Assistant (CNA -provides essential daily care to patients in nursing homes under the supervision of nursing staff) staff present on the shift, stated the bed linen was clean, however, the resident stated the linen was not clean when she was placed on it. The DSD stated the facility was required to hold a bed for seven days when a resident went to the hospital. The DSD stated the facility process was to leave personal belongings in place during bed holds, however, the bed and the linens were cleaned. The DSD stated she expected the facility staff to remove the belongings of previous residents and provide a safe and clean environment to every resident upon arrival. During an interview on [DATE] at 3:12 p.m. with the Infection Prevention Nurse (IP), the IP stated she had been working at the facility in her role since 2021. The IP stated she was familiar with Res 1's concerns. The IP stated she heard from her colleagues when she started her shift on [DATE] that Res 1 was very upset about her bed, personal storage space, and the floor. The IP stated Res 1's concerns were regarding cleanliness of the bed and the dirty and sticky flooring. The IP stated it was not acceptable to have sticky flooring or dirty beds. The IP stated Res 1 was very upset, and the dirty floors and dirty bed could potentially be a source of infection. The IP stated the facility's normal process was to clean the floor and bed in between residents and she was unable to comment whether the facility's normal process was followed. The IP stated she was unsure if the bed was clean or dirty prior to admitting Res 1. The IP stated the facility process was to clean the bed prior to each admission.During an interview on [DATE] at 3:20 p.m. with the BM, the BM stated he was made aware of Res 1's concerns. The BM stated he spoke to Res 1 to get her signatures on the admission paperwork. The BM stated Res 1 notified him of her concerns regarding cleanliness of the floor. The BM stated the floor appeared to have a sticky residue in the back corner. The BM stated he was unable to comment regarding whether the bed was dirty or had soiled linen. The BM stated Res 1 was already on a clean bed when he went to talk to her. The BM stated he went in to speak with Res 1 around 9:00 a.m. and Res 1 arrived at facility around 6:20 a.m. The BM stated he did not open the closet or the drawer, but stated Res 1 mentioned the drawer had some belongings from the previous resident. During an interview on [DATE] at 3:58 p.m. with Registered Nurse (RN) 1, RN 1 stated she was the admitting nurse for Res 1 upon admission to the facility. RN 1 stated Res 1 arrived right before her shift ended. RN 1 stated she went in to check on Res 1 and did not recall Res 1 mentioning any concerns to her. RN 1 stated the admission assessment and paperwork were completed by the incoming shift staff. RN 1 stated she did not recall noticing any personal belongings in the bed side storage.During an interview on [DATE] at 4:15 p.m. with Res 2, Res 2 stated she was present in the next bed in the same room when Res 1 was admitted . Res 2 stated Res 1 was placed in a dirty bed and it had personal belonging of [Res 3], who was sent to hospital. Res 2 stated the closet, the drawer and the bed had items from the previous resident and the facility was holding the bed for Res 3's return. Res 2 stated it was not fair to Res 1 to lie in someone else's dirty bed. During an interview on [DATE] at 4:01 p.m. with Housekeeping Staff (HS) 1, HS 1 stated she had been working at the facility for a year. HS 1 stated the facility process when someone was discharged from the facility or sent out to hospital, CNAs collected all the personal belonging and emptied bedside drawers and the closet. HS 1 stated the HS team did not clean closets or drawers unless they had been emptied completely. HS 1 further stated the bed linens and personal belongings had to be removed for the HS team to clean the bed. HS 1 stated she was not working when Res 1 was admitted to the facility and was not able to comment on Res 1's concerns or whether the facility process was followed.During an interview on [DATE] at 10:17 a.m. with HS 2, HS 2 stated she had been working at the facility for over ten years. HS 2 stated the room turn over process was that when a resident left, the CNA stripped [removes everything from the bed ] the bed and called the housekeeping staff to clean the room. HS 2 stated the housekeeping team member got the bed ready by wiping and disinfecting the bed. HS 2 stated she also cleaned the drawer and the closet as soon as she could after the CNA emptied them. HS 2 stated housekeeping staff did not touch personal belongings. HS 2 stated if the facility was holding the bed for a resident to return to the facility then the housekeeping team left the bed alone and did not remove personal belongings. HS 2 stated she was familiar with Res 1 and worked with Res 1 upon her admission. HS 2 stated she started her shift at 7:00 a.m. shortly after the Res 1's arrival to the facility. HS 2 stated the nursing staff was in Res 1's room with Res 1's roommate, when she first started her shift and she had planned to return. HS 2 stated shortly after she returned to Res 1's room and Res 1 expressed concerns to her regarding the dirty bed, dirty floor, closets and bed side drawer. HS 2 stated she apologized to Res 1 and cleaned everything in Res 1's room. HS 2 stated Res 1 was very appreciative and stated she was little tired from the long ride to the facility. HS 2 stated as far as she was aware, the facility was waiting for the previous resident to return to the facility to the same bed. HS 2 stated the facility did not have HS staff at night and she did not work on the same side the previous week and was not able to comment whether the room was cleaned or not. HS 2 stated the floor was dirty with sticky stuff, however, the patient was already on the bed, and she was unable to comment whether the linen was dirty when the resident first arrived to the facility. During an interview on [DATE] at 12:40 p.m. with the RN 2, RN 2 stated she was the primary RN for Res 1 when she was admitted . RN 2 stated she did not recall Res 1 expressing any concerns when she completed Res 1's initial assessment. RN 2 stated when she assessed Res 1, she was already on the bed. RN 2 stated she did notice items in the closet and asked CNA to put everything away and empty the closet for Res 1's use. During an interview on [DATE] at 10:30 a.m. with the administrator (ADM), the ADM stated he was made aware of Res 1's concerns regarding the sticky floors. The ADM stated he was not aware of any other concerns. The ADM stated as far as he was aware no one at the facility saw any belongings in the bed side storage or the bed being dirty upon Res 1's admission. The ADM stated he would have to check with admissions person as they make arrangements and was not able to comment on whether the bed where Res 1 was placed was on hold for Res 3 prior to Res 1's arrival. The ADM stated it was not common for night shift to receive admissions and there was a possibility the staff may not have realized the previous resident's personal belongings needed to be removed prior to admitting Res 1, however, he needed to validate with the facility staff. The ADM stated he had not heard that the bed linens or the bed was dirty when Res 1 was admitted . During an interview on [DATE] at 2:09 p.m. with the ADM, the ADM stated if the bed was on hold for Res 3 prior to Res 1's admission, the facility staff would not have removed the personal belongings and housekeeping would not have cleaned the drawers and storage closet. The ADM stated the facility process was to clean the bed after the resident's transfer or discharge from the facility, even if the bed was placed on hold and the resident returned to the facility. The ADM stated this (Res 1's) admission was an unusual circumstance, as the hold [for Res 3's bed] was up at midnight and Res 1 was admitted around six in the morning. The ADM stated it was unusual for the night shift staff to admit residents and the facility could have done a better job with coordinating the admission and ensuring Res 1 was satisfied. The ADM stated he was not able to validate the concerns regarding the dirty bed or soiled linens, however, it could be possible that Res 3's belongings were left in a closet and/or bedside drawers when Res 1 arrived at the facility. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Home like environment, dated [DATE], the P&P indicated, . Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include . Clean, sanitary and orderly environment . Clean bed and bath linens that are in good condition .During a review of the facility's P&P titled, Infection Control, dated [DATE], the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .The objectives of our infection control policies and practices are to .maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public .During a review of facility's P&P titled, Quality of Life - Dignity, dated February 2020, the P&P indicated, . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem . Residents are treated with dignity and respect at all times . The facility culture is one that supports and encourages humanization and individuation of residents, and honors resident choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay . Residents' private space and property are respected at all times .During a review of the facility's P&P titled, Resident Rights, dated [DATE], the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity . rights that include the resident's right to . dignified existence . be treated with respect, kindness, and dignity . be free from abuse, neglect, misappropriation of property, and exploitation .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment when the transition strip (a narrow piece of material used to bridge the gap between two different types of flooring) between the residents' room and hallway to room [ROOM NUMBER] was approximately 0.5 inches (unit of measurement) in height and the transition strip to room [ROOM NUMBER], 3, 4, 5, 6, 9, 10, 12, 14, 15, 16, 17, 18, 19, 20, and 21 were cracked and uneven. This failure had the potential to result in hazardous conditions for four of four sampled residents (Resident 1, 2, 3, and 4) which could lead to falls and injury. Findings: During a concurrent observation and interview on 2/13/26 at 9:33 a.m. with Resident 1 in room [ROOM NUMBER], Resident 1 was sitting on his bed. Resident 1 stated he fell one month ago. Resident 1 stated he was sitting in his wheelchair while going backward to get out of his room. Resident 1 stated there was a lip (transition strip) on the floor between the room and hallway, and Resident 1 was unable to push his wheelchair pass the lip. Resident 1 stated he stood up to push the wheelchair back behind him and when the wheelchair moved back, he lost his balance and fell onto the floor landing on his bottom. Resident 1 stated he hurt his back during the fall. Resident 1 stated he pushed himself backward while sitting in the wheelchair to get out of his room because the back wheels were bigger making it easier to get over the lip. Resident 1 pointed to the transition strip at the entrance, which was cracked and uneven. During a record review of Resident 1's admission Record (AR), dated 2/13/26, the AR indicated Resident 1 had a diagnosis of Hepatitis C (a viral infection that causes liver swelling and inflammation), Coccidioidomycosis (also known as Valley Fever is a fungal infection caused by inhaling Coccidioides spores found in the soil of arid regions like the southwestern U.S. and California) and Muscle Weakness. During a record review of Resident 1's Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life), dated 1/22/26, the BIMS score was 15 (a score of 0 to 7 indicated severe cognitive impairment, 8 to 12 indicated moderate cognitive impairment, and 13 to 15 indicated minimal to no cognitive impairment). During a concurrent observation and interview on 2/13/26 at 10:05 a.m. with the Director of Maintenance (DOM), the transition strip to room [ROOM NUMBER] was measured to be approximately 0.25 inches in height. The DOM stated the transition strip was cracked and uneven and needed to be replaced. The transition strip to room [ROOM NUMBER] was made of wood and was approximately 0.5 inches in height. The DOM stated the standard American Disability Act (ADA) height requirement for a transition strip was 0.25 inches. The transition strip to rooms 2, 3, 4, 5, 6, 9, 10, 12, 14, 15, 16, 17, 18, 19, 20 and 21 were made of plastic and measured to be approximately 0.25 inches in height. The DOM stated the transition strips to rooms 1, 2, 3, 4, 5, 6, 9, 10, 12, 14, 15, 16, 17, 18, 19, 20, and 21 could be difficult for residents to get pass safely. The DOM stated the transition pieces were high, uneven, and cracked which could tip the resident over in the wheelchair and fall. During a concurrent observation and interview on 2/13/26 at 10:10 a.m. with Resident 2 outside room [ROOM NUMBER] in the hallway, Resident 2 was sitting in his wheelchair with two family members. Resident 2 stated room [ROOM NUMBER] was his room. Resident 2 stated the transition strip made it difficult to go in and out of his room. Resident 2 stated sometimes the transition strip would cause the wheelchair to spin. Resident 2 stated the transition strip would cause the wheelchair to turn as he crossed the transition strip. Resident 2 stated the transition strip could cause a fall. During a record review of Resident 2's AR, dated 2/13/26, the AR indicated Resident 2 had a diagnosis of Chronic Obstructive Pulmonary Disease (a progressive, incurable lung disease that causes severe, long-term breathing difficulty), Hypertensive Heart Disease (chronic high blood pressure leading to heart muscle thickening, stiffening, and eventual failure), Dorsalgia (pain in any part of the back, including the neck, mid-back, or lower back), and Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). During a record review of Resident 2's BIMS, dated 2/9/26, the BIMS score was 11. During a concurrent observation and interview on 2/13/26 at 10:30 a.m. with Resident 3 in room [ROOM NUMBER], Resident 3 was sitting in her wheelchair next to bed 2. Resident 3 stated she had been using the wheelchair for mobilization for seven years due to a history of fibromyalgia (a chronic, non-progressive neurological condition characterized by musculoskeletal pain, fatigue, sleep disturbances and disruption in mental processes). Resident 3 stated the transition strip in her room was not an issue for her because she was strong enough to pass it in her wheelchair, but the transition strip could be difficult for other residents. Resident 3 stated she has seen residents go backward in their wheelchair to get in and out of their rooms because the back wheels were bigger which made it easier to pass the transition strip. Resident 3 stated going backward in the wheelchair could cause a fall. Resident 3 stated some residents shuffle (not lifting the feet off the floor completely when walking), and an uneven and cracked transition strip could cause them to trip and fall. Resident 3 stated the transition strip should be smooth, flat, and even to provide easy access to pass. During a record review of Resident 3's AR, dated 2/13/26, the AR indicated Resident 3 had a diagnosis of Sepsis (a life-threatening medical emergency caused by the body's extreme, dysfunctional response to an infection, resulting in widespread inflammation, tissue damage, and potential organ failure), Type 2 Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar due to insulin resistance), Cellulitis (acute, spreading bacterial infection of the deep dermis and subcutaneous tissue) and Hypertensive Heart Disease. During a record review of Resident 3's BIMS, dated 2/18/26, the BIMS score was 14. During a concurrent observation and interview on 2/13/26 at 10:35 a.m. with Resident 4 in room [ROOM NUMBER], Resident 4 was lying in bed 3. Resident 4 stated she used a walker and wheelchair for mobilization. Resident 4 stated the bump (transition strip) on the floor at the entrance was difficult to pass. Resident 4 stated she was unable to get pass the transition strip using her walker and wheelchair and must call staff for assistance when going in and out of her room. During a record review of Resident 4's AR, dated 2/13/26, the AR indicated Resident 4 had a diagnosis of Discitis of lumbar region (medical condition characterized by inflammation of the intervertebral disc space in the lower back), Sepsis, Type 2 Diabetes Mellitus, and Cutaneous Abscess of back (a localized, painful collection of pus, dead tissue, and bacteria that forms within the deep skin layers on the back). During a record review of Resident 4's BIMS, dated 1/17/26, the BIMS score was 13. During an interview on 2/13/26 at 10:44 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated pushing the residents in and out of the rooms in the wheelchair was difficult because the transition strips were bumpy. CNA 1 stated some transition strips were more cracked and uneven than others and could cause a fall. During an interview on 2/13/26 at 10:54 a.m. with CNA 3, CNA 3 stated the transition strips to the residents' rooms were difficult to push residents in and out of their rooms in their wheelchairs and with the shower chair (an assistive device designed to provide a stable, water-resistant seating surface for individuals who have limited mobility, poor balance, or reduced physical strength). CNA 3 stated the shower chairs had small and hard wheels which made it more difficult to get pass the transition strips. CNA 3 stated going backward in a wheelchair could cause the wheelchair to tilt backward, resulting in a fall. CNA 3 stated the transition strip could cause a fall going forward in a wheelchair or shower chair since the transition strip was not flat, smooth, and even. CNA 3 stated assisting heavier residents in a wheelchair and shower chair was more difficult to get pass the transition strips and had a higher risk of falling. During a concurrent observation and interview on 2/13/26 at 11:48 a.m. with the Director of Staff Development (DSD), the transition strips to rooms 1, 2, 3, 4, 5, 6, 9, 10, 12, 14, 15, 16, 17, 18, 19, 20, and 21 were observed. The DSD stated the transition strips were cracked and uneven and could be a fall hazard. The DSD stated the transition strip should be flat, smooth, and even so residents and staff could pass without difficulty. The DSD stated the facility should be a safe, functional, sanitary, and comfortable environment for residents and staff. During an interview on 2/20/26 at 3:26 p.m. with the Administrator (ADM), the ADM stated the transition strip was not hazardous. The ADM stated residents walked past the transition strips 1000 times and there was no fall. The ADM stated Resident 1 chose to go backward in the wheelchair and caused himself to fall. The ADM stated the facility should provide a safe, functional, sanitary, and comfortable environment for residents and staff. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2027, the P&P indicated, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation: .2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI (Quality Assurance and Performance Improvement - a mandatory, data-driven framework for nursing homes and home health agencies to improve care quality and resident safety) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. 3.When accident hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. During a review of the facility's P&P titled, Maintenance Service, dated 2001, the P&P indicated, Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: .b. maintaining the building in good repair and free from hazards. During a professional reference review retrieved from https://www.access-board.gov/files/ada/ADA-Standards.pdf titled, Americans with Disabilities Act (ADA) Standards, dated 2010, the professional reference indicated, ADA CHAPTER 1: APPLICATION AND ADMINISTRATION. (Section) 101.1 General. This document contains scoping and technical requirements for accessibility to sites, facilities, buildings, and elements by individuals with disabilities. The requirements are to be applied during the design, construction, additions to, and alteration of sites, facilities, buildings, and elements to the extent required by regulations issued by Federal agencies under the Americans with Disabilities Act of 1990 (ADA). CHAPTER 3: BUILDING BLOCKS. 302. Floor or Ground Surfaces. 302.1 General. Floor and ground surfaces shall be stable, firm, and slip resistant and shall comply with 302. 303 Changes in Level. 303.1 General. Where changes in level are permitted in floor or ground surfaces, they shall comply with 303. 303.2 Vertical. Changes in level of 1/4 inch (6.4 mm) high maximum shall be permitted to be vertical.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice, manufacturer instructions, and the facilities medication management policies when: 1. Discontinued medications for three of 51 sampled Residents (Residents 32, 30, and 9) were found in the East Station medication cart, indicating medications without active orders were stored in the cart.These failures had the potential to result in medication errors, including the risk of administering medications that were no longer prescribed, which could result in adverse effects or harm to the residents. 2. An opened bottle of sterile (completely free from germs so nothing could grow in it or cause an infection) sodium chloride (saltwater solution used to clean wounds or body parts), which was labeled for single use only, had been kept in the [NAME] Treatment Cart after it was opened. This failure had the potential to result in contamination and posed a risk to residents' health and safety for 51 sampled residents. Findings: 1. During an observation 12/17/25 at 2:45 p.m., the medication cart for East Station was inspected. The medication cart was observed to have Ondansetron (a prescription anti-nausea and anti-vomiting medication) ODT (orally disintegrating tablet-dissolves quickly in the mouth without water) 4 milligram (mg- a small unit to measure weight often used to measure medicine) tablets that were individually packaged and stored. The medications were stored in separate bubble packs and labeled with each resident's identifier labeled in the medication cart. During a concurrent interview and review on 12/17/25 at 3:02 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 30's electronic health record, undated was reviewed. LVN 1 stated Resident 30 did not have an active order for [Brand name]. The bubble pack issue date was reviewed with LVN 1 and indicated the ondansetron was issued on 11/19/25. A review of the Medication Administration Record (MAR) dated 12/2025, indicated the medication was ordered to be used as needed for 14 days and was discontinued on 12/2/25. During a concurrent interview and record review on 12/17/25 at 3:05 p.m. with LVN 1, Resident 32's electronic health record, undated was reviewed. LVN 1 stated Resident 32 did not have an active order for [ondansetron]. During a concurrent interview and review of Resident 9's electronic health record on 12/17/25 at 3:08 p.m. with LVN 1, LVN 1 stated Resident 9 did not have an active order for [ondansetron]. During an interview on 12/17/25 at 3:10p.m. with LVN 1, LVN 1 stated the process was to remove medications from the medication cart as soon as an order was discontinued. LVN 1 stated she removed the discontinued medications and completed the destruction of the medications. LVN 1 stated as long as the medication was not a narcotic (a strong medicine used to relieve pain that could also make a person feel sleepy or relaxed and could be addictive [a person's body could start to depend on the medicine, making it hard to stop using it even if it was harmful]; if not used correctly), she could perform the destruction independently . LVN 1 also stated if medications remained in the cart without an active order, there was a risk of medication error, and these medications should not be stored in the medication cart because they were not active medications. During a review of Resident 9's Medication Administration Record (MAR), dated November 2025, the MAR indicated Resident 9 did not have an active order for [ondansetron]. During a review of Resident 32's Progress Note, dated 11/12/25, the Progress Note indicated the facility received Resident 32's ondansetron from the pharmacy; however, Resident 32 refused to take the medication. The physician was notified and subsequently ordered [ondansetron] to be discarded. During an interview on 12/19/25 at 2:05p.m. with the Director of Nursing (DON), the DON stated there should not be discontinued medications stored in the medication carts. During a review of facilities policy and procedure (P&P) titled, Storage of Medications, dated 11/2020, the P&P indicated, discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During a review of facilities P&P titled, Discontinued Medications, dated 4/2007, the P&P indicated, .discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. 2. During an observation on 12/16/25 at 3:57p.m. of the [NAME] Treatment Cart, a partially used 100 milliliter (ml-a unit of measurement used to measure liquid, such as medicine or water) bottle of sodium chloride irrigation solution was observed stored in the cart. The product label clearly stated DO NOT REUSE in bold lettering and indicated the contents were sterile in the unopened package. During a concurrent observation and interview on 12/16/25 at 4:07 p.m. with Treatment Nurse (TN) 1, TN 1 stated her practice was to keep opened sodium chloride bottles for 24 hours. TN 1 stated she opened the bottle and poured the anticipated amount needed into a medication cup, then recapped the bottle and stored the opened bottle for up to 24 hours. TN 1 stated the bottle would be considered not sterile since it had been opened. TN 1 stated there was a risk of contamination with reuse of the bottles, because the product did not contain preservatives. TN 1 stated residents were at risk because they already had wounds and new bacteria could be introduced to the residents through the sodium chloride solution. During an interview on 12/19/25 at 10:15a.m. with the Infection Preventionist (IP), the IP stated if a bottle indicated do not reuse, it should not be reused. The IP further stated there was a risk of contamination associated with reuse of the bottle. During an interview on 12/19/25 at 2:05p.m. with the DON, the DON stated she did not know the bottle label indicated DO NOT REUSE. The DON stated the bottles should not be reused if the label specified this. During a review of sodium chloride-sodium chloride irrigant monograph by [Brand Name of solution] dated 9/23, the package insert warning indicated, after opening container, its contents should be used promptly to minimize the possibility of bacterial (germs) growth.discard unused portion of irrigating solution since it contains no preservatives.

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation practices were followed in the kitchen when the ice machine and food preparation sink did not have an air gap.These failures had the potential for contaminated water to flow back into the sink and ice machine and result in pathogenic (viruses, bacteria and other types of germs that can cause disease) microorganism (small organism that can only be viewed under a microscope) growth that could inadvertently (accidentally) be transferred to food and water served to residents and staff in the facility, causing foodborne illness. During a concurrent observation and interview on 12/16/25 at 8:50 a.m. during the initial tour in the kitchen, observed food preparation sink did not have an air gap and ice machine located in the dining room did not have a functioning air gap. Dietary [NAME] (DC) 2 stated she was not aware the ice machine did not have a functioning air gap and the drain basin behind the ice machine was dirty and appeared to not have been cleaned. DC 2 stated the Certified Dietary Manager (CDM) was responsible for cleaning the ice machine and was not sure if she also cleaned the drain basin. During a concurrent observation and interview on 12/16/25 at 2:35 p.m. with the CDM in the kitchen. The CDM stated the food preparation sink did not have an air gap and ever since she assumed her position as CDM four years ago there was no air gap. The CDM stated the facility had been working on it for almost two years now and she was not sure when they started to install the air gap. The CDM stated it was her responsibility to deep clean the ice machine once a month. The CDM stated she did not notice the drain tube from the ice machine was pushed down past the grill covering the drain basin. The CDM stated the drain basin was also dirty and the air gap was not functioning as it should have been. The CDM stated there was no facility P&P specific to an air gap. During a concurrent observation and interview on 12/16/25 at 2:45 p.m. with the Maintenance Supervisor (MS), the MS stated the facility was aware of the food prep sink inside the kitchen did not have an air gap. The MS stated he was not sure when the work would start because the facility already had a contract signed and submitted. The MS stated he was not responsible to deep clean the ice machine but they called him when there were issues. The MS checked the air gap behind the ice machine and stated the drain from the ice machine was pushed down by at least four inches past the grill covering the drain basin. The MS pulled the drain pipe and stated the tip was dirty and there should be at least two inches gap between the tip of the drain pipe and the drain basin. The MS stated the purpose of the air gap was to prevent the backing of dirty water into the ice machine and the food prep sink which could cause residents and staff to get sick. During a phone interview on 12/19/25 at 10:45 a.m. with the Registered Dietitian (RD), the RD stated it was important to ensure there was an air gap installed under the food prep sink and ice machine to prevent back flow of dirty water to the sink which could contaminate food in the sink. The RD stated an air gap was important for the ice machine to prevent contamination of the water and ice to prevent food borne illnesses to residents and staff. During a review of facility's policy and procedure (P&P) titled, Food Preparation, dated 2023, the P&P indicated, .Employees will prepare food in a clean and safe manner to protect residents and staff from foodborne illness . Sinks, cutting boards, utensils and equipment will be cleaned and sanitized after each use . During a review of a professional reference titled, FDA Food Code Section 5-402.11 Backflow Prevention, dated 2022, the FDA Food Code indicated, . 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . During a review of the Food and Drug Administration (FDA), Food Code Section 5-203.14 Backflow Prevention Device, dated 2022, the FDA Food Code indicated, . A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT .backflow prevention is required by LAW, by: (A) Providing an air gap .

Based on observation, interview, and record review the facility failed to maintain infection prevention and control standards for three of 14 sampled residents (Resident 13, 33, and 64) when:1. Licensed Vocational Nurse (LVN) 3 administered an insulin (medication injected into the body to treat high blood sugar levels) injection to Resident 33 without changing gloves or performing hand hygiene. Immediately afterward, LVN 3 gave Resident 33 a medication by mouth (PO).This failure had the potential to cause pathogens (germs that can enter the body and cause illness) to spread to Resident 33 as a result of cross contamination (unintentional transfer of harmful germs or allergens from one surface or object to another).2. Urinals for Resident 13 and Resident 64 were not labeled with the date they were first used and the room number.These failures had the potential for Resident 13 and Resident 64 to be exposed to cross contamination when urinals were used by other residents. Findings: 1. During an observation on 12/17/25 at 11:52 a.m. during a medication pass for Resident 33, LVN 3 administered an insulin injection into Resident 33's abdomen and then prepared and administered Resident 33 their PO gabapentin (medication used primarily to nerve pain and partial seizures) medication without changing gloves or performing hand hygiene. During an interview on 12/19/25 at 9:57 a.m. with LVN 3, LVN 3 stated he should not have given the insulin injection first. LVN 3 stated the proper order of medication administration was mouth first and then injection. LVN 3 stated he should have changed his gloves or done hand hygiene after giving the injection because the abdomen was considered a dirty area and he had the possibility to come in contact with the resident's blood. LVN 3 stated the improper administration order could have caused Resident 33 to receive an infection due to cross contamination from pathogens on his abdomen traveling to his mouth. During an interview on 12/19/25 at 10:11 a.m. with the Infection Preventionist (IP), the IP stated LVN 3 should have changed his gloves or performed hand hygiene when going from an injection to a PO medication. The IP stated the insulin injection was administered in the abdomen and that was considered a dirty area. The IP stated pathogens could have traveled to Resident 33's mouth during administration of the PO medications. The IP stated nurses should never go from a dirty to clean area because it could cause cross contamination. During an interview on 12/19/25 at 10:42 a.m. with the Director of Nursing (DON), the DON stated nurses should know when to perform hand hygiene or change gloves when giving medications. The DON stated it was important for the nurses to follow proper infection control standards because it stopped cross contamination from occurring. During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK138494/, the article titled, Indications for glove use in health care, undated, the PR indicated, . Change gloves: between tasks and procedures on the same patient, and after contact with material that may contain a high concentration of microorganisms . During a review of the PR, found on https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, the article titled, Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, the PR indicated, . [employees should clean their hands] Before moving from work on a soiled body site to a clean body site on the same patient . During a review of the PR, found on https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, the article titled, Considerations for Blood Glucose Monitoring and Insulin Administration dated 8/7/24, the PR indicated, . Change gloves between patient contacts. Change gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces. Discard gloves in appropriate receptacles (containers). Perform hand hygiene immediately after removing gloves and before touching other medical supplies intended for use on other persons . 2. During an observation on 12/16/25 at 9:28 a.m. during initial tour at Resident 64's bedside, observed a urinal (pee bottle) with no lid containing a small amount of yellow urine hung on the side of a garbage can at bedside, urinal did not have label with date, room, and bed number. During an observation on 12/16/25 at 9:32 a.m. during initial tour in Resident 13's room, Resident 13 was lying in bed and did not answer questions asked. The urinal was observed with no lid containing a small amount of urine, hung on the side of a garbage can at bedside, the urinal did not have a label with the date, room, and bed number. During a review of Resident 13's Minimum Date Set (MDS-a resident assessment tool used to identify resident cognitive [process of thinking, knowing, learning, and understanding], physical abilities and needs) assessment, dated 12/10/25, the MDS assessment indicated Resident 13's Brief Interview for Mental Status (BIMS- screening tool to assess resident cognitive status) 0-15 scale (0-6 severe cognitive deficit, 7-12-moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 13 had no cognitive deficit. During a review of Resident 64's MDS assessment, dated 4/18/25, the MDS assessment indicated Resident 64's BIMS assessment score was 15 out of 15 which indicated Resident 64 had no cognitive deficit. During an interview on 12/16/25 at 9:49 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated urinals of Resident 13 and 64 did not have a label with the date, room, and bed number and should have. CNA 3 stated the practice was to change urinals every seven days or weekly and to ensure the urinals were labeled with date, room number, and resident name. CNA 3 stated it was to ensure staff knew when it was replaced and which resident the urinal belonged to and to avoid residents using other resident's urinal. During an interview on 12/18/25 at 2:35p.m. with the Infection Preventionist (IP), the IP stated urinals were changed every seven days and as needed. The IP stated the facility practice was to ensure urinals were labeled with the date and room number including bed number of the resident. The IP stated the labeling urinals was an infection control issue and to prevent cross contamination. During an interview on 12/19/25 at 2:45 p.m. with the Director of Nursing (DON), the DON stated her expectation was for urinals to be labeled with the date and room number and to be replaced every seven days and as needed. The DON stated CNAs were responsible for ensuring urinals were changed every seven days and labeled to reduce infection. During a review of facility's policy and procedure titled, Disinfection of Bedpan/Urinals, dated 2001, the P&P indicated, .Bedpans and urinals are for single resident use only . Discard bedpans and urinals every seven days or when damaged . Bedpan/Urinal must be labeled with room number and date .

Based on observation, interview, and record review, the facility failed to promote and facilitate one of six sampled residents (Resident 45), right to self-determination when the facility denied Resident 45's request to use an iron to press his clothes and refused his request for hot water to make instant coffee in his room. The facility did not complete individualized assessment of Resident 45's ability to safely perform these tasks, nor did the facility attempt to identify or implement alternative interventions or accommodations to incorporate the resident's stated preferences into his care plan. Instead, the requests were denied based on generalized safety concerns without evidence of an interdisciplinary team review, despite Resident 45 identifying these preferences as very important.These failures resulted in the restriction of Resident 45's preferences and had the potential to cause frustration, decreased autonomy or reduced quality of life.Findings:During a review of Resident 45's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 10/15/25 , the AR indicated Resident 45 had the following diagnoses: protein-calorie malnutrition (a condition where a person did not get enough protein and calories from food, causing the body to become weak and not work the way it should) and esophageal obstruction ( a condition where something blocked the esophagus [ the tube that carried food and drinks from the mouth down to the stomach [a organ that held food and mixed it with acids to help break it down so the body could use it], making it hard for food or liquid to pass from the mouth to the stomach).During a review of Resident 45's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 10/22/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 45 had no cognitive impairment.During an interview on 12/16/25 at 9:49 a.m. with Resident 45 in his room, Resident 45 stated the facility would not provide hot water for him to make instant coffee at his bedside. Resident 45 reported the facility offered room-temperature water or already prepared coffee but would not provide prepared coffee before 7:00a.m. Resident 45 stated he typically awoke at approximately 5:00 a.m. and preferred to have coffee around that time. Resident 45 stated he did not understand the difference between 5:00 a.m. and 7:00 a.m. and stated being unable to have coffee when he awoke made him feel frustrated and punished. Resident 45 stated he was accustomed to ironing his clothes at home and stated his personal appearance was important to him and reflected how he was perceived by the public. Resident 45 stated when his clothes were wrinkled, he felt unkempt and preferred to remain in his room.During an interview on 12/18/25 at 8:45 a.m. with Resident 45 in his room, Resident 45 stated this was a new issue. Resident 45 stated he was previously admitted to the facility in January 2025, and during that admission, he was allowed to iron his clothes in his room. Resident 45 stated upon his readmission in October 2025, he was informed that he could no longer have an iron. Resident 45 reported staff entered his room on one occasion and removed the iron from his closet, informing him that he was no longer permitted to have it. Resident 45 stated he spoke with staff in the office regarding this issue and no alternatives were provided. Resident 45 stated the same individuals who had previously allowed him to have an iron were the same individuals who later informed him he could no longer have one. Resident 45 stated he requested permission to iron his clothes in the laundry room; however, this request was denied due to stated liability concerns. Resident 45 also stated hot water had previously been available but was later discontinued. Resident 45 stated the current process required him to ask a Certified Nursing Assistant (CNA) for hot water, who would then go to the kitchen. Resident 45 stated if the request was made before 7 a.m., the CNA informed him that he would need to wait until 7:00a.m. Resident 45 stated he did not understand the significance of this time restriction. Resident 45 further stated when hot water was provided, it was barely warm and that he had difficulty dissolving powdered creamer in it, the water in the bathroom was warmer.During an interview on 12/18/25 at 11:06 a.m. with CNA 1, CNA 1 described Resident 45 as alert and independent. CNA 1 stated Resident 45 was quiet and did not like to receive a lot of assistance and attempted to complete his own care. CNA 1 stated she was aware of the situation involving Resident 45's iron. CNA 1 stated she observed Resident 45 ironing in his room the previous week and reported this to the nurse supervisor. CNA 1 stated the Social Services Director (SSD) subsequently removed the iron from Resident 45's room for safety reasons. CNA 1 stated Resident 45 frequently requested coffee or hot water. CNA 1 stated staff were not permitted to provide residents with hot water and that there were time restrictions on when coffee could be provided. CNA 1 stated residents could not get coffee before 7:00a.m. due to the kitchen being busy with the tray line. CNA 1 stated that her process was to notify the nurse and ask whether hot water could be provided; however, the nurse would state that it could not be given. CNA 1 stated she would return to the resident and offer coffee from the kitchen and if the request was made before 7:00a.m., informed the resident that coffee would be provided after 7:00 a.m.During an interview on 12/18/25 at 11:21 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was aware of the incident in which Resident 45 was found ironing in his room. LVN 2 stated residents were not permitted to have an iron at bedside due to safety concerns and stated she believed the iron was removed from Resident 45's room. LVN 2 stated the process required the CNA to ask her whether the resident could receive hot water. LVN 2 stated coffee could be provided; however, plain hot water could not be given due to safety concerns. LVN 2 described Resident 45 as alert and independent, requiring monitoring only, and stated he was his own responsible party.During an interview on 12/18/25 at 11:40 a.m. with the SSD, the SSD stated when Resident 45 was admitted in October, his family reported that he preferred his clothes to be neatly pressed and ironed. SSD stated staff discussed with the family that Resident 45 would not be permitted to iron his clothes due to safety concerns, and the family expressed understanding. The SSD stated she did not discuss this issue directly with Resident 45. The SSD stated for safety reasons, residents were not allowed to iron their clothes. The SSD stated at the time of Resident 45's admission in October, there would have been no way Resident 45 could physically perform the task; however, he had shown significant improvement since that time. The SSD stated decisions regarding such matters were not made by her alone but required input from the interdisciplinary team (IDT). The SSD stated she would discuss such issues with IDT to determine how it could be addressed.During a concurrent interview and record review on 12/18/25 at 11:52 a.m. with the SSD, Resident 45's electronic health record, undated was reviewed. The SSD stated she did not observe any documentation in Resident 45's health record regarding a preference for ironing his clothes or the incident in which he was found with an iron. The SSD stated if the charge nurse had spoken with Resident 45 and he was not receptive; the matter could have been referred to the IDT.During a concurrent interview and record review on 12/19/25 at 11:03 a.m. with the Clinical Supervisor (CS) 1, Resident 45's electronic health record, undated was reviewed. CS 1 stated the facility supported residents' choices regarding their daily routines by discussing their choices and preferences with them. CS 1 stated during admission, residents were asked if they needed anything, and that any identified choices or preferences were assessed by the SSD. CS 1 stated the IDT would be notified if issues arose. CS 1 stated when balancing resident choice and safety, the facility ensured that choices could be supported safely through education and teaching. CS 1 stated self-determination meant the ability to do things independently and that this provided residents with satisfaction. CS 1 stated she was familiar with Resident 45 and reported that he had shown improvement, including progress in activities of daily living. When asked how the resident was involved in decisions related to his requests to iron his clothes and have hot water, CS 1 stated nursing staff were expected to refer to the facility policy and follow it. CS 1 stated decisions regarding whether such requests were permitted would be made by the IDT. CS 1 stated Resident 45 had not been assessed for his ability to iron and that such assessment should have occurred. CS 1 stated the facility did not evaluate Resident 45's ability to safely handle hot water due to potential risk for burn injury. CS 1 stated such factors such as resident cognitive status, mobility, ADL's and personal choices were considered when determining how activities could be safely supported. CS 1 stated IDT was responsible for approving such requests and that the IDT should meet with Resident 45 to listen to his choices. CS 1 stated there were no IDT notes in Resident 45's record addressing these issues or preferences. CS 1 stated the facility did not provide hot water to residents and only supplied room-temperature water. CS 1 stated the kitchen prepared coffee at a specific temperature and would not provide hot water at the same temperature as coffee. CS 1 stated providing hot water would require supervision and noted that if a resident was alert and able to eat and drink independently, supervision should not be necessary. CS 1 stated ironing would require supervision. CS 1 stated resident preferences were discussed with residents and incorporated into the care plan; however, Resident 45's care plan did not address ironing or having hot water in his room. CS 1 stated there was no nursing documentation in the care plan regarding these preferences. CS 1 stated Resident 45 should have been reassessed and that any changes in abilities, whether improvement or decline, should have been documented through a progress note and care plan update. CS 1 stated supporting resident requests promoted satisfaction, improved well-being and honored resident choice and emphasized that the facility was the resident's home and residents should have input into decisions affecting their daily lives. During an interview on 12/19/25 at 1:40 p.m. with the Director of Nursing (DON), the [NAME] was asked how the facility supported residents in making choices about their daily routines. The DON stated any electronic device brought into the facility was required to be inspected by maintenance prior to use. The DON stated resident capability was considered when evaluating requests and acknowledged that Resident 45 had since improved, Resident 45 was initially very weak upon readmission and appropriate notification should have occurred. When asked how the facility balanced resident choice with safety when a resident wished to perform tasks independently, the DON stated accommodations could be made based on the resident's functional abilities and level of independence with activities of daily living. The DON stated self-determination meant allowing residents to make their own choices while ensuring safety. When asked whether Resident 45 was involved in decisions related to his requests to iron clothes and receive hot water, the DON stated Resident 45 did not bring the requests directly to her attention and she was not aware at the time. The DON stated staff did not currently have a method to measure water temperature if water was heated and that plan would need to be developed. The DON stated the facility aimed to provide person-centered care and that resident requests should be reviewed by the IDT to identify appropriate solutions. The DON further stated when residents requested specific activities or accommodations, the requests should be reevaluated. The DON stated supporting these requests promoted resident self-determination by encouraging independence and allowing residents to complete tasks independently when safe to do so.During a review of Resident 45's MDS Section F-Preferences for Customary Routine and Activities (MDS- F), dated 10/22/25, the MDS- F indicated Resident 45 indicated that choosing what clothes to wear was very important and rated this preference as a 1 (Very Important). Resident 45 also indicated that having snacks available between meals was very important, rating this preference as a 1 (Very Important).During a review of Resident 45's MDS Section GG-Functional Abilities-admission (MDS- GG), dated 10/22/25, the MDS- GG indicated Resident 185 had no impairment or functional limitation in range of motion of the upper and lower extremities. The MDS further indicated Resident 45 required set-up or clean-up assistance with eating.During a review of the facilities policy and procedure (P&P) titled, Resident Rights, dated 12/2016, the P&P indicated, federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: e. self-determination.During a review of the facilities P&P titled, Quality of Life-Resident Self Determination and Participation, dated 12/2016, the P&P indicated, 1.Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, values, assessments and plans of care, including a. daily routine, such as sleeping walking, eating exercise and bathing schedules.e. activities, hobbies and interests.2. In order to facilitate resident choices, the administration and staff b. gather information about the residents' personal preferences on initial assessment and periodically thereafter and document these preferences in the medical record.c. include information gathered about the resident's preferences in the care planning process.4. Residents are provided assistance as needed to engage in their preferred activities on a routine basis.During a review of the facilities P&P titled, Quality of Life-Dignity, dated 2/2020, the P&P indicated, the facility culture is one that supports and encourages humanization and individuation of residents and honors resident choices, preferences, values and beliefs.some examples of ways In which respect for choices and values are exercised include: clothing-residents are encouraged to dress in clothing that they prefer, d. schedules-residents may choose when to sleep, eat and conduct activities of daily living.staff do not handle or move a resident's personal belongings without the resident's permission.During a review of the facilities P&P titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, 2. the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risk for individual residents.3. the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.4. Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff.b. assigning responsibility for carrying out interventions.c. provide training, as necessary.d. ensuring that interventions are implemented.e. documenting interventions.the facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly.

Based on observation, interview, and record review, the facility failed to follow their policy on change in condition or status for one of three sampled residents (Resident 17), when Resident 17 was transferred out to general acute care hospital (GACH) on 12/17/25 and there was no documentation the medical doctor was notified and no information in Resident 17's medical record regarding a change in condition.This failure had the potential to place Resident 17 at risk of not meeting significant changes in needs. Findings: During a review of Resident 17's admission Record (AR-a document containing resident profile information), dated 12/3/25, the AR indicated Resident 17 was admitted to the facility on [DATE] with diagnoses which included alcoholic cirrhosis of liver with ascites (severe liver scarring from long-term heavy drinking causing high blood pressure in the liver that forces fluid to build up in the abdomen, leading to painful swelling, weight gain, and shortness of breath), hepatomegaly (enlarged liver) and subdural hematoma (brain bleed). During a concurrent observation and interview on 12/16/25 at 9:33 a.m. during initial tour in Resident 17's room, Resident 17 was observed with rounded abdominal area and appeared uncomfortable while sitting at the edge of the bed watching TV. Resident 17 stated she was uncomfortable because of her abdomen and stated the hospital was not able to drain fluid when she was sent out to GACH on 12/13/25. Resident 17 was tearful and stated her abdomen was getting uncomfortable and it was hard to sleep at night and stated the facility need to do something. During a concurrent observation and interview on 12/19/25 at 9:15 a.m. in Resident 17's room, Resident 17 was observed sitting at the edge of her bed watching TV and was smiling. Resident 17 stated she was sent out to the emergency room on [DATE]. Resident 17 stated, They removed 3.7 L [liter-unit of measurement] and I am feeling much better now. During a concurrent interview and record review on 12/19/25 at 9:34 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 17's clinical record, undated was reviewed. LVN 2 stated she was familiar with Resident 17 and she was the assigned nurse. LVN 2 stated the clinical record indicated Resident 17 was sent out to the emergency department on 12/17/25. LVN 2 stated she was not able to find documentation of Resident 17's assessment and notification of the medical doctor. LVN 2 stated the practice was to document a complete head to toe assessment, MD notification, and reason why Resident 17 was sent out. During a concurrent interview and record review on 12/19/25 at 10 a.m. with Clinical Supervisor (CS) 1, Resident 17's clinical record was reviewed. CS 1 stated Resident 17 was sent out to GACH on 12/17/25 and she was not able to find nursing progress note. CS 1 stated there should have been a significant change of condition created and documented assessment when Resident 17 was sent out to GACH and there was none. CS 1 stated she did not find documentation MD and family were notified of Resident 17's transfer to GACH. During an interview on 12/19/25 at 2:32 p.m. with the Director of Nursing (DON), the DON stated her expectation was to ensure the nurse documents in resident's clinical records and vital signs (V/S- measurements of the body's most basic functions like temperature, heart rate, respiratory rate), resident condition at time of transfer and family and MD notification when sending resident to GACH. The DON stated a change of condition should have been completed. During a review of facility policy (P&P) titled, Change in a Resident's Condition or Status, dated 5/17, the P&P indicated, .1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .g. need to transfer the resident to a hospital/treatment center . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff . The nurse will record in the resident's medical record information relative to changes in the resident's medical/ mental condition or status .

Number of residents sampled: 5Number of residents cited: 1Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of five sampled residents (Resident 17), when Resident 17 did not have a care plan when she was sent out to the general care hospital (GACH) on 12/17/25 and a paracentesis (medical procedure where a needle is inserted into the abdomen to drain excess fluid [ascites]) procedure was performed. Resident 17 returned to the facility on [DATE] and there was no care plan created to care for the paracentesis procedure.This failure placed Resident 17 at risk for complications such as persistent fluid leakage, infection, bleeding and low blood pressure which could lead to worsening health. During a concurrent observation and interview on 12/19/25 at 9:15 a.m. in Resident 17's room, Resident 17 was seated at the edge of her bed watching TV. Resident 17 stated she went to the hospital emergency department on 12/17/25 because her abdomen was getting too uncomfortable and 3.7 L (liter-unit of measurement) was removed. Resident stated she returned to the facility the same day. During a review of Resident 17's admission Record [AR-document containing resident profile information], dated 12/3/25, the AR indicated Resident 17 was admitted to the facility on [DATE] with diagnoses which included alcoholic cirrhosis of liver with ascites (liver is severely scarred causing fluid to build up in the abdomen due to high pressure in liver blood vessels leading to significant bloating, swelling and discomfort), hepatomegaly (enlarged liver) and subdural hematoma (brain bleed).During a review of Resident 17's Minimum Date Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment, dated 12/5/25, the MDS assessment indicated Resident 17's Brief Interview for Mental Status (BIMS- screening tool to assess resident cognitive status) 0-15 scale (0-6 severe cognitive deficit, 7-12-moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 17 had no cognitive deficit. During a review of Resident 17's Order Summary, dated 12/19/25, the Order Summary indicated, . May send resident out to [emergency room] for further [evaluation] and [treatment] . Start Date: 12/17/2025 . During a concurrent interview and record review on 12/19/25 at 9:40 a.m. with Licensed Vocational Nurse (LVN) 5, Resident 17's clinical record, undated was reviewed. LVN 5 stated Resident 17 was sent out to the GACH on 12/17/25 and returned to the facility the same day. LVN 5 stated Resident 17 had a paracentesis (medical procedure where a needle is inserted into the abdomen to drain excess fluid) done when she was out at the GACH. LVN 5 stated she did not find a care plan initiated to care for Resident 17's procedure. LVN 5 stated care plans were important in order to care for the needs of the residents. LVN 5 stated it was the responsibility of licensed nurses to make sure care plans were initiated for any significant changes. During a concurrent interview and record review on 12/19/25 at 10:05 a.m. with LVN 3, Resident 17's clinical record, undated was reviewed. LVN 3 stated the clinical record indicated there was no care plan created when Resident 17 was sent out to the GACH and a paracentesis was performed on 12/17/25. LVN 3 stated Resident 17 returned to the facility the same day on 12/17/25. LVN 3 stated the licensed nurse who sent Resident 17 to GACH should have started a care plan for the paracentesis but there was none. During an interview on 12/19/25 at 2:45 p.m. with the Director of Nursing (DON), the DON stated her expectation was for charge nurses to create a care plan and clinical supervisors to help. The DON stated the care plan was important because it lets the nursing team know the type of care each resident needs. The DON stated each resident should be made aware of the type of care they were receiving. The DON stated care plans should be individualized and should be created as soon as possible when there was a change of condition. During a review of facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, .The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided . Incorporate identified problem areas; Incorporate risk factors associated with identified problems . Reflect treatment goals, timetables and objectives . Aid in preventing or reducing decline in the resident's functional status and or functional levels .

Based on interview and record review, the facility failed to meet professional standards of practice for one of three sampled residents (Resident 41), when Resident 41's physician order to check Vitamin D level (blood test result showing how much Vitamin D the body has stored, indicating if body has enough for healthy bones, muscles, and immune functions [fighting off harmful invaders like germs]) ordered on 10/17/25 was not carried out and no follow-up by the nursing staff.This deficient practice placed Resident 41 at risk of developing Vitamin D deficiency and not recognizing the signs and symptoms resulting in not treating the deficiency. Findings: During a review of Resident 41's, admission Record (AR-a document containing resident profile information), dated 12/19/25, the AR indicated Resident 41 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of thyroid gland (small, butterfly shaped gland in the neck-thyroid cancer), multiple myeloma (blood cancer), aplastic anemia (blood disorder where the bone marrow stops producing enough new blood cells) and Vitamin D deficiency (lack of vitamin D). During a review of Resident 41's, Order Summary Report (OSR), dated 12/19/25, the OSR indicated, . [brand name] Oral Tablet 25 [microgram (MCG)-unit of measurement] . Give 2 (two) tablet by mouth one time a day related to VITAMIN D DEFICIENCY . Order date:9/23/25 . During a review of Resident 41s Minimum Date Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment, dated 9/30/25, the MDS assessment indicated Resident 41's Brief Interview for Mental Status (BIMS- screening tool to assess resident cognitive status) 0-15 scale (0-6 severe cognitive deficit, 7-12-moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 41 had no cognitive deficit. During a review of the facility document titled, Note to Attending Physician/Prescriber, dated 11/16/25, the The Note to Attending Physician/Prescriber indicated, .This resident is receiving Vitamin D. Please consider to order Vitamin D level on next lab day to monitor therapy . Noted 11/17/25. During a concurrent interview and record review on 12/19/25 at 9:28 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 41's clinical record, undated was reviewed. LVN 2 stated the nurse supervisor was responsible in carrying out pharmacy recommendations. LVN 2 stated Resident 41 had an order to check Vitamin D level in November but was not able to find a Vitamin D level result and was not sure if it was completed. During a concurrent interview and record review on 12/19/25 at 9: 55 a.m. with Clinical Supervisor (CS) 1, Resident 41's clinical records titled, Note to Attending Physician/Prescriber and laboratory results undated was reviewed. CS 1 stated Resident 41 had an order to check Vitamin D level on 10/17/25 but she did not find a laboratory result. CS 1 stated it should have been completed because the laboratory draws and collects samples in the facility three times a week (every Monday, Wednesday, and Friday). CS 1 stated it was her responsibility to ensure physician orders were carried out. CS 1 stated she did not know what happened and why the order was not completed, because she did not follow up with the laboratory. CS 1 stated Resident 41's Vitamin D level may be elevated or below normal and caused complications to Resident 41 and staff were not addressing the issue. During an interview on 12/19/25 at 3:04 p.m. with the Director of Nursing (DON), DON stated it was her responsibility to review pharmacy recommendations and ensure orders were carried out. The DON stated Resident 41's Vitamin D level was not done and should have been. The DON stated LVN 3 entered the order but did not contact the laboratory. The DON stated Resident 41's Vitamin D level may not be within therapeutic level and did not treat which could have resulted in complications because the laboratory was not completed. During a review of facility's policy and procedure (P&P) titled, Medication Regimen Review (MMR), dated 5/19, the P&P indicated, . 5. The MMR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problem, medication errors and other irregularities, for example . inadequate monitoring for adverse consequences . 14. The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports. 15. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. During a professional reference review of an article retrieved from https://www.ncbi.nlm.nih.gov/books/NBK43696/, undated, the article indicated, .Whether they are printed on paper or available for electronic access, development and implementation of well designed , preprinted physician orders requires engineering, education, and enforcement . Orders are the initial means that enable physicians to communicate with a variety of interdisciplinary hospital caregivers, and they represent the starting point for action and care. In the healthcare environment, nothing goes forward without calling on the assistance of and providing direction through physician orders .

Based on observation, interview, and record review, the facility failed to provide food in accordance with resident preferences for one of three sampled residents (Resident 7), when Resident 7 preferred to receive gravy on his tray and Resident 7 was not served gravy. This failure had the potential for Resident 7 to not consume his preferred food and not to receive the full nutritional benefit of his meal which could lead to weight loss.Findings: During a review of Resident 7's admission Record (AR- a document containing resident profile information), dated 12/17/25, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses which included intellectual disability, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and dysphagia (difficulty swallowing). During a review of Resident 7's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 8/12/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 7 had no cognitive impairment. During observation on 12/16/25 at 11:49 a.m. in the dining room, Resident 7 was served lunch with minced meat, minced green vegetables, minced bread and drinks. There was no four-ounce (unit of measure) gravy served to Resident 7. Resident 7 started to eat lunch and did not respond to questions. During a concurrent interview and record review on 12/16/25 at 11:55 a.m. with Certified Nursing Assistant (CNA) 2, Resident 7's meal ticket, dated 12/16/25 was reviewed, CNA 2 stated Resident 7's four-ounce gravy should have been included in his meal tray but it was not. CNA 2 stated she did not know why Resident 7 should have gravy in his meal tray. CNA 2 stated she did not check the food in Resident 7's meal tray before she served Resident 7 and should have. CNA 2 stated she did not check the meal trays because she saw Licensed Vocational Nurse (LVN) 4 checked all the meal trays served to residents eating in the dining room. During an interview on 12/16/25 at 12:05 p.m. with LVN 4, LVN 4 stated she checked the meal trays for residents eating in the dining room before it was served to residents. LVN 4 stated she was not sure she noticed Resident 7's gravy was missing in his meal tray. LVN 4 stated Resident 7's gravy should have been included in the meal tray if it was listed in the diet slip. LVN 4 stated gravy was ordered to add to resident's food to add moisture, enhanced taste of food and for ease of swallowing. LVN 4 stated not having gravy added to Resident 7's food may result in difficulty swallowing food resulting in not consuming all of his food leading to possible weight loss. During an interview on 12/17/25 at 2:30p.m. with the Certified Dietary Manager (CDM), the CDM stated Resident 7 was supposed to receive the gravy on his meal tray for lunch on 12/16/25. The CDM stated Resident 7's gravy was a preference to add moisture to his food and more palatable or he will not eat his food. The CDM stated the cook should have made sure it was added to Resident 7's meal tray, but it was missed and the licensed nurse who checked the meal tray did not notice the gravy was missing and the certified nursing assistant did not check the meal tray before it was served to Resident 7. During a phone interview on 12/19/25 at 10:40 a.m. with the Registered Dietitian (RD), the RD stated gravy was ordered for residents to encourage them to eat and makes them happy. The RD stated not having gravy could make Resident 7 less likely to eat his food which could result in weight loss. The RD stated Resident 7's order for gravy was a preference and dietary staff should make sure resident food preferences were followed. During a review of facility's policy and procedure (P&P) titled, Resident Nutrition Services, dated 12/09, the P&P indicated, .Nursing personnel will ensure that residents are served the correct food tray. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident .If an incorrect meal has been delivered, nursing staff will report to the Food Service Manager . During a review of facility P&P titled, Resident Food Preferences, dated 11/08, the P&P indicated, .Upon the resident's admission, or within twenty-four (24) hours after his/her admission, the Dietitian or the nursing staff will identify a resident's food preferences . The Dietitian will discuss resident food presences with the resident . The Dietitian and nursing staff, assisted by the physician, will identify any nutritional issues or dietary restrictions that might affect the facility's efforts to accommodate resident preferences . The resident's clinical record . will document the resident's likes and dislikes and special dietary instructions . The nursing staff will inform the kitchen about resident requests .

Based on observation during the survey period of 12/16/25 through 12/19/25, the facility failed to ensure each bedroom accommodated no more than four residents per room for four of 19 rooms (rooms 1, 2, 5, and 6). This failure had the potential for residents to not have reasonable privacy or adequate space.Findings: During the initial tour on 12/19/25 at 9:13 a.m., the following rooms had more than four residents in each bedroom. Although the bedrooms accommodated more than four residents, each room met the particular needs of each resident. There was adequate closet and storage space. Wheelchair and toilet facilities were accessible. There was sufficient room for nursing care and for residents to ambulate. Bedside stands were available for each resident. The health and safety of residents would not be adversely affected by the continuance of this waiver. Room Number Number of Beds1 52 55 5 6 5 Recommend waiver continue in effect. _____________________________________HFES Signature Date Request waiver continue in effect. ____________________________________ Facility Administrator Signature Date

Based on observation, interview, and record review during the survey period of 12/16/25 through 12/19/25, the facility failed to provide the minimum of at least 80 square feet per resident for eight of 19 multiple resident rooms (rooms 1, 2, 5, 6, 9, 10, 11, and 12). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.Findings: During a concurrent observation and interview on 12/19/25 at 9:33 a.m. with the Maintenance Supervisor (MS), an environmental tour was conducted. The MS measured eight rooms and stated the rooms did not meet the minimum square footage of 80 square feet per resident as required by the regulation. There was sufficient room for nursing care and resident ambulation. Wheelchairs and toilet facilities were accessible. The closets and storage space were adequate. Bedside stands were available. The waiver will not adversely affect the health and safety of residents. Room Beds Square Feet1 5 356.92 5 398.55 5 345.56 5 384.09 3 232.710 3 239.011 3 239.712 3 239.4 Recommend waiver continue in effect. _____________________________________HFES Signature Date Request waiver continue in effect. ____________________________________ Facility Administrator Signature Date

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases (illnesses that can be spread from one person, animal, or object to another) and infections for five of seven residents (Resident 2, 3, 4, 5, and 6) when: 1. Resident 2, 3, 4, 5, and 6's personal trash bins (a metal or plastic container used for discarding garbage) without lids located at the bedside contained used blue rubber gloves (protective coverings for the hands designed to shield against chemicals, contamination, and other harmful substances). 2. Two of six large yellow barrels (a cylindrical container) with lids labeled soiled linen (gowns, bedsheets, drawsheets, towels etc. which were exposed to fluids from the human body such as stool; fecal matter, urine, and vomit) located in the east hall contained used blue rubber gloves. These failures had the potential to expose Resident 2, 3, 4, 5, and 6, and staff to the transmission of communicable diseases and infections. Findings: During an interview on 4/9/25 at 2:34 p.m. with Resident 1, Resident 1 stated she was admitted on [DATE] after having back surgery. Resident 1 stated she was transferred to the hospital with an infection on her back on 3/26/25. Resident 1 stated the Certified Nursing Assistant (CNA) changed the roommate's briefs (adult diaper) and Resident 1 witnessed the CNA discard a pair of used blue rubber gloves into the trash bin by her bed after the care was provided. Resident 1 was unable to recall the CNA's name and the date. Resident 1 stated the trash bin did not have a lid. Resident 1 stated the trash bin had a foul odor when she went to inspect the trash bin and she found the used blue rubber gloves with stool on it. Resident 1 stated she tied the trash liner (a plastic bag covering a container) and the stool got on her hands. Resident 1 stated she reported the incident to a staff member and the facility installed a large trash bin in the room with a lid. During a review of Resident 1's Admission Record (AR) , dated 4/16/25, the AR indicated Resident 1 was admitted on [DATE] with a history of Intervertebral Disc Displacement, Lumbar Region (protrusion or herniation of the cushion-like disc resting between any two of the five lumbar vertebrae; vertebrae L1 through L5 in the lower spine). During a review of Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) , dated 3/8/25, the BIMS score was 14 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). During a review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long-term care nursing facilities), dated 3/26/25, the MDS indicated Resident 1 required setup assistance (helper sets up or cleans up and resident completes activity) with toileting hygiene (the ability to maintain cleanliness after voiding or bowel movement). During a review of Resident 1's Progress Notes (PN) , dated 3/26/25, the PN indicated, . resident wants to go to hospital for her pain . resident state I have pain 10:10 (ten out of ten- pain scale used to measure the level of pain a person is experiencing with a score of zero indicating no pain up to a score of ten indicating worse pain imaginable) and I want to go to hospital. MD (Medical Doctor) notified via phone call and MD gave phone order to transfer the resident to acute care facility for further evaluation . resident transferred to [name of hospital] at 2:15 p.m. During a concurrent observation and interview on 4/16/25 at 9:45 a.m. in Resident 2's room with CNA 1, the small trash bin without a lid located next to Resident 2's bed contained a pair of used blue rubber gloves. CNA 1 stated staff were required to don (the act of putting on personal protective equipment [PPE] such as gloves, gowns, and face mask in the healthcare setting) blue rubber gloves when providing care to the residents. CNA 1 stated after the care was provided, staff were required to discard the used blue rubber gloves in a bin with a lid or in the yellow barrels labeled soiled linen in the hallway. CNA 1 stated used blue rubber gloves may contain urine and stool. CNA 1 stated the used blue rubber gloves should not have been discarded in the small trash bin by Resident 2's bed. CNA 1 stated the small trash bin next to Resident 2's bed was for Resident 2's personal use. CNA 1 stated the used blue rubber gloves should have been discarded in a trash bin with a lid to prevent cross contamination and infection. During an interview on 4/16/25 at 10:00 a.m. with the Infection Preventionist (IP), the IP stated used blue rubber gloves should be discarded in trash bins with a lid in the residents' room and soiled linen should be discarded in the yellow barrel labeled soiled linen outside the residents' room. The IP stated waste product such as urine and stool should be contained in a plastic bag and discarded in trash bins with lids. The IP stated staff were permitted to use the yellow barrels labeled soiled linen to transport waste product to the trash bins located outside the facility. The IP stated if staff discarded wasted products in the yellow barrels, it must be contained in a separate plastic bag and discarded immediately. The IP stated discarding used blue rubber gloves in the trash bins by the resident's bed and in the yellow barrels uncontained was unacceptable and can increase the transmission of diseases and the spread infection. During a concurrent observation and interview on 4/16/25 at 10:05 a.m. in the east hall with the IP, six yellow barrels labeled soiled linen with lids were lined up next to one another. One yellow barrel contained used blue rubber gloves and linen mixed together. The IP stated the soiled linen should be contained in a separate plastic bag and the used blue rubber gloves should be contained in a separate plastic bag. The IP stated it was unacceptable to mix used blue rubber gloves and soiled linen together. During a concurrent observation and interview on 4/16/25 at 10:10 a.m. in Resident 3's room with the IP and CNA 2, the small trash bin without a lid located next to Resident 3's bed contained a pair of used blue rubber gloves. CNA 2 stated used blue rubber gloves should not be discarded in Resident 3's personal trash bin and should be discarded in trash bins with lids to minimize the transmission of diseases and prevent the spread infection. The IP stated discarding the used blue rubber gloves in Resident 3's personal trash bin was unacceptable. During a concurrent observation and interview on 4/16/25 at 10:15 a.m. in Resident 4's room with the IP, the small trash bin without a lid located next to Resident 4's bed contained a pair of used blue rubber gloves. The IP stated discarding the used blue rubber gloves in Resident 4's personal trash bin was unacceptable. During a concurrent observation and interview on 4/16/25 at 10:20 a.m. in Resident 5's room with Resident 5 and the IP, the small trash bin without a lid located next to Resident 5's bed contained a pair of used blue rubber gloves. Resident 5 stated staff provided care in the morning for him with the blue rubber gloves and staff discarded the used blue rubber gloves in the trash bin after the care. The IP stated discarding the used blue rubber gloves in Resident 5's personal trash bin was unacceptable. During a concurrent observation and interview on 4/16/25 at 10:25 a.m. in Resident 6's room with the IP, the small trash bin without a lid located next to Resident 6's bed contained a pair of used blue rubber gloves. The IP stated discarding the used blue rubber gloves in Resident 6's personal trash bin was unacceptable. During a concurrent observation and interview on 4/16/25 at 10:31 a.m. Resident 7's room with CNA 3 and the IP, there was a plastic bag tied at the top with used wipes containing stool. The plastic bag was placed on the floor by the door. CNA 3 stated she had just finished providing care to Resident 7 and was going to transport the plastic bag with the used wipes in a yellow barrel labeled soiled linen to discard the plastic bag into the trash bins located outside the facility. When CNA 3 obtained the yellow barrel labeled soiled linen, there was no plastic liner inside the barrel and two pairs of used blue rubber gloves were at the bottom of the barrel. CNA 3 stated the used blue rubber gloves should have been contained in a plastic bag and discarded in the trash waste bin outside the facility to minimize the transmission of diseases and prevent the spread infection. The IP stated discarding the used blue rubber gloves in the yellow barrel uncontained was unacceptable. During an interview on 4/16/25 at 12:07 p.m. with the Laundry Staff (LS), the LS stated the laundry staff were responsible to collect the soiled linen from the yellow barrels labeled soiled linen to be washed. The LS stated there was trash and soiled linen in the barrels. The LS stated the laundry staff would have to separate the trash from the soiled linen. The LS stated she would find used blue rubber gloves in the soiled linen barrel but was contained in a plastic bag and were discarded in the gray trash bins outside the facility. The LS stated used blue rubber gloves were required to be contained in a plastic bag because they were considered dirty and could possibly have germs on them. The LS stated containing the used blue rubber gloves was required for the prevention of infection and cross contamination. During an interview on 4/16/25 at 11:00 a.m. with the Director of Maintenance (DM), the DM stated staff were required to discard used blue rubber gloves in trash bins with lids. The DM stated soiled linen barrels were dedicated for soiled linen only and gray barrels with lids will be provided in the hallway for staff to discard waste products such as used PPEs. The DM stated each room had large bins with lids and were being washed outside the facility and will be returned to each room for staff to discard waste products into. The DM stated the small trash bins located next to the residents' bedside were for residents' personal use and staff should not be discarding used blue rubber gloves or other waste products in it. The DM stated the Infection Prevention Program was required to minimize cross contamination to prevent spread of infections. During an interview on 4/16/25 at 11:10 a.m. with the IP, the IP stated Infection Prevention In-services (training and education) were provided to staff every month. The IP stated staff were in-serviced on the use of the yellow soiled linen barrels and staff were in-serviced on discarding used PPEs. The IP stated soiled linen barrels were dedicated for soiled linen only. The IP stated waste products such as used PPEs and wipes should be contained in plastic bags and discarded in a gray bin with a lid. The IP stated waste products and soiled linen should not be mixed in the soiled linen barrels without containment. The IP stated the small trash bins without a lid located next to the residents' bed were for residents' personal use and staff should not be discarding waste products and used PPEs in it. The IP stated once a blue rubber glove was used, the glove was considered contaminated and should be discarded in a gray trash bin with a lid. The IP stated the Infection Prevention Program was required to prevent infection and ensure a safe and sanitary environment for residents and staff. During an interview on 4/16/25 at 11:46 a.m. with the Director of Nursing (DON), the DON stated staff should not be mixing uncontained waste products and soiled linen together. The DON stated laundry staff could be exposed to contamination when separating linen for laundry services. The DON stated the gray bin with a lid were provided in each resident's room for dedicated waste products such as used blue rubber gloves and other used PPEs. The DON stated if staff discarded waste products in the resident's bins, the liner in the bin should be contained and emptied right away into a trash bin with a lid and the liner replaced. The DON stated all used PPEs should be discarded in a gray trash bin with a lid. The DON stated the Infection Control Program was required to prevent cross contamination and prevent spread of infection. During an interview on 4/16/25 at 12:03 p.m. with the Administrator (ADM), the ADM stated staff discarding used blue rubber gloves in the residents' personal trash bins was unacceptable and staff should be discarding the used blue rubber gloves in the proper bin with a lid for containment. The ADM stated soiled linen should be discarded in the soiled linen barrel only. The ADM stated waste products and used PPEs should be discarded in gray waste bins with lids. The ADM stated staff discarding used blue rubber gloves in the soiled linen barrel exposed laundry staff to waste product contamination and was unacceptable. The ADM stated proper bins were dedicated to discard proper waste to minimize cross contamination and minimize spread of infection. During a review of the facility's policy and procedure (P&P) titled, Policies and Practices - Infection Control , dated 10/2023, the P&P indicated, Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 1. This facility infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike . 2. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the facility; b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. establish guidelines for implementing isolation precautions, including standard and transmission-based precautions . 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control . During a review of the facility's P&P titled, Waste Disposal , dated 1/2012, the P&P indicated, Policy Statement: All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner. Policy Interpretation and Implementation: 1. All infectious and regulated waste destined for disposal shall be placed in a closable leak-proof containers or bags that are color-coded or labeled as herein described. The Infection Preventionist and Environmental Services Director will ensure that waste is properly disposed of and the following rules are observed: a. If outside contamination of the container or bag is likely to occur, a second leak-proof container or bag which is closable and labeled (or color-coded) shall be placed over the outside of the first container or bag and closed to prevent leakage during handling, storage, and transport. b. Disposal of all infectious and regulated waste shall be in accordance with applicable federal, state, and local regulations . During a review of the facility's P&P titled, Laundry and Bedding, Soiled , dated 9/2022, the P&P indicated, Policy Statement: Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Policy Interpretation and Implementation: Handling. 1. All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting). 2. Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used). 3. Leak-resistant containers or bags are used for linens or textiles contaminated with blood or body substances. 4. Sorting and rinsing of contaminated laundry at the point of use, hallways, or other open resident care spaces is prohibited. 5. Staff handle soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces, and persons. Transport: Contaminated linen and laundry bags/containers are not held close to the body or squeezed during transport. 2. There are no additional requirements (e.g., double bagging or categorizing as biohazard [any biological agent that can cause death, injury, or illness to a person]) for transporting linen from rooms where transmission-based precautions are in effect . During a professional reference review retrieved from https://www.cdc.gov/infection-control/hcp/environmental-control/regulated-medical-waste.html#:~:text=Regulated%20medical%20wastes%20are%20treated,deposited%20in%20a%20sterile%20site titled, Regulated Medical Waste, dated 1/8/24, the professional reference indicated, . 2. Categories of Medical Waste . Health-care facility medical wastes targeted for handling and disposal precautions include laboratory waste, pathology and anatomy waste (human or animal tissues, organs, and body parts removed during medical procedures), blood specimens from clinics and laboratories, blood products, and other body-fluid specimens (saliva, vomit, urine, and feces) . 3. Management of Regulated Medical Waste in Health-Care Facilities . Medical wastes require careful disposal and containment before collection and consolidation for treatment. OSHA (Occupational Safety and Health Administration; a US Department of Labor agency responsible for ensuring safe and healthy working conditions for patients and employees) has dictated initial measures for discarding regulated medical-waste items. These measures are designed to protect the workers who generate medical wastes and who manage the wastes from point of generation to disposal. A single, leak-resistant biohazard bag is usually adequate for containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded without contaminating the bag's exterior. The contamination or puncturing of the bag requires placement into a second biohazard bag. All bags should be securely closed for disposal .

Based on observation, interview, and record review, the facility failed to protect one of four residents (Resident 1) right to be free from physical abuse by Certified Nursing Assistant (CNA) 1 when a pitcher (a large container with a handle and a lip, used for holding and pouring liquids) filled with hot water by CNA 1 spilled onto Resident 1's left thigh on 2/3/25. This failure resulted in a Resident 1 experiencing second-degree burns (an injury that affects the outer layer of skin and part of the underlying layer of skin) to the left thigh and severe pain that required the administration of hydrocodone (a medication used to treat moderate to severe pain). Findings: During a concurrent observation and interview on 2/6/25 at 2:16 p.m. with Resident 1 in Resident 1's room, a palm size red patch was observed on Resident 1's left anterior (front) and lateral (side) thigh. One quarter size open wound was on the anterior thigh. Two quarter size fluid filled blisters were on the anterior left thigh. Three quarter size fluid filled blisters were on the lateral left thigh. Resident 1 stated on 2/3/25 at 7:30 p.m. she requested water to wash her face before going to bed. Resident 1 stated Certified Nursing Assistant (CNA) 1 brought her hot water in a pitcher without a lid and set the pitcher on the bedside table. Resident 1 stated when she moved the bed up to access the water and the bed moved the bedside table Resident 1 stated CNA 1 responded by moving the bedside table and the pitcher with the hot water tipped over and spilled onto her left thigh. Resident 1 stated the water was scalding (a form of thermal burn resulting from heated fluids such as boiling water or steam) hot. Resident 1 stated she screamed in pain and staff came and placed ice packs on her left thigh and gave her hydrocodone for 10 out of 10 (scale used to measure the level pain a person is experiencing with a score of 0 indicating no pain up to a score of 10 indicating worse pain imaginable) pain. During a review of Resident 1's Admission Record (AR), dated 2/7/25, the AR indicated Resident 1 was admitted on [DATE] with a history of right femur fracture (broken upper leg bone) and unspecified open wound left lower leg. During a review of Resident 1's Minimum Data Set (MDS; a federally mandated process for clinical assessment of all residents of long term care nursing facilities), dated 11/24/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 15 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 was dependent with transfer (unable to move without help from another person or persons) from bed to chair and required assistance with dressing and personal hygiene (habits to maintain cleanliness). During a review of Resident 1's Medication Administration Record (MAR), dated 2/3/25, the MAR indicated, Resident 1 was administered hydrocodone 7.5 mg (milligrams; unit of measurement)/325 mg was administered at 7:37 p.m. with a pain level of 8 (indicating severe pain). During an interview on 2/6/25 at 3:05 p.m. with CNA 1, CNA 1 stated on 2/3/25 around 7 p.m. Resident 1 requested hot water to wash her face before going to bed. CNA 1 stated she went to the dining room and filled a pitcher with the hot water from the dining room sink. CNA 1 stated the water from the resident's room took too long to get hot. CNA 1 stated the pitcher was set on Resident 1's bedside table without a lid and when CNA 1 moved the bedside table, the pitcher tipped over spilling the hot water onto Resident 1's left thigh. CNA 1 stated Resident 1 screamed, was in pain, and Resident 1's left thigh was red. CNA 1 stated she should have filled a basin (a bowl used for washing) for stability instead of a pitcher and did not know the water from the dining room sink was out of the acceptable temperature range. CNA 1 stated extreme hot water can cause severe burn injury to the skin. During a review of the facility's IDT (Interdisciplinary Team; a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) Notes, dated 2/4/25, the IDT Notes indicated, Brought to review by IDT r/t (related to) resident (Resident 1) spilling hot water on self-resulting in a burn injury on 2/3/2025 in PM shift . Around 1900 (7:00 p.m.), assigned staff member (CNA 1) notified LN (Licensed Nurse) that resident spilled hot water on her L (left) thigh. LN went to assess the resident immediately. Upon assessment, redness was noted to the L upper thigh, and resident complained of burning sensation . During a review of the facility's IDT Notes, dated 2/6/25, the IDT Notes indicated, In addendum to previous IDT note it was brought to review by IDT r/t burn injury on 2/3/25 on PM shift. It was brought to Dietary Supervisor attention of PM dietary aide witnessing employee involved in incident taking hot water from the coffee dispenser and not from dining room sink as stated by employee . During an interview on 2/11/24 at 3:39 p.m. with the Dietary Aide (DA), the DA stated she worked in the kitchen on 2/3/25. The DA stated she saw CNA 1 open the door to the kitchen and fill a pink pitcher with hot water from the coffee machine. The DA was unable to recall the time but stated it was after dinner. The DA stated the water in the coffee machine was 165 degrees Fahrenheit (F; unit of measurement). The DA stated exposure to the skin can burn the skin bad. During a review of the facility's video surveillance, dated 2/3/25 at 7:02 p.m., the video surveillance indicated, CNA 1 entered the facility's kitchen with a pink pitcher and stood by the door for eight seconds then proceeded into the hallway with the pink pitcher. During an observation and interview on 2/6/25 at 2:45 p.m. with The Registered Dietitian (RD) in the facility's kitchen, the [brand name] coffee machine was on the counter next to the kitchen door. The hot water from the coffee machine was measured with a digital thermometer (a device that measures temperature using a sensor an electronic display) at 165 degrees. The RD stated, the hot water from the coffee machine measured 165 degrees F. The RD stated the hot water temperature was set at the manufacturer's guideline. During a review of the facility's coffee machine [brand name] manufacturer's guideline, the guideline indicated, [brand name] coffee machine's temperature setting range was 160 to 206 degrees F. During a concurrent observation and interview on 2/6/25 at 3:45 p.m. with Maintenance Supervisor (MS) in the facility's dining room, there was a Caution Hot Water sign posted next to the sink. The hot water from the dining room's faucet was measured with a digital thermometer while running and reached 140 degrees F in 39 seconds. The MS stated the dining room's hot water faucet reached 140 degrees F in 39 seconds. MS stated staff and residents used the dining room to eat during break time and mealtimes. MS stated water temperature at 140 degrees F was not safe to use. During a concurrent observation and interview on 2/6/25 at 4:40 p.m. with the MS in the facility's dining room, the valve (a device for controlling the passage of fluid or air through a pipe, duct, etc., especially an automatic device allowing movement in one direction only) to the hot and cold water line was shut off. The hot and cold water was not running when turned on. MS stated the hot water temperature was out of range and the sink was put out of commission (not in service or not in working order) due to the unsafe hot water temperature. During an interview on 2/7/25 at 10:41 a.m. with the Director of Nursing (DON), the DON stated on 2/3/25 Resident 1 requested water to wash her face. The DON stated CNA 1 filled a pitcher with hot water from the coffee machine in the kitchen according to the facility's video surveillance. The DON stated CNA 1 informed her the hot water was obtained from the dining room. The DON stated the dining room's sink hot water temperature should not been hot enough to cause the burn injury to Resident 1's left thigh. The DON stated CNA's were expected to ask the Charge Nurse for hot water when residents request hot water to ensure safety. The DON stated she was not aware the dining room sinks hot water temperature was 140 degrees F. The DON stated the acceptable hot water temperature should be no more than 120 degrees F. The DON stated hot water above 120 degrees F can cause skin injury. The DON stated exposing residents to scalding hot water was physical abuse and it was not acceptable. During an interview on 2/7/25 at 3:44 p.m. with the Administrator (ADM), the ADM stated the facility's video surveillance dated 2/3/25 at 7:02 p.m. indicated CNA 1 obtained the hot water from the coffee machine in the kitchen. The ADM stated CNA 1 used to work in the kitchen and was comfortable going to the kitchen to get hot water. The ADM stated he was aware the facility's dining room sink's water temperature was out of the acceptable range and was waiting for HCAI (Health Care Access and Information; an agency that reviews plans, inspect construction, and enforce building codes in healthcare facilities to ensure safety and quality) to approve installing a permanent valve to control the water temperature. The ADM stated the acceptable water temperature range was 80 to 120 degrees F. The ADM stated temperatures above 120 degrees F can cause skin injury. The ADM stated exposing residents to scalding hot water was physical abuse and it was not acceptable. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 12/2016, the P&P indicated, Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents . During a review of the facility's P&P titled, Resident Rights, dated 12/2016, the P&P indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; . During a review of the facility's job description titled, Certified Nursing Assistant, dated 4/2013, the job description indicated, Purpose of Your Job Position: The primary purpose of your job position is to provide your assigned residents with routine daily nursing care in accordance with our established nursing care procedures, and as may be directed by your supervisors . Major Duties and Responsibilities: . Personnel Functions: Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors . Resident Rights: . Ensure that you treat all residents fairly, and with kindness, dignity, and respect . During a review of Professional Reference from https://dds.dc.gov/sites/default/files/dc/sites/dds/publication/attachments/ABA%20Scald%20Injury%20Prevention%20Educator%27s%20Guide.pdf, titled, SCALD INJURY PREVENTION, undated, indicated, . Although scald burns can happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. Most scald burn injuries happen in the home, in connection with the preparation or serving of hot food or beverages, or from exposure to hot tap water in bathtubs or showers . The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit . At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur (most severe type of burns). When the temperature of a hot liquid is increased to 140 (degrees) F/60 C (Celsius; unit of measurement) it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 F/71-82 C, resulting in almost instantaneous burns that will require surgery . High risk groups . Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids . Based on observation, interview, and record review, the facility failed to protect one of four residents (Resident 1) right to be free from physical abuse by Certified Nursing Assistant (CNA) 1 when a pitcher (a large container with a handle and a lip, used for holding and pouring liquids) filled with hot water by CNA 1 spilled onto Resident 1's left thigh on 2/3/25. This failure resulted in a Resident 1 experiencing second-degree burns (an injury that affects the outer layer of skin and part of the underlying layer of skin) to the left thigh and severe pain that required the administration of hydrocodone (a medication used to treat moderate to severe pain). Findings: During a concurrent observation and interview on 2/6/25 at 2:16 p.m. with Resident 1 in Resident 1's room, a palm size red patch was observed on Resident 1's left anterior (front) and lateral (side) thigh. One quarter size open wound was on the anterior thigh. Two quarter size fluid filled blisters were on the anterior left thigh. Three quarter size fluid filled blisters were on the lateral left thigh. Resident 1 stated on 2/3/25 at 7:30 p.m. she requested water to wash her face before going to bed. Resident 1 stated Certified Nursing Assistant (CNA) 1 brought her hot water in a pitcher without a lid and set the pitcher on the bedside table. Resident 1 stated when she moved the bed up to access the water and the bed moved the bedside table Resident 1 stated CNA 1 responded by moving the bedside table and the pitcher with the hot water tipped over and spilled onto her left thigh. Resident 1 stated the water was scalding (a form of thermal burn resulting from heated fluids such as boiling water or steam) hot. Resident 1 stated she screamed in pain and staff came and placed ice packs on her left thigh and gave her hydrocodone for 10 out of 10 (scale used to measure the level pain a person is experiencing with a score of 0 indicating no pain up to a score of 10 indicating worse pain imaginable) pain. During a review of Resident 1's Admission Record (AR), dated 2/7/25, the AR indicated Resident 1 was admitted on [DATE] with a history of right femur fracture (broken upper leg bone) and unspecified open wound left lower leg. During a review of Resident 1's Minimum Data Set (MDS; a federally mandated process for clinical assessment of all residents of long term care nursing facilities), dated 11/24/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 15 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 was dependent with transfer (unable to move without help from another person or persons) from bed to chair and required assistance with dressing and personal hygiene (habits to maintain cleanliness). During a review of Resident 1's Medication Administration Record (MAR), dated 2/3/25, the MAR indicated, Resident 1 was administered hydrocodone 7.5 mg (milligrams; unit of measurement)/325 mg was administered at 7:37 p.m. with a pain level of 8 (indicating severe pain). During an interview on 2/6/25 at 3:05 p.m. with CNA 1, CNA 1 stated on 2/3/25 around 7 p.m. Resident 1 requested hot water to wash her face before going to bed. CNA 1 stated she went to the dining room and filled a pitcher with the hot water from the dining room sink. CNA 1 stated the water from the resident's room took too long to get hot. CNA 1 stated the pitcher was set on Resident 1's bedside table without a lid and when CNA 1 moved the bedside table, the pitcher tipped over spilling the hot water onto Resident 1's left thigh. CNA 1 stated Resident 1 screamed, was in pain, and Resident 1's left thigh was red. CNA 1 stated she should have filled a basin (a bowl used for washing) for stability instead of a pitcher and did not know the water from the dining room sink was out of the acceptable temperature range. CNA 1 stated extreme hot water can cause severe burn injury to the skin. During a review of the facility's IDT (Interdisciplinary Team; a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) Notes, dated 2/4/25, the IDT Notes indicated, Brought to review by IDT r/t (related to) resident (Resident 1) spilling hot water on self-resulting in a burn injury on 2/3/2025 in PM shift . Around 1900 (7:00 p.m.), assigned staff member (CNA 1) notified LN (Licensed Nurse) that resident spilled hot water on her L (left) thigh. LN went to assess the resident immediately. Upon assessment, redness was noted to the L upper thigh, and resident complained of burning sensation . During a review of the facility's IDT Notes, dated 2/6/25, the IDT Notes indicated, In addendum to previous IDT note it was brought to review by IDT r/t burn injury on 2/3/25 on PM shift. It was brought to Dietary Supervisor attention of PM dietary aide witnessing employee involved in incident taking hot water from the coffee dispenser and not from dining room sink as stated by employee . During an interview on 2/11/24 at 3:39 p.m. with the Dietary Aide (DA), the DA stated she worked in the kitchen on 2/3/25. The DA stated she saw CNA 1 open the door to the kitchen and fill a pink pitcher with hot water from the coffee machine. The DA was unable to recall the time but stated it was after dinner. The DA stated the water in the coffee machine was 165 degrees Fahrenheit (F; unit of measurement). The DA stated exposure to the skin can burn the skin bad. During a review of the facility's video surveillance, dated 2/3/25 at 7:02 p.m., the video surveillance indicated, CNA 1 entered the facility's kitchen with a pink pitcher and stood by the door for eight seconds then proceeded into the hallway with the pink pitcher. During an observation and interview on 2/6/25 at 2:45 p.m. with The Registered Dietitian (RD) in the facility's kitchen, the [brand name] coffee machine was on the counter next to the kitchen door. The hot water from the coffee machine was measured with a digital thermometer (a device that measures temperature using a sensor an electronic display) at 165 degrees F. The RD stated, the hot water from the coffee machine measured 165 degrees F. The RD stated the hot water temperature was set at the manufacturer's guideline. During a review of the facility's coffee machine [brand name] manufacturer's guideline, the guideline indicated, [brand name] coffee machine's temperature setting range was 160 to 206 degrees F. During a concurrent observation and interview on 2/6/25 at 3:45 p.m. with Maintenance Supervisor (MS) in the facility's dining room, there was a Caution Hot Water sign posted next to the sink. The hot water from the dining room's faucet was measured with a digital thermometer while running and reached 140 degrees F in 39 seconds. The MS stated the dining room's hot water faucet reached 140 degrees F in 39 seconds. MS stated staff and residents used the dining room to eat during break time and mealtimes. MS stated water temperature at 140 degrees F was not safe to use. During a concurrent observation and interview on 2/6/25 at 4:40 p.m. with the MS in the facility's dining room, the valve to the hot and cold water line was shut off. The hot and cold water was not running when turned on. MS stated the hot water temperature was out of range and the sink was put out of commission (not in service or not in working order) due to the unsafe hot water temperature. During an interview on 2/7/25 at 10:41 a.m. with the Director of Nursing (DON), the DON stated on 2/3/25 Resident 1 requested water to wash her face. The DON stated CNA 1 filled a pitcher with hot water from the coffee machine in the kitchen according to the facility's video surveillance. The DON stated CNA 1 informed her the hot water was obtained from the dining room. The DON stated the dining room's sink hot water temperature should not been hot enough to cause the burn injury to Resident 1's left thigh. The DON stated CNA's were expected to ask the Charge Nurse for hot water when residents request hot water to ensure safety. The DON stated she was not aware the dining room sinks hot water temperature was 140 degrees F. The DON stated the acceptable hot water temperature should be no more than 120 degrees F. The DON stated hot water above 120 degrees F can cause skin injury. The DON stated exposing residents to scalding hot water was physical abuse and it was not acceptable. During an interview on 2/7/25 at 3:44 p.m. with the Administrator (ADM), the ADM stated the facility's video surveillance dated 2/3/25 at 7:02 p.m. indicated CNA 1 obtained the hot water from the coffee machine in the kitchen. The ADM stated CNA 1 used to work in the kitchen and was comfortable going to the kitchen to get hot water. The ADM stated he was aware the facility's dining room sink's water temperature was out of the acceptable range and was waiting for HCAI (Health Care Access and Information; an agency that reviews plans, inspect construction, and enforce building codes in healthcare facilities to ensure safety and quality) to approve installing a permanent valve to control the water temperature. The ADM stated the acceptable water temperature range was 80 to 120 degrees F. The ADM stated temperatures above 120 degrees F can cause skin injury. The ADM stated exposing residents to scalding hot water was physical abuse and it was not acceptable. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 12/2016, the P&P indicated, Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents . During a review of the facility's P&P titled, Resident Rights, dated 12/2016, the P&P indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; . During a review of the facility's job description titled, Certified Nursing Assistant, dated 4/2013, the job description indicated, Purpose of Your Job Position: The primary purpose of your job position is to provide your assigned residents with routine daily nursing care in accordance with our established nursing care procedures, and as may be directed by your supervisors . Major Duties and Responsibilities: . Personnel Functions: Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors . Resident Rights: . Ensure that you treat all residents fairly, and with kindness, dignity, and respect . During a review of Professional Reference from https://dds.dc.gov/sites/default/files/dc/sites/dds/publication/attachments/ABA%20Scald%20Injury%20Prevention%20Educator%27s%20Guide.pdf, titled, SCALD INJURY PREVENTION, undated, indicated, . Although scald burns can happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. Most scald burn injuries happen in the home, in connection with the preparation or serving of hot food or beverages, or from exposure to hot tap water in bathtubs or showers . The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit . At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur (most severe type of burns). When the temperature of a hot liquid is increased to 140 (degrees) F/60 C (Celsius; unit of measurement) it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 F/71-82 C, resulting in almost instantaneous burns that will require surgery . High risk groups . Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids .

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards for one of four residents (Resident 1), when a pitcher (a large container with a handle and a lip, used for holding and pouring liquids) filled with hot water by Certified Nursing Assistant (CNA) 1 spilled onto Resident 1's left thigh on 2/3/25. The facility's hot water temperatures were measured in sinks and showers with a digital thermometer (a device that measures temperature using a sensor an electronic display) on 2/6/25. A dining room sink was found to have a hot water temperature of 140 degrees Fahrenheit (F; unit of measurement). The Maintenance Supervisor (MS) who was responsible for maintaining water temperatures was not aware of the dining room sink's temperature of 140 degrees F. The facility's policy and procedure titled, Water Temperatures, Safety of, did not indicate how often the MS should measure, monitor and document the facility's water temperatures. This failure resulted in a Resident 1 experiencing second-degree burns (an injury that affects the outer layer of skin and part of the underlying layer of skin) to the left thigh, severe pain that required the administration of hydrocodone (a medication used to treat moderate to severe pain) and the potential for other residents that used the dining room sink to be burned. Findings: During an interview on 2/6/25 at 2:10 p.m. with the MS, the MS stated the facility's water temperature should be no more than 120 degrees F in the residents' room sinks and shower rooms. The MS stated Maintenance staff was not required to monitor or document the facility's water temperature. The MS stated staff was required to complete a work order if there was an issue with the facility's water supply. The MS stated water temperature above 120 degrees F can burn the skin. During a concurrent observation and interview on 2/6/25 at 2:16 p.m. with Resident 1 in Resident 1's room, a palm size red patch was observed on Resident 1's left anterior (front) and lateral (side) thigh. One quarter size open wound was on the anterior thigh. Two quarter size fluid filled blisters were on the anterior left thigh. Three quarter size fluid filled blisters were on the lateral left thigh. Resident 1 stated on 2/3/25 at 7:30 p.m. she requested water to wash her face before going to bed. Resident 1 stated Certified Nursing Assistant (CNA) 1 brought her hot water in a pitcher without a lid and set the pitcher the bedside table. Resident 1 stated when she moved the bed up to access the water, the bed moved the bedside table. Resident 1 stated CNA 1 responded by moving the bedside table and the pitcher with the hot water tipped over and spilled onto her left thigh. Resident 1 stated the water was scalding (a form of thermal burn resulting from heated fluids such as boiling water or steam) hot. Resident 1 stated she screamed in pain and staff came and placed ice packs on her left thigh and gave her hydrocodone for 10 out of 10 (scale used to measure the level pain a person is experiencing with a score of 0 indicating no pain up to a score of 10 indicating worse pain imaginable) pain. During a review of Resident 1's Admission Record (AR), dated 2/7/25, the AR indicated, Resident 1 was admitted on [DATE] with a history of right femur fracture (broken upper leg bone) and unspecified open wound left lower leg. During a review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long term care nursing facilities), dated 11/24/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 15 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 was dependent with transfer (unable to move without help from another person or persons) from bed to chair and required assistance with dressing and personal hygiene (habits to maintain cleanliness). During a review of Resident 1's Medication Administration Record (MAR), dated 2/3/25, the MAR indicated, Resident 1 was administered hydrocodone 7.5 mg (milligrams; unit of measurement)/325 mg was administered at 7:37 p.m. with a pain level of 8 (indicating severe pain). During an interview on 2/6/25 at 3:05 p.m. with CNA 1, CNA 1 stated on 2/3/25 around 7 p.m. Resident 1 requested hot water to wash her face before going to bed. CNA 1 stated she went to the dining room and filled a pitcher with the hot water from the dining room sink. CNA 1 stated the water from the resident's room took too long to get hot. CNA 1 stated the pitcher was set on Resident 1's bedside table without a lid and when CNA 1 moved the bedside table, the pitcher tipped over spilling the hot water onto Resident 1's left thigh. CNA 1 stated Resident 1 screamed, was in pain, and Resident 1's left thigh was red. CNA 1 stated she should have filled a basin (a bowl used for washing) for stability instead of a pitcher. CNA 1 stated, she did not know the water from the dining room sink was out of the acceptable temperature range. CNA 1 stated extreme hot water can cause severe burn injury to the skin. During a review of the facility's IDT (Interdisciplinary Team; a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well being of residents and staff) Notes, dated 2/4/25, the IDT Notes indicated, Brought to review by IDT r/t (related to) resident (Resident 1) spilling hot water on self-resulting in a burn injury on 2/3/2025 in PM shift . Around 1900 (7:00 p.m.), assigned staff member (CNA 1) notified LN (Licensed Nurse) that resident spilled hot water on her L (left) thigh. LN went to assess the resident immediately. Upon assessment, redness was noted to the L upper thigh, and resident complained of burning sensation . During a review of the facility's IDT Notes, dated 2/6/25, the IDT Notes indicated, In addendum to previous IDT note it was brought to review by IDT r/t burn injury on 2/3/25 on PM shift. It was brought to Dietary Supervisor attention of PM dietary aide witnessing employee involved in incident taking hot water from the coffee dispenser and not from dining room sink as stated by employee . During an interview on 2/11/24 at 3:39 p.m. with the Dietary Aide (DA), the DA stated she worked in the kitchen on 2/3/25. The DA stated she saw CNA 1 open the door to the kitchen and fill a pink pitcher with hot water from the coffee machine. The DA was unable to recall the time but stated it was after dinner. The DA stated the water in the coffee machine was 165 degrees F. The DA stated exposure to the skin can burn the skin bad. During a review of the facility's video surveillance, dated 2/3/25 at 7:02 p.m., the video surveillance indicated, CNA 1 entered the facility's kitchen with a pink pitcher and stood by the door for eight seconds then proceeded into the hallway with the pink pitcher. During an observation and interview on 2/6/25 at 2:45 p.m. with The Registered Dietitian (RD) in the facility's kitchen, the [brand name] coffee maker was on the counter next to the door. The hot water from the coffee machine was measured with a digital thermometer at 165 degrees F. The RD stated, the hot water from the coffee machine measured 165 degrees F. The RD stated the hot water temperature was set at the manufacturer's guideline. During a review of the facility's coffee machine [brand name] manufacturer's guideline, the guideline indicated, [brand name] coffee machine's temperature setting range was 160 to 206 degrees F. During a concurrent observation and interview on 2/6/25 at 3:45 p.m. with the MS in the facility's dining room, there was a Caution Hot Water sign posted next to the sink. The hot water from the dining room's faucet was measured with a digital thermometer while running and reached 140 degrees F in 39 seconds. The MS stated the dining room's hot water faucet reached 140 degrees F in 39 seconds. MS stated staff and residents used the dining room to eat during break time and mealtimes. MS stated water temperature at 140 degrees F was not safe to use. During an interview on 2/6/25 at 4:15 p.m. with CNA 2, CNA 2 stated staff used the dining room during break time and residents used the dining room during mealtimes. CNA 2 stated she used the dining room sink to wash her hands. CNA 2 stated the hot water was too hot and the cold water was needed to be on with the hot water to wash her hands. CNA 2 stated she did not know the acceptable water temperature and stated hot water can burn skin. During an interview on 2/6/25 at 4:18 p.m. with CNA 3, CNA 3 stated she used the dining room sink to wash her hands. CNA 3 stated the hot water was too hot and the cold water was needed to be on with the hot water to wash her hands. CNA 3 stated she did not know the acceptable water temperature and stated hot water can burn skin. During an interview on 2/6/25 at 4:21 p.m. with CNA 4, CNA 4 stated she used the dining room sink to wash her hands. CNA 3 stated the hot water was too hot and the cold water was needed to be on with the hot water to wash her hands. CNA 4 stated she did not know the acceptable water temperature and stated hot water can burn skin. During an interview on 2/6/25 at 4:25 with Licensed Vocational Nurse (LVN) 1, LVN 1 stated staff and residents used the dining room during break time and mealtimes. LVN 1 stated she was not aware the water temperature from the dining room sink was 140 degrees F. LVN 1 stated if residents requested hot water staff need to get water from the bathroom in their room. LVN 1 stated she did not know the acceptable water temperature. LVN 1 stated hot water can cause skin injury. During an interview on 2/6/25 at 4:30 p.m. with LVN 2, LVN 2 stated staff and residents used the dining room during break time and mealtimes. LVN 2 stated she used the dining room sink to wash her hands. LVN 2 stated she was not aware of how hot the dining room sink water was and she used both hot and cold water to wash her hands. LVN 2 did not know the acceptable water temperature. LVN 2 stated hot water can burn the skin. During an interview on 2/6/25 at 4:36 p.m. with LVN 3, LVN 3 stated staff and residents eat in the dining room during break time and mealtimes. LVN 3 stated staff used the dining room sink to wash their hands. LVN 3 was unable to recall if there was a Caution Hot Water sign posted next to the sink. LVN 3 stated the dining room sink's hot water was too hot and she needed to turn on the cold water with the hot water to wash hands. LVN 3 did not know the acceptable water temperature. LVN 3 stated hot water can cause skin injury. During a concurrent observation and interview on 2/6/25 at 4:40 p.m. with the MS in the facility's dining room, the valve (a device for controlling the passage of fluid or air through a pipe, duct, etc., especially an automatic device allowing movement in one direction only) to the hot and cold water line was shut off. The hot and cold water was not running when turned on. MS stated the hot water temperature was out of range and the sink was put out of commission (not in service or not in working order) due to the unsafe hot water temperature. During a concurrent observation and interview on 2/6/25 at 4:45 p.m. seven residents entered the dining room to have dinner. Residents 2, 3 and 4 were part of the seven residents in the dining area. Resident 2 stated he ate every meal in the dining room and used the dining room sink to wash his hands. Resident 2 stated the hot water in the dining room sink was too hot and he used the hot and cold water together to wash his hands. Resident 2 stated hot water can burn the skin. During a review of Resident 2's AR, dated 2/6/25, the AR indicated, Resident 2 was admitted on [DATE]. During a review of Resident 2's BIMS, dated 12/24/24, the BIMS indicated a score of 15. During an interview on 2/6/25 at 4:47 p.m. with Resident 3, Resident 3 stated she ate every meal in dining room. Resident 3 stated she had not used the dining room sink. Resident 3 stated, she was unaware that the dining room sink's hot water was too hot. Resident 3 stated hot water can burn the skin. During a review of Resident 3's AR, dated 2/6/25, the AR indicated Resident 3 was admitted on [DATE]. During a review of Resident 3's BIMS, dated 1/27/25, the BIMS indicated a score of 15. During an interview on 2/6/25 at 4:50 p.m. with Resident 4, Resident 4 stated she ate every meal in dining room. Resident 4 stated she had not used the dining room sink . Resident 4 stated, she was unaware that the dining room sink's hot water was too hot. Resident 4 stated hot water can burn the skin. During a review of Resident 4's AR, dated 2/6/25, the AR indicated Resident 4 was admitted on [DATE]. During a review of Resident 4's BIMS, dated 1/8/25, the BIMS indicated a score of 15. During an interview on 2/7/25 at 10:41 a.m. with the Director of Nursing (DON), the DON stated, on 2/3/25 Resident 1 requested water to wash her face. The DON stated CNA 1 filled a pitcher with hot water from the coffee machine in the kitchen according to the facility's video surveillance. The DON stated CNA 1 informed her the hot water was obtained from the dining room. The DON stated the dining room sink's hot water temperature should not have been hot enough to cause the burn injury to Resident 1's left thigh. The DON stated CNA's were expected to ask the Charge Nurse for hot water when residents request hot water to ensure safety. The DON stated she was not aware the dining room sink's hot water temperature was 140 degrees F. The DON stated the acceptable hot water temperature should be no more than 120 degrees F. The DON stated hot water above 120 degrees F can cause skin injury. The DON stated the facility's current policy required Maintenance staff to check the facility's water temperatures periodically but did not specify how often Maintenance staff should be checking and documenting the temperatures. The DON stated, she expected Maintenance staff to check water temperatures regularly and have a schedule to check water temperatures to ensure safe temperature levels. The DON stated, water temperatures should be monitored monthly or quarterly and documented. During an interview on 2/7/25 at 3:44 p.m. with the Administrator (ADM), the ADM stated the facility's video surveillance dated 2/3/25 at 7:02 p.m. indicated, CNA 1 obtained the hot water from the coffee machine in the kitchen. The ADM stated, CNA 1 used to work in the kitchen and was comfortable going to the kitchen to get hot water. The ADM stated he was aware the facility's dining room sink's water temperature was out of the acceptable range. The ADM stated the acceptable water temperature range was 80 to 120 degrees F. The ADM stated water temperatures above 120 degrees F can cause skin injury. The ADM stated, a survey team (a group of State Agency employees who inspect and approve facilities for insurance services) informed him last year that the dining room sink's hot water temperature was out of range during the inspection process and he was instructed to post a Caution Hot Water sign next to the sink until the facility installed a valve to ensure safe water temperatures. The ADM stated the facility was still waiting for HCAI (Health Care Access and Information; an agency that reviews plans, inspect construction, and enforce building codes in healthcare facilities to ensure safety and quality) to approve installing a permanent valve to control the water temperature. The ADM stated the facility's current water safety policy and procedure indicated water temperatures should be checked periodically but did not indicate how often. The ADM stated the policy and procedure needed revision to ensure Maintenance staff check the facility's water temperatures weekly and document the water temperatures. During a review of the facility's policy and procedure (P&P) titled, Water Temperatures, Safety of, dated 12/2009, the P&P indicated, Policy Statement: . water in the facility shall be kept within a temperature range to prevent scalding of residents. Policy Interpretation and Implementation: 1. Water heaters that service resident rooms, bathroom, and tub/shower area shall be set to temperatures of no more than 120 (degrees) F (48 C; Celsius - unit of measurement), or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility. 3 Maintenance staff may conduct periodic tap water temperature checks and record the water temperatures if there's a fluctuation or concern with the water temperature . During a review of the facility's job description titled, Building & Maintenance Supervisor, dated 4/2023, the job description indicated, Purpose of Your Job Position: Responsible for overall management of laundry and maintenance/janitorial personnel to ensure a clean, safe and orderly living environment for residents of the Nursing Home . Major Duties and Responsibilities: . Solely responsible for the housekeeping, maintenance, central supply, and laundry services for the facility. The primary function of this position is to ensure nursing home residents enjoy a clean, well maintained, orderly living environment . Develops systems and programs for maximizing the effectiveness of the housekeeping, laundry, central supply, and maintenance functions . Complies with Department of Public Health and State Fire Marshall directives pertaining to the Nursing Home's fire and safety program . Oversees maintenance of plumbing, heating and cooling, refrigeration, electrical and communication systems . During a review of the facility's job description titled, Certified Nursing Assistant, dated 4/2013, the job description indicated, Purpose of Your Job Position: The primary purpose of your job position is to provide your assigned residents with routine daily nursing care in accordance with our established nursing care procedures, and as may be directed by your supervisors . Major Duties and Responsibilities: . Personnel Functions: Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors . Resident Rights: . Ensure that you treat all residents fairly, and with kindness, dignity, and respect . During a review of Professional Reference from https://dds.dc.gov/sites/default/files/dc/sites/dds/publication/attachments/ABA%20Scald%20Injury%20Prevention%20Educator%27s%20Guide.pdf, titled, SCALD INJURY PREVENTION, undated, indicated, . Although scald burns can happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. Most scald burn injuries happen in the home, in connection with the preparation or serving of hot food or beverages, or from exposure to hot tap water in bathtubs or showers . The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit . At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur (most severe type of burns). When the temperature of a hot liquid is increased to 140 (degrees) F/60 C (Celsius; unit of measurement) it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 F/71-82 C, resulting in almost instantaneous burns that will require surgery . High risk groups . Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids . Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards for one of four residents (Resident 1), when a pitcher (a large container with a handle and a lip, used for holding and pouring liquids) filled with hot water by Certified Nursing Assistant (CNA) 1 spilled onto Resident 1's left thigh on 2/3/25. The facility's hot water temperatures were measured in sinks and showers with a digital thermometer (a device that measures temperature using a sensor an electronic display) on 2/6/25. A dining room sink was found to have a hot water temperature of 140 degrees Fahrenheit (F; unit of measurement). The Maintenance Supervisor (MS) who was responsible for maintaining water temperatures was not aware of the dining room sink's temperature of 140 degrees F. The facility's policy and procedure titled, Water Temperatures, Safety of, did not indicate how often the MS should measure, monitor and document the facility's water temperatures. This failure resulted in a Resident 1 experiencing second-degree burns (an injury that affects the outer layer of skin and part of the underlying layer of skin) to the left thigh, severe pain that required the administration of hydrocodone (a medication used to treat moderate to severe pain) and the potential for other residents that used the dining room sink to be burned. Findings: During an interview on 2/6/25 at 2:10 p.m. with the MS, the MS stated the facility's water temperature should be no more than 120 degrees F in the residents' room sinks and shower rooms. The MS stated Maintenance staff was not required to monitor or document the facility's water temperature. The MS stated staff was required to complete a work order if there was an issue with the facility's water supply. The MS stated water temperature above 120 degrees F can burn the skin. During a concurrent observation and interview on 2/6/25 at 2:16 p.m. with Resident 1 in Resident 1's room, a palm size red patch was observed on Resident 1's left anterior (front) and lateral (side) thigh. One quarter size open wound was on the anterior thigh. Two quarter size fluid filled blisters were on the anterior left thigh. Three quarter size fluid filled blisters were on the lateral left thigh. Resident 1 stated on 2/3/25 at 7:30 p.m. she requested water to wash her face before going to bed. Resident 1 stated Certified Nursing Assistant (CNA) 1 brought her hot water in a pitcher without a lid and set the pitcher the bedside table. Resident 1 stated when she moved the bed up to access the water, the bed moved the bedside table. Resident 1 stated CNA 1 responded by moving the bedside table and the pitcher with the hot water tipped over and spilled onto her left thigh. Resident 1 stated the water was scalding (a form of thermal burn resulting from heated fluids such as boiling water or steam) hot. Resident 1 stated she screamed in pain and staff came and placed ice packs on her left thigh and gave her hydrocodone for 10 out of 10 (scale used to measure the level pain a person is experiencing with a score of 0 indicating no pain up to a score of 10 indicating worse pain imaginable) pain. During a review of Resident 1's Admission Record (AR), dated 2/7/25, the AR indicated, Resident 1 was admitted on [DATE] with a history of right femur fracture (broken upper leg bone) and unspecified open wound left lower leg. During a review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long term care nursing facilities), dated 11/24/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 15 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 was dependent with transfer (unable to move without help from another person or persons) from bed to chair and required assistance with dressing and personal hygiene (habits to maintain cleanliness). During a review of Resident 1's Medication Administration Record (MAR), dated 2/3/25, the MAR indicated, Resident 1 was administered hydrocodone 7.5 mg (milligrams; unit of measurement)/325 mg was administered at 7:37 p.m. with a pain level of 8 (indicating severe pain). During an interview on 2/6/25 at 3:05 p.m. with CNA 1, CNA 1 stated on 2/3/25 around 7 p.m. Resident 1 requested hot water to wash her face before going to bed. CNA 1 stated she went to the dining room and filled a pitcher with the hot water from the dining room sink. CNA 1 stated the water from the resident's room took too long to get hot. CNA 1 stated the pitcher was set on Resident 1's bedside table without a lid and when CNA 1 moved the bedside table, the pitcher tipped over spilling the hot water onto Resident 1's left thigh. CNA 1 stated Resident 1 screamed, was in pain, and Resident 1's left thigh was red. CNA 1 stated she should have filled a basin (a bowl used for washing) for stability instead of a pitcher. CNA 1 stated, she did not know the water from the dining room sink was out of the acceptable temperature range. CNA 1 stated extreme hot water can cause severe burn injury to the skin. During a review of the facility's IDT (Interdisciplinary Team; a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well being of residents and staff) Notes, dated 2/4/25, the IDT Notes indicated, Brought to review by IDT r/t (related to) resident (Resident 1) spilling hot water on self-resulting in a burn injury on 2/3/2025 in PM shift . Around 1900 (7:00 p.m.), assigned staff member (CNA 1) notified LN (Licensed Nurse) that resident spilled hot water on her L (left) thigh. LN went to assess the resident immediately. Upon assessment, redness was noted to the L upper thigh, and resident complained of burning sensation . During a review of the facility's IDT Notes, dated 2/6/25, the IDT Notes indicated, In addendum to previous IDT note it was brought to review by IDT r/t burn injury on 2/3/25 on PM shift. It was brought to Dietary Supervisor attention of PM dietary aide witnessing employee involved in incident taking hot water from the coffee dispenser and not from dining room sink as stated by employee . During an interview on 2/11/24 at 3:39 p.m. with the Dietary Aide (DA), the DA stated she worked in the kitchen on 2/3/25. The DA stated she saw CNA 1 open the door to the kitchen and fill a pink pitcher with hot water from the coffee machine. The DA was unable to recall the time but stated it was after dinner. The DA stated the water in the coffee machine was 165 degrees F. The DA stated exposure to the skin can burn the skin bad. During a review of the facility's video surveillance, dated 2/3/25 at 7:02 p.m., the video surveillance indicated, CNA 1 entered the facility's kitchen with a pink pitcher and stood by the door for eight seconds then proceeded into the hallway with the pink pitcher. During an observation and interview on 2/6/25 at 2:45 p.m. with The Registered Dietitian (RD) in the facility's kitchen, the [brand name] coffee maker was on the counter next to the door. The hot water from the coffee machine was measured with a digital thermometer at 165 degrees F. The RD stated, the hot water from the coffee machine measured 165 degrees F. The RD stated the hot water temperature was set at the manufacturer's guideline. During a review of the facility's coffee machine [brand name] manufacturer's guideline , the guideline indicated, [brand name] coffee machine's temperature setting range was 160 to 206 degrees F. During a concurrent observation and interview on 2/6/25 at 3:45 p.m. with the MS in the facility's dining room, there was a Caution Hot Water sign posted next to the sink. The hot water from the dining room's faucet was measured with a digital thermometer while running and reached 140 degrees F in 39 seconds. The MS stated the dining room's hot water faucet reached 140 degrees F in 39 seconds. MS stated staff and residents used the dining room to eat during break time and mealtimes. MS stated water temperature at 140 degrees F was not safe to use. During an interview on 2/6/25 at 4:15 p.m. with CNA 2, CNA 2 stated staff used the dining room during break time and residents used the dining room during mealtimes. CNA 2 stated she used the dining room sink to wash her hands. CNA 2 stated the hot water was too hot and the cold water was needed to be on with the hot water to wash her hands. CNA 2 stated she did not know the acceptable water temperature and stated hot water can burn skin. During an interview on 2/6/25 at 4:18 p.m. with CNA 3, CNA 3 stated she used the dining room sink to wash her hands. CNA 3 stated the hot water was too hot and the cold water was needed to be on with the hot water to wash her hands. CNA 3 stated she did not know the acceptable water temperature and stated hot water can burn skin. During an interview on 2/6/25 at 4:21 p.m. with CNA 4, CNA 4 stated she used the dining room sink to wash her hands. CNA 3 stated the hot water was too hot and the cold water was needed to be on with the hot water to wash her hands. CNA 4 stated she did not know the acceptable water temperature and stated hot water can burn skin. During an interview on 2/6/25 at 4:25 with Licensed Vocational Nurse (LVN) 1, LVN 1 stated staff and residents used the dining room during break time and mealtimes. LVN 1 stated she was not aware the water temperature from the dining room sink was 140 degrees F. LVN 1 stated if residents requested hot water staff need to get water from the bathroom in their room. LVN 1 stated she did not know the acceptable water temperature. LVN 1 stated hot water can cause skin injury. During an interview on 2/6/25 at 4:30 p.m. with LVN 2, LVN 2 stated staff and residents used the dining room during break time and mealtimes. LVN 2 stated she used the dining room sink to wash her hands. LVN 2 stated she was not aware of how hot the dining room sink water was and she used both hot and cold water to wash her hands. LVN 2 did not know the acceptable water temperature. LVN 2 stated hot water can burn the skin. During an interview on 2/6/25 at 4:36 p.m. with LVN 3, LVN 3 stated staff and residents eat in the dining room during break time and mealtimes. LVN 3 stated staff used the dining room sink to wash their hands. LVN 3 was unable to recall if there was a Caution Hot Water sign posted next to the sink. LVN 3 stated the dining room sink's hot water was too hot and she needed to turn on the cold water with the hot water to wash hands. LVN 3 did not know the acceptable water temperature. LVN 3 stated hot water can cause skin injury. During a concurrent observation and interview on 2/6/25 at 4:40 p.m. with the MS in the facility's dining room, the valve to the hot and cold water line was shut off. The hot and cold water was not running when turned on. MS stated the hot water temperature was out of range and the sink was put out of commission (not in service or not in working order) due to the unsafe hot water temperature. During a concurrent observation and interview on 2/6/25 at 4:45 p.m. seven residents entered the dining room to have dinner. Residents 2, 3 and 4 were part of the seven residents in the dining area. Resident 2 stated he ate every meal i [TRUNCATED]

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for two of 12 residents (Resident 1 and Resident 3) when: 1. Resident 1's care plan was not developed to reflect an assessment and interventions for the use of bed rails. This failure put Resident 1 at risk of harm due to improper use of bed rails. 2. Resident 3's care plan was not developed and implemented to reflect assessments and interventions to address Resident 3's edema (medical term for swelling) to the right and left lower legs, or the use of a brace for Resident 3's right leg. These failures resulted in Resident 3 suffering from a wound to the right shin (lower front leg) and Resident 3 suffered from a trauma induced skin injury to the right inner ankle that caused severe pain and negatively affected Resident 3's mobility. Findings: 1. During an observation on 11/5/24 at 8:35 a.m., Resident 1 was observed in bed sleeping. Bed rails were observed raised on both sides at the head of Resident 1's bed. Fall mats were observed on the right and left side of Resident 1's bed. During a review of Resident 1's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 11/8/24, the AR indicated, Resident 1 was admitted on [DATE] with diagnoses of Alzheimer's (a disease characterized by a progressive decline in mental abilities), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), psychosis (a mental disorder characterized by a disconnection from reality), fracture of the left femur (a break in the thigh bone), hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and transient ischemic attack (TIA - a short period of symptoms similar to those of a stroke [damage to the brain from interruption of it's blood supply], caused by a brief blockage of blood flow to the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/4/24, the MDS section C indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 1 was severely cognitively impaired. During a review of Resident 1's medical record, Resident 1 was observed to have no documentation of a care plan for the use of bed rails, no documentation of a bed rail assessment, no physician orders for the use of bed rails, and no consent on file for the use of bed rails. During a concurrent interview and record review on 11/6/24 at 9:44 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's medical record was reviewed. Resident 1's medical record indicated, no physician orders for the use of bed rails for Resident 1, no consent on file for the use of bed rails for Resident 1, no care plan was in place for the use of bed rails for Resident 1 and no bed assessment was documented for the use of bed rails for Resident 1. LVN 1 stated Resident 1 should have orders, a care plan, and a bed assessment for the use of bed rails on Resident 1's bed. LVN 1 stated Resident 1 should have had physician orders for bed rails. LVN 1 stated bed rails were considered a restrictive device. LVN 1 stated if a bed was not assessed for bed rails, the bed rails could be unsafe, and the resident could get hurt. LVN 1 stated a care plan was to ensure staff who assisted Resident 1 with turning and repositioning were using the bed rails appropriately. During a review of the facility's job duties document titled, Floor Nurse, dated 4/2013, the document indicated, . documentation . encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies . report all discrepancies noted concerning physician's orders . to the Director of Nursing (DON) . use restraints when necessary and in accordance with established policies and procedures . ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes . monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies . review care plans daily to ensure that appropriate can (care) is being rendered. Inform the DON of any changes that need to be made on the care plan . ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care or treatment . review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs . ensure that your assigned certified nursing assistants (CNAs) are aware of the resident care plans. Ensure that the CNAs refer to the resident's care plan prior to administering daily care to the resident . 2. During a concurrent observation and interview on 11/5/24 at 11:11 a.m. with Resident 3 in Resident 3's room, Resident 3 was observed dressed, sitting in his wheelchair. Resident 3 was alert and answered questions clearly. Resident 3 stated he had been at the facility for a long time. Resident 3 stated he was at the facility due to having a stroke. Resident 3 stated he was getting daily physical therapy (PT) and returned from PT earlier this morning. Resident 3 stated he wore a brace on his right lower leg which cut into his right ankle. Resident 3 was observed to have a wound on his right lower leg above his foot with no dressing. Resident 3 stated the nurse would put a band aide on his wounds. Resident 3 stated he had pain in his right lower leg above his ankle. Resident 3 stated he took acetaminophen for his pain, which helped his pain. During a record review of Resident 3's AR, dated 11/8/24, the AR indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain) affecting the right dominant side. During a review of Resident 3's MDS, dated [DATE], the MDS section C indicated, Resident 3 had a BIMS score of 15, which indicated Resident 3 was cognitively intact. During an interview on 11/7/24 at 9:12 a.m. with Resident 3, Resident 3 stated he wore compression stockings years ago, but they kept going missing and were not replaced. Resident 3 stated he took acetaminophen this morning for his leg pain. Resident 3 stated the nurse put an adhesive dressing on his right inner ankle wound this morning. During a concurrent observation and interview on 11/7/24 at 9:27 a.m. with the Certified Nursing Assistant/Rehabilitation Nurse Assistant (CNA/RNA), in the hallway near Resident 3's room, the CNA/RNA was observed applying a right lower extremity brace to Resident 3. The CNA/RNA stated when Resident 3's right leg gets swollen, Resident 3 would let her know. The CNA/RNA stated it had been months since Resident 3 wore compression stockings. The CNA/RNA observed the open wound to Resident 3's right shin with no dressing. The CNA/RNA verbalized observation of an adhesive dressing to Resident 3's right inner ankle. The CNA/RNA stated Resident 3's wounds should have been covered with gauze. During a concurrent observation and interview on 11/7/24 at 12:00 p.m. with Resident 3 and the Clinical Supervisor Nurse (CSN) in Resident 3's room, Resident 3's right inner ankle wound was observed to be bleeding through the adhesive Dressing, onto Resident 3's sock. Resident 3 stated the right leg brace was pinching his skin. The CSN was observed checking Resident 3's right ankle wound. The CSN stated the charge nurse needed to assess the wound immediately to get the right treatment for Resident 3 to prevent infection. The CSN stated applying an adhesive dressing was not the right treatment. During a concurrent observation and interview on 11/7/24 at 1:50 p.m. with the Treatment Nurse (TN) in Resident 3's room, the TN was observed assessing Resident 3's wounds. The TN stated she contacted the Wound Care Nurse Practitioner (NP) and received orders for Resident 3's wound care. The TN stated she was not aware Resident 3 had wounds. During a concurrent interview and record review on 11/8/24 at 8:20 a.m. with the CNA/RNA, Resident 3's Restorative Nursing Referral (RNR), dated 1/5/24, was reviewed. The RNR indicated a list of goals and treatment plan, which did not include the use of a walking brace when ambulating. The CNA/RNA stated the RNR did not indicate the use of a walking brace when ambulating Resident 3. The CNA/RNA stated that Resident 3 was on the RNA program for ambulation with the use of a walking brace. The RNA stated she received training from the Physical Therapist (PT) regarding the brace application during ambulation. The CNA/RNA stated she observed an adhesive dressing on Resident 3's right inner ankle on 11/4/24 and 11/5/24. The CNA/RNA stated she did not report to the nurse about the adhesive dressing on Resident 3's right inner ankle. The CNA/RNA stated she thought the nurse knew about Resident 3's wounds as nurses were the only staff members with access to the locked treatment cart. The CNA/RNA stated she always applied Resident 3's brace when he ambulated. The CNA/RNA stated nurses did not apply the brace to Resident 3. The CNA/RNA stated nurses should have checked the brace when it was applied to Resident 3's leg to be sure the brace fit properly, and the brace was properly applied to Resident 3's leg to prevent injury. The CNA/RNA stated Resident 3 would be injured if the brace was not properly fitted to the resident and was not put on correctly. The CNA/RNA stated she observed a white dressing applied on the right shin area of Resident 3 when she ambulated the resident on 11/5/24. The CNA/RNA stated Resident 3 told her his shin wound was oozing and weeping. The CNA/RNA stated Resident 3 always had swelling in his bilateral lower extremities. During a concurrent interview and record review on 11/8/24 at 9:01 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 3's Order Summary Report, dated 11/8/24, was reviewed. The Order Summary Report indicated, no order for the use of Resident 3's brace. Resident 3's Care Plan, undated, was also reviewed. The Care Plan indicated; no care plan was in place for monitoring Resident 3's skin while using a brace, and no care plan was in place for monitoring Resident 3's BL LE edema. LVN 1 stated monitoring the skin was important to prevent skin issues. LVN 1 stated the order for Resident 3's use of compression stockings was discontinued on 3/16/24. LVN 1 stated she could not remember why the order for the use of compression stockings for Resident 3 was discontinued. LVN 1 stated she had no time to assess Resident 3's wound or to put a nursing note in Resident 3's electronic medical chart. LVN 1 stated there should have been a physician's order and care plan in place for Resident 3's use of a brace. LVN 1 stated monitoring the application of the brace, and the skin was important to prevent skin issues. LVN 1 stated Resident 3 reported he was bleeding this morning. LVN 1 stated she assessed Resident 3 and observed an open wound to Resident 3's right inner ankle. LVN 1 stated she covered Resident 3's wound with an adhesive dressing. LVN 1 stated Resident 3 informed her his brace was causing the wound to his right inner ankle. LVN 1 stated Resident 3 had been using the brace since she started working at the facility in 2019. LVN 1 stated Resident 3 used the brace when he ambulated with the CNA/RNA. LVN 1 stated the CNA/RNA applied the brace and the nurse would help the CNA/RNA apply the brace to verify it was applied properly and did not harm the resident. LVN 1 stated she did not remember getting training on the brace application. During an interview on 11/8/24 at 9:42 a.m. with the PT, the PT stated Resident 3 was a long-term resident who came to the facility with an AFO (ankle foot orthosis [brace]). The PT stated the AFO was appropriate for the resident. The PT stated that Resident 3's brace required a bigger shoe size. The PT stated if Resident 3's shoe was too tight, the brace would not fit properly. The PT stated he informed the Social Service Director (SSD) two weeks ago to call the family to change the shoes to a one-inch size bigger shoe to properly fit the brace. The PT stated the PT Department instructed the CNA/RNA how to properly put on and take off Resident 3's brace, and to check for skin redness. During an interview on 11/8/24 at 11:33 a.m. with the SSD, the SSD stated she spoke to Resident 3 this morning about how his shoe fit his brace. The SSD stated Resident 3 informed her he believed the problem was the brace and not his shoe. Resident 3 stated he did not want the care conference team to call his daughter since she was very busy. The SSD stated the PT would call the Orthotic company to evaluate Resident 3's brace. During an interview on 11/8/24 at 2:38 p.m. with the Director of Nursing (DON), the DON stated Resident 3 should have had a care plan for edema to monitor the edema. The DON stated the skin could open due to swelling and skin breakdown could occur. The DON stated Resident 3 should have had a physician's order and care plan for the use of a brace when the brace was initially applied to Resident 3. The DON stated nurses should have been applying Resident 3's brace to ensure the brace was properly applied to prevent skin breakdown. The DON stated nurses did not receive training on the use of Resident 3's brace. The DON stated her assessment of Resident 3's right ankle indicated the tramatic wound was caused from using the brace. The DON stated Resident 3's wound to the right inner ankle was avoidable. The DON stated her expectation was that all nurses followed the policies and procedures when providing care and treatment for residents including skin and wound assessment, Medical Doctor (MD) notification of change of resident's condition, and establishing a care plan. The DON stated it was important for nurses to initiate and develop a care plan if issues arise, to monitor the resident's condition and ensure proper care was being followed by staff. The DON stated applying an adhesive dressing to the wound was not appropriate treatment for Resident 3. During an interview on 11/8/24 at 3:22 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated it was important to develop an individualized care plan so staff would be aware of the plan of care for the resident. During an interview on 11/8/24 at 3:48 p.m. with the CSN, the CSN stated a care plan should have been initiated when Resident 3's brace was applied. The CNS stated the care plan would have had a specified goal for Resident 3. The CSN stated if a care plan was not done, anything could happen to the resident and put the resident in danger of harm. During a record review of Resident 3's Progress Notes, dated 10/29/24, the Progress Notes indicated Resident 3 started cephalexin 500 mg one capsule four times a day on 10/16/24 for cellulitis (a deep infection of the skin caused by bacteria). The Progress Notes indicated Resident 3 completed cephalexin on 10/25/24. During a record review of Resident 3's Weekly Nursing Note dated 10/29/24, and 11/5/24, the Weekly Nursing Note indicated, no skin breakdown, and no skin impairments treated in the last seven days. During a record review of Resident 3's Physician Progress Note, dated 10/16/24, the Physician Progress Note indicated, . BL (bilateral) LE (lower extremity) edema (swelling)/cellulitis . continue TED (specially designed stockings that help prevent blood clots and swelling in the legs) hose; keep the extremity above the level of the heart to decrease swelling . During a review of the facility's job description document titled, Floor Nurse, dated 4/2013, the document indicated, . documentation . encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies . report all discrepancies noted concerning physician's orders . to the Director of Nursing (DON) . provide leadership to CNA's nursing personnel assigned to your unit/shift . make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary . review the resident's chart for specific treatments, medication orders . as necessary . make periodic checks to ensure that prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status . ensure that direct nursing care be provided by a certified nursing assistant, and/or a nurse aide trainee qualified to perform the procedure . notify the resident's attending physician and next-of-kin when there is a change in the resident's condition . ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes . monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies . participate, as requested, in the development and implementation of the procedures for the safe operation of all nursing service equipment . ensure that only trained and authorized personnel operate your unit/shift's equipment . review care plans daily to ensure that appropriate can (care) is being rendered. Inform the DON of any changes that need to be made on the care plan . ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care or treatment . review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs . ensure that your assigned certified nursing assistants (CNAs) are aware of the resident care plans. Ensure that the CNAs refer to the resident's care plan prior to administering daily care to the resident . During a review of the facility's job description document titled, MDS Coordinator, dated 4/2013, the document indicated, . the primary purpose of your job position is to conduct and coordinate the development and completion of the resident assessment instrument (MDS) and the resident's care plan . work with the Interdisciplinary Care Plan Team in developing a comprehensive resident assessment and care plan for each resident . conduct or coordinate the interviewing of each resident for the resident's assessment . evaluate each resident's condition and pertinent medical data . develop preliminary and comprehensive assessments of the nursing needs of each resident . coordinate the development of a written plan of care (preliminary and comprehensive) for each resident that identifies the problems/need of the resident, indicates the care to be given . During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . the care planning process will . include an assessment of the resident's strengths and needs . the comprehensive, person-centered care plan will . include measurable objectives and timeframes . describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including . incorporate identified problem areas . identify the professional services that are responsible for each element of care . reflect currently recognized standards of practice for problem areas and conditions . areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan . assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . During a review of the facility's P&P titled, Comprehensive Assessments and the Care Delivery Process, dated 12/2016, indicated, . comprehensive assessments will be conducted to assist in developing person-centered care plans . comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions . symptom or condition-related assessments . During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 5/2017, indicated, . our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition . the nurse will notify the resident's Attending Physician or physician on call when thee has been a(an) . discovery of injuries of an unknown source . specific instruction to notify the Physician of changes in the resident's condition . a significant change of condition is a major decline or improvement in the resident's status that . requires interdisciplinary review and/or revision to the care plan . During a review of the facility's P&P titled, Wound Care, dated 2021, indicated, . the purpose of this procedure is to provide guidelines for the care of wounds to promote healing . verify that there is a physician's order for this procedure . review the resident's care plan to assess for any special needs of the resident . 51345

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (Illnesses caused by viruses or bacteria that people spread to one another through contact with contaminated surfaces, bodily fluids, blood products, insect bites, or through the air) and infections for 53 of 54 residents when: 1. Staff stored personal lunch bags and a drink canister on top of the dining room ice-machine and not in the locker room refrigerator per the facility's policy and procedure (P&P) Cafeteria Meals, This failure had the potential for cross-contamination (process by which bacteria is transferred from one object or substance to another, with harmful effect) and exposure to foodborne illnesses (stomach illness acquired from ingesting contaminated food) for residents, staff, and visitors. 2. Resident 2's feeding tube (a flexible plastic tube placed into the stomach or bowel [intestine] to provide nutrition when a person cannot eat or drink safely by mouth) bottle of nourishment did not have a start date indicating when the bottle was hung to determine the discard date per the facility's in-service document Feeding Pump, This failure had the potential to place Resident 2 at risk of receiving an expired tube feeding exposing Resident 2 to bacteria and risk of infection. 3. Licensed Vocational Nurse (LVN) 2 did not follow proper procedure for donning the appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and proper hand hygiene while providing direct care to Resident 2 who was on enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) per the facility's P&P Administering Medications through an Enteral Tube. This failure had the potential to place residents at risk of infection due to cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). 4. LVN 1 did not follow proper hand hygiene procedures prior to checking blood sugar levels on Resident 27 and Resident 35, and LVN 1 did not follow proper procedures for sanitizing (to reduce or eliminate pathogenic agents [such as bacteria] on surfaces) the blood glucose meter (glucometer - a device that reads the amount of sugar in the blood) after checking the blood sugar levels on Resident 27 and Resident 35 per the facility's P&P's Obtaining a Fingerstick Glucose Level, and To clean and disinfect the Meter. This failure had the potential to place Residents 27 and 35 at risk of infection due to cross-contamination. 5. Dirty Halloween Decorations were on a table in the dining room where Resident 26 was eating his lunch meal not in accordance with the Infection Control (IC) practices. This failure had the potential to place Resident 26 at risk of infection due to cross-contamination. 6. Resident 26's urine catheter (a hollow tube inserted into the bladder to drain or collect urine into a bag) bag was observed on his lap while he was eating his lunch meal not in accordance with the facilities IC practices and per the facility's P&P titled, Catheter Care, Urinary. This failure had the potential to place Resident 26 at risk of infection due to cross-contamination. Findings: 1. During a concurrent observation and interview on [DATE] at 2:46 p.m., in the dining room, with Dietary [NAME] (DC) 2. Three lunch bags and one drink canister was observed on top of the ice machine. DC 2 stated staff lunch bags and or drink canisters should not be stored on top of the dining room ice machine. DC 2 stated DC 1 and Dietary Services Supervisor were responsible for cleaning the ice machine. DC 2 stated staff lunch bags could have fallen into the ice machine and caused cross contamination. DC 2 stated staff lunch bags and or drink canister were not sanitary. During an interview on [DATE] at 2:18 p.m., with the Registered Dietitian/Interim Dietary Manager (IDM/RD), the IDM/ RD stated personal items such as lunch bags should not be stored on top of the dining room ice machine. The IDM/RD stated staff lunch bags could have bacteria on them and could have fallen into the ice machine. The IDM/RD stated there was a potential risk for cross-contamination to residents, staff and visitors that could have caused then to got sick. The IDM/RD stated staff should have stored lunch bags and canisters in the employee designated locker, refrigerators and not on top of the dining room ice machine. The IDM/RD stated staff did not followed the policy and procedure for Cafeteria Meals. During a concurrent observation and interview on [DATE] at 3:10 p.m., in the dining room with DC 3 , a black lunch bag was observed on top of the ice machine above a posted sign posted stating, Do not place any items on top of the ice machine! DC 3 stated staff lunch bags should not be stored on top of the ice machine. DC 3 stated the ices could have been cross contaminated from staff lunch bags and could have gotten residents infected and sick. During an interview on [DATE] at 6:02 p.m., with the Infection Prevention (IP), the IP stated staff lunch bags were dirty and had bacteria on them. The IP stated staff's dirty lunch bags could have fallen into the ice and caused contamination. The IP stated staff, visitors and resident were at risk for infection from drinking contaminated ice from the ice machine. The IP stated the dietary kitchen staff were responsible for making sure the ice machine was cleaned. During an interview on [DATE] at 6:10 p.m., with the Director of Staff Development (DSD), the DSD stated there should not have been any items on top of the ice machine. The DSD stated the staff should have stored their lunch bags and cups in the staff refrigerator. The DSD stated storing lunch bags and cups in the staff refrigerator could prevent cross-contamination and getting resident sick. The DSD stated an in-service should have been provided to the staff. During a review of the facility's policy and procedure (P&P) titled, Cafeteria Meals, dated revised ,d+[DATE], the P&P indicated, .6. Employees need to utilize their lunch bag in the locker room and refrigerator . 2. During a concurrent observation and interview on [DATE] at 9:44 a.m., with LVN 1 in Resident 2's room, Resident 2 was observed dressed, and sleeping in bed. Resident 2's bottle of feeding tube nutrition was observed handing on an infusion pole undated. LVN 1 stated the feeding tube nutrition bottle should have had a date and time labeled indicating when the bottle was hung and when the feeding started. LVN 1 stated having a date and time on the feeding bottle would let nurses know when the bottle was changed. LVN 1 stated if the bottle was not changed there would be a risk of the feeding to go bad. LVN 1 stated giving Resident 2 a feeding that had gone bad would put Resident 2 at risk of getting sick. During a review of resident 2's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], Resident 2's AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), aphasia (a disorder that makes it difficult to speak), dysphasia (difficulty swallowing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis(muscle weakness or partial paralysis on one side of the body) following cerebral infarction, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS section C indicated, Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of ,d+[DATE] ) score of four (a score of ,d+[DATE] suggests severe cognitive impairment, ,d+[DATE] suggests moderately impaired, ,d+[DATE] suggests cognitively intact), which suggested Resident 2 was severely impaired. During an interview on [DATE] at 11:26 a.m. with the Registered Dietician (RD), the RD stated she did not know the requirement about dating the feeding tube bottle. The RD stated she would need to check the facility's policy on dating the feeding tube bottle of nutrition when hung. During a review of the facility in-service document titled Feeding Pump, dated [DATE], the document indicated, . ask your nutritionist how much formula to add to the feeding bag at a time. Formula can spoil if it hangs in the bag too long . throw the bag out if it has been used for 24 hours . if you are not going to restart the feeding right away, store the feeding set in an airtight container in the refrigerator . 3. During an observation on [DATE] at 3:02 p.m. in Resident 2's room, Resident 2 was observed laying down in bed with her eyes open. A notice that Resident 2 was on EBP was observed on the wall above Resident 2's bed. LVN 2 was observed checking Resident 2's gastric tube (G-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement by infusing 10 ml (a measure of volume in the metric system) of air into Resident 2's G-tube and listening with a stethoscope (a medical instrument for detecting sounds produced in the body that are conveyed to the ears of the listener through rubber tubing connected with a piece placed upon the area to be examined). LVN 2 placed the supplies to check Resident 2's G-tube placement and begin Resident 2's feeding on a paper towel that was placed on the windowsill next to Resident 2. Resident 2's feeding pump was observed to have a dried, caked on substance on the infusion pump where the feeding tube line was inserted. LVN 2 was observed to leave the room to get assistance with programming the infusion pump. LVN 2 was observed to not perform hand hygiene after removing her gloves and leaving Resident 2's room. LVN 2 did not don a gown prior to performing the procedure on Resident 2. During an interview on [DATE] at 3:23 p.m. with the Clinical Nurse Supervisor (CNS), the CNS stated EBP was for residents with wounds, G-tubes, and Foley catheters (a common type of indwelling catheter inserted into the bladder, used to drain urine). The CNS stated it was important for staff to wear a gown and do handwashing when performing procedures on residents on EBP to prevent infection. The CNS stated staff needed to wash their hands before doing resident care. The CNS stated Resident 2's infusion pump should have been cleaned each time a new bag was hung. The CNS stated a dirty pump could cause Resident 2 to get an infection. During an interview on [DATE] at 5:02 p.m. with the Infection Preventionist (IP), the IP stated staff needed to perform hand washing or hand hygiene with alcohol prior to performing procedures. The IP stated if the hands were soiled, or if staff touched blood, staff would need to wash their hands. The IP stated staff had to do hand hygiene prior to donning gloves. The IP stated hand hygiene was important because hands were full of germs. The IP stated if staff put gloves on without hand hygiene, germs were still spreadable and there would be the possibility for cross-contamination. The IP stated for EBP, her expectations were for staff to don gloves and a gown for high contact activities such as, hygiene, bathing, showering, changing linens, changing briefs, toilet help, g-tube access, dialysis port dressing changes, wound care, catheter care, and care of all assistive devices. The IP stated it was not acceptable to put the feeding tube (FT) supplies on a paper towel on the windowsill. The IP stated the windowsill was not clean. The IP stated placing the tube feeding supplies on the windowsill created a risk for the resident to get an infection. The IP stated if nurses saw the infusion pump was dirty when setting up an infusion, they should clean the pump. During an interview on [DATE] at 11:46 a.m. with the Director of Staff Development (DSD), the DSD stated for residents on EBP, staff needed to use PPE (gown and gloves) when providing direct care to the resident. During a review of Resident 2's Care Plan (CP), undated, the CP indicated, . (Resident 2) is on ENHANCED BARRIER PRECAUTIONS R/T (Related to) INVASIVE DEVICE . date initiated: [DATE] . donning and doffing of PPE before entering and exiting by Health care personnel . educate staff and patient about appropriately disinfect and cleaning of equipment's and environment . perform hand hygiene before and after contact with resident . During a review of the facility document titled, Medication Administration Competency Checklist for Enteral Tube, dated [DATE], signed by LVN 2, indicated, . (step) 1. Washed hands . placed resident in proper position . wash hands per policy . verify tube placement . attach tube to continuous feeding . wash hands per policy . document . During a review of the facility policy and procedure (P&P), titled, Administering Medications through an Enteral Tube, dated ,d+[DATE], indicated, . steps in the procedure . wash your hands . arrange supplies in the medication room or move the medication cart outside the resident's room . place medications on the bedside table or tray . discard all disposable items into designated containers . wash your hands . 4. During an observation on [DATE] at 11:27 a.m. in Resident 27's room, LVN 1 was observed gathering supplies to perform a blood sugar check on Resident 27. LVN 1 placed an unopened bag of cotton balls into a basket that contained supplies for the procedure. LVN 1 did not wash her hands or perform hand hygiene prior to donning gloves. LVN 1 opened the bag of cotton balls at Resident 27's bedside and performed a blood sugar check on Resident 27 by poking his finger and placing a drop of blood on the glucometer strip. LVN 1 discarded the supplies, changed her gloves, and wiped the glucometer with a Sani wipe (a wipe containing a powerful germ-killing formula), but did not wait the two-minute dwell time (the time specified by a manufacturer that a disinfectant must be left on a surface to ensure disinfection) and placed it back into the basket of supplies containing the bag of cotton balls. LVN 1 removed her gloves, performed hand hygiene, and placed the blood sugar meter back into Resident 27's blood sugar meter bag. LVN 1 then placed the glucometer bag and bag of cotton balls back into the medication cart. LVN 1 did not wrap the glucometer with the Sani wipe for two minutes and let it air dry per policy prior to returning the glucometer to the bag. LVN 1 did not wipe the cotton ball bag with Sani wipes and let it sit for two minutes prior to returning it to the medication cart. During a review of Resident 27's AR, dated [DATE], the AR indicated, Resident 27 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, ( a condition where the blood sugar levels in the body are too high) and fracture of unspecified lumbar vertebra (break in the bone of the lower part of the spine). During a review of Resident 27's MDS, dated [DATE], the MDS section C indicated Resident 27 had a BIMS score of 15, which indicated Resident 27 was cognitively intact. During a concurrent observation and interview on [DATE] at 11:40 a.m. in Resident 35's room, LVN 1 was observed checking Resident 35's blood sugar. LVN 1 was observed cleaning the glucometer and leaving it in the Sani wipe for the dwell time of two minutes. LVN 1 proceeded to place the clean glucometer back into the supply basket. LVN 1 did not clean the basket prior to placing the glucometer back into the used supply basket. LVN 1 stated she did not wipe the basket, only the glucometer. During a review of Resident 35's AR, dated [DATE], the AR indicated Resident 35 was admitted on [DATE] with diagnoses of type 1 diabetes mellitus with hyperglycemia (elevated sugar in the blood) and psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) substance abuse. During a review of Resident 35's MDS, dated [DATE], the MDS section C indicated Resident 35 had a BIMS score of 15, which indicated Resident 35 was cognitively intact. During an interview on [DATE] at 5:02 p.m. with the IP, the IP stated staff should do hand washing or hand hygiene with alcohol prior to performing procedures. The IP stated if the hands were soiled or touched blood, staff would need wash their hands. The IP stated staff had to do hand hygiene prior to donning gloves. The IP Stated it was important to do hand hygiene because hands are full of germs. The IP stated if staff put gloves on without performing hand hygiene, germs were still spreadable and there was the possibility for cross-contamination. The IP stated it was not acceptable to put supplies that were at the resident's bed side back into the medication cart. The IP stated the supplies could have contaminated items in the cart. The IP stated her expectation for the glucometer use was to wash hands, use manufacturer instructions for Sani wipes, make a burrito with the glucometer in the Sani wipe, let sit for two minutes, then air dry. The IP stated there was a risk for infection if the hand hygiene and sanitation of supplies and reusable equipment procedures were not being followed. The IP stated she felt she would need to do monitoring more often. During an interview on [DATE] at 4:14 p.m. with the Director of Nursing (DON), the DON stated when staff performed blood glucose checks, staff should have washed their hands, provided resident privacy, identified the resident, explained the procedure, donned gloves, and performed the procedure. The DON stated staff should had performed hand hygiene, cleaned the meter, taken off their gloves, washed hands, wiped the meter, wrapped the glucometer, and left the glucometer wrapped inside the wipe (followed the time on manufacturer's instructions), then air dried the meter. The DON stated there was a risk of cross-contamination and spreading infection if the supplies were not properly sanitized after use. The DON stated staff should have taken what was needed out of the cotton bag to the resident's bed side. The DON stated staff should have cleaned the cotton bag before putting it back in the medication cart, after completing the same dwell time after cleaning. The DON stated taking supplies from the resident's bed side and putting them back in the medicine cart could have spread infections to other residents from cross-contamination. The DON stated her expectation was nurses should have been following the standards of practice and policies and procedures for performing glucose checks and cleaning the glucometer. The DON stated the IP observed nurses for competency. The DON stated the IP and DON were responsible for monitoring the nurses. The DON stated nurses were not monitored every day. During a review of the facility's (P&P) titled, Obtaining a Fingerstick Glucose Level, dated 2001, indicated, . equipment . disinfected blood glucose meter (glucometer) . ,d+[DATE] cotton balls . always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . wear clean gloves . discard disposable supplies in the designated containers . clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice . remove gloves . wash hands . During a review of the facility document titled, To clean and disinfect the Meter, undated, the document indicated, . wash hands thoroughly with soap and water. Wear a clean pair of gloves . with ONLY PDI Super Sani Cloth Wipes . rub the entire outside of the meter using 3 circular wiping motions . to disinfect: Using fresh wipes, make sure that all outside surfaces of the meter remain wet for 2 minutes . 5. During a concurrent observation and interview on [DATE] at 11:54 a.m. with the Certified Nursing Assistant/Restorative Nurse Assistant (CNA/RNA), in the Activities Room Resident 26 was observed dressed sitting in a geriatric chair (Geri-chair - a large, padded chair that is designed to help seniors with limited mobility) at a table eating his meal with dirty Halloween decorations on the table next to his food. The CNA/RNA stated the Halloween decorations should not have been on the table. The CNA/RNA stated the tables should have been cleaned after every activity. The CNA/RNA stated Resident 26 had a change in diet, so she was watching him. During a review of Resident 26's AR dated, [DATE], the AR indicated, Resident 26 was admitted on [DATE] with diagnoses of fracture of lumbar vertebra, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and dysphasia (difficulty swallowing). During a review of Resident 26's MDS, dated [DATE], the MDS section C indicated Resident 26 had a BIMS score of 12, which indicated Resident 26 was moderately impaired. During an interview on [DATE] at 12:15 p.m. with the IP, the IP stated the dining room tables should have been free of any non-meal items. The IP stated the tables should have been wiped down, cleaned, and disinfected after each use. The IP stated whoever was in charge of dining, and Housekeeping should have wiped down the tables. The IP stated all staff training included the frequency of cleaning before and after dining. The IP stated dirty tables and dirty items on the dining table could have caused cross-contamination of the resident's food and placed a risk of infection for the residents. The IP stated residents could get sick. During a review of the facility's job duty document titled, Janitor, dated ,d+[DATE], the document indicated, . the job of Janitor is done for the purpose/s of maintaining an attractive, sanitary and safe facility for residents . 6. During a concurrent observation and interview on [DATE] at 11:54 p.m. with the CNA/RNA in the Activities Room, Resident 26 was observed eating his lunch meal with his urine catheter bag placed on his lap. The CNA/RNA stated Resident 26's catheter bag should not have been on his lap. The CNA/RNA stated the urinary catheter bag should have been hanging below Resident 26's waist, on the back of his chair. The CNA/RNA stated Resident 26 had just come back from an appointment and she wanted to hurry and get him his meal, as he had another appointment to go to. During an interview on [DATE] at 12:15 p.m. with the IP, the IP stated staff had foley catheter training. The IP stated the catheter should have been free of any kinks and obstructions, off floor and hung below Resident 26's waist to reduce the risk of infection. The IP stated urine could go back up to the bladder if the catheter was not hung below the waist which would increase the risk of infection. The IP stated having the catheter bag on Resident 26's lap was not acceptable. During a review of the facility's P&P titled, Catheter Care, Urinary, dated ,d+[DATE], indicated, . the purpose of this procedure is to prevent infection of the resident's urinary tract . the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . 49949 51345

Based on observation, interview, and record review, the facility failed to ensure the kitchen food was stored and maintained in a safe and sanitary manner when: 1. The facility failed to store food in Resident 105's room in a safe manner in accordance with the facility's policy and procedure (P&P) Foods Brought by Family/Visitors. 2. An open jar of garlic was stored in the refrigerator without an open labeled date in accordance with the facility's P&P Sanitation and Infection Control. 3. A case of bran muffins was found in the refrigerator missing half of the labeled date identifying the placed in the freezer date per the facility's P&P Sanitation and Infection Control. 4. Two dented tomato sauce cans were stored in the pantry for use and not set aside in a designated area for return to the vendor or disposed of properly per the facility's P&P Sanitation and Infection Control. These failures had the potential risk of cross contamination (process by which bacteria is transferred from one object or substance to another, with harmful effect) and exposure of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) from improperly stored and labeled food for 52 of 53 residents. Findings: 1. During a concurrent observation and interview on [DATE] at 9:05 a.m., in Resident 105's room with Resident 105 and Registered Nurse (RN) 1, Resident 105 had two lidded bowls, of perishable (likely to decay, spoil, or become unsafe to eat if not kept refrigerated or frozen) food on her bedside table. Resident 105 stated the food had been brought in by family members the day before. Resident 105 stated the food was hot when family brought it in to the facility, but it was cold now. RN 1 stated the food in the bowls were stew with liquid and a bread product called [NAME] (South Asian flatbread made with whole wheat flour). RN 1 stated the food containers were not labeled or dated. During a review of Resident 105's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 105 was admitted to the facility on [DATE] with a diagnosis of Pulmonary Mycobacterial Infection (a lung infection caused by a type of bacteria called mycobacteria, which are naturally found in soil and water, and can be breathed in). During a review of Resident 105's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function), dated [DATE], the MDS indicated Resident 105's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 13 out of 15 (a score of ,d+[DATE] indicates cognitively intact, ,d+[DATE] indicates moderately impaired, and ,d+[DATE] indicates severe impairment). The BIMS assessment indicated Resident 105 was cognitively intact. During an interview on [DATE] at 5:38 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the expectation for perishable foods at the resident's bedside would be to make sure the foods were safe for the resident to eat. LVN 3 stated food that was not dry food should have been wasted after the family leaves the facility. During an interview on [DATE] at 9:27 a.m., with the Interim Dietary Manager/Registered Dietician (IDM/RD), the IDM/RD stated the food that was on Resident 105's bedside was perishable and needed to be consumed immediately by the resident or refrigerated. The IDM/RD stated that because the food was not labeled or stored appropriately, we can't be sure it's safe. The IDM/RD stated placing the dated labels on the food containers were important because it would prevent time and temperature abuse and potential food-borne illness (food poisoning). The IDM/RD stated if Resident 105 ate the food on [DATE] that she could have acquired food poisoning and potentially been sent to the hospital. The IDM/RD stated symptoms of food poisoning would be nausea, vomiting, diarrhea, weight loss and dehydration (occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions). The IDM/RD stated staff did not follow the facility policy and procedure (P&P) Foods Brought by Family/Visitors. During an interview on [DATE] at 11:15 a.m., with the Director of Nursing (DON), the DON stated the expectation for Resident 105's family would have been to take the food that was not eaten at the facility home when they were done visiting with the resident that day. The DON stated they do not store perishable food for the residents. The DON stated staff can't ensure that the food at Resident 105's bedside was safe to eat. The DON stated if Resident 105 had consumed the non-labeled food, that she could have gotten sick. The DON stated staff did not follow the P&P Foods Brought by Family/Visitors. During an interview on [DATE] at 3:28 p.m., with the Infection Preventionist (IP), the IP stated the food at the resident bedside should be considered a meal tray and taken away after the resident had eaten what she wanted. The IP stated the facility educated the family and told them whatever food was left, it needed to be taken back home with them that same day. The IP stated if the food was consumed, the resident could have been hospitalized due to a food-borne illness because the facility did not know if it were safe to eat or not. The IP stated the facility did not follow the P&P Foods Brought by Family/Visitors. During a review of facility's P&P titled, Foods Brought by Family/Visitors, dated [DATE], the P&P indicated, Policy Statement: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a home like environment with the nutritional and safety needs of residents. Policy Interpretation and Implementation: . 4. Family/visitors are asked to prepare and transport food using safe food handling practices, including a. Safe cooling and reheating processes; b. Holding temperatures; c. Preventing cross contamination with raw or undercooked foods; . 7. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility prepared food . b. Containers will be labeled with the resident's name, the item and the use by date . c. No foods requiring refrigeration will be allowed except when can be consumed immediately . 10. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than two hours will be discarded . 49949 2. During a concurrent observation and interview on [DATE] at 7:48 p.m., in the kitchen an open jar of garlic had a received labeled date for [DATE] and no open labeled date. Dietary [NAME] (DC) 1 stated the open garlic jar should have an open labeled date along with the received labeled date. DC 1 stated it was important to have an open labeled date on the garlic jar to know the shelf- life (length of time for which an item remains usable, fit for consumption). DC 1 stated kitchen staff does not keep food items longer than two weeks. DC 1 stated the open garlic jar should have been thrown away since it did not have an open labeled date. DC 1 stated kitchen staff does not want to served resident expired food. DC 1 stated serving residents expired food could have caused foodborne illness. DC 1 stated kitchen staff should have labeled the jar when the jar was opened. During an interview on [DATE] at 2:18 p.m., with the Interim Dietary Manager/ Registered Dietitian (IDM/RD), the IDM/RD stated the jar of garlic should have had an opened labeled date The IDM/RD stated an opened labeled date was needed to ensure the jar of garlic was not used beyond the expiration date. The IDM/RD stated using food items beyond the expiration date was putting resident at risk for foodborne illness and cross-contamination. The IDM/RD stated the staff did not follow the policy and procedure for labeling. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2023, the P&P indicated, .All the perishable food items purchased by the department of food and dining services will be stored properly .10. Leftover food or unused portions of packaged foods should be covered, labeled, and dated to assure they will be used first . 3. During an observation on [DATE] at 7:50 a.m,. in the kitchen with DC 1, 24 bran muffins were in the refrigerator in a sealed box missing half of the labeled date. DC 1 stated the box of bran muffins were brought out of the freezer this morning and were placed in the refrigerator. DC 1 stated she labeled the bran muffins with the date it was placed in the freezer. DC 1 stated she was not able to see the labeled date on the bran muffin and it was missing half of the labeled date. DC 1 stated the labeled date should have been on the bran muffin. DC 1 stated it was important to have the labeled date on the bran muffin to ensured residents were not served expired items. DC 1 stated, serving expired bran muffin to residents could cause residents to be sick. DC 1 stated the bran muffins could have been old and should have been thrown away. DC 1 stated kitchen staff should have labeled the bran muffin with the date it was placed in the freezer. During an interview on [DATE] at 2:18 p.m., with the IDM/RD, the IDM/RD stated the policy for labeling was not followed. The IDM/RD stated the bran muffins should have been thrown away when kitchen staff noticed the label date was missing. The IDM/RD stated a missing label date could have cause confusion for the kitchen staff. The IDM/RD stated labeling items was important to ensured bran muffins and other food items were opened and received and safe to consumed. The IDM/RD stated kitchen staff should have clear labeling practices. The IDM/RD stated not following the labeling practice was putting residents at risk for food borne illness. The IDM/RD stated it was the responsibility of the morning cooks or dietary manager to inspect bran muffins before serving it for breakfast. During a review of the facility's menu titled, Fall menus, dated [DATE], the Fall menu indicated, .Bran Muffin cupcake size 2 oz . During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control. dated 2018, the P&P indicated, .6. Frozen food should be labeled with the date it was placed in the freezer . 4. During a concurrent observation and interview on [DATE] at 8:28 a.m. in the pantry with DC 1 two dented tomato sauce cans were stored on the shelf ready for use. DC 1 stated she checked the storage pantry every Mondays and Thursdays for dented cans and or expired dated items. DC 1 stated she was not sure why the dented cans were still stored on the shelf for use. DC 1 stated the dented cans should have been transferred to an area to be returned to the supplier and not on the shelf for use. DC 1 stated dented cans were not good to use and had bacteria. DC 1 stated bacteria from the dented cans could have gotten residents sick. During an interview at [DATE] at 2:18 p.m., with the IDM/RD, the IDM/RD stated dented cans should have been moved to the designated area and not on the shelf for use. The IDM/RD stated dented cans could have botulism (a rare but serious toxin produced by bactera that disease that attacks the body when consumed) and could have gotten residents sick if served. The IDM/RD stated the dented cans should have been inspected for dents on the dated received. The IDM/RD stated kitchen staff did not follow the facilities policy. During a review of the facility's policy and procedure (P&P) tilted, Sanitation and Infection Control, dated 2018, Subject: Canned and Dry Goods Storage: Policy: All the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly .10. Canned food items should be routinely inspected for damages such as dented, bulging, or leaking cans. These items should be set aside in a designated area for return to the vendor or disposed of properly .

Based on observation, interview, and record review, the facility failed to keep the environment free from insects in accordance with the facility's policy and procedure (P&P) Pest Control when flies were observed in resident rooms and in the common areas of the dinning room and activities room and had the potential for rodents to enter from two holes on the laundry room wall. These failures led to insects being observed in the facility and had the potential to allow rodents to enter the facility from the outside, posing a risk of infection to residents due to cross-contamination. Findings: 1. During a concurrent observation and interview on 11/5/24 at 10:45 a.m., with Resident 40 in her room, Resident 40 was in her bed, had a fly swatter in her hand with three flies were flying around her. Resident 40 stated she hated the flies, and they were always in her room. Resident 40 stated she was unable to move in bed, or walk, because of a tumor (an abnormal growth of tissue in the body that occurs when cells divide and grow more than they should, or don't die when they should) on the inside of her right lower leg wrapped with gauze) by her ankle. Resident 40 stated staff gave her the fly swatter to keep the flies away from the tumor. During an observation on 11/5/24 at 12:15 p.m., in the Resident Dining Room while residents were eating lunch, there were two flies flying around and an electric LED (light emitting diode [type of lighting that converts electricity to light] that attracts multiple species of flying insects while trapping them inside) fly trap on the wall that was inoperable (not working) due to not being plugged in to the wall electrical outlet (power plug). During a review of Resident 40's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 40 was admitted to the facility on [DATE] with a diagnosis which included Mass/Lump Right Lower Limb (leg) and Morbid Obesity (a person's weight that exceeds an individual's desirable weight by more than 100 pounds). During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function), dated 9/21/24, the MDS indicated Resident 40's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 40 was cognitively intact. During an interview on 11/6/24 at 4:45 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 40 had asked her to kill flies in her room before. CNA 5 stated she had seen flies in that room and she gets the flies for her. During an interview on 11/7/24 at 6:10 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the expectation of the facility is to be free from flies. LVN 3 stated flies could put the residents at risk of infections. LVN 3 stated Resident 40 was vulnerable because she was very weak and could not move herself in bed. During an interview on 11/8/24 at 9:25 a.m., with CNA 6, CNA 6 stated she had seen flies in Resident 40's room before and they are a constant problem. CNA 6 stated in the past, she had housekeeping clean Resident 40's room because of flies, but after the cleaning she still saw flies and stated, I don't know why. During an interview on 11/8/24 at 11:16 a.m., with the Director of Nursing (DON), the DON stated the expectation was for the facility to be free from flies and insects. The DON stated flies in the facility could spread infections. The DON stated flies in the facility meant the pest control program they had in place was ineffective. During an interview on 11/8/24 at 2:31 p.m., with the Facility Administrator (ADM), the ADM stated flies in the facility was a constant problem. The ADM stated the flies were a legitimate concern for the facility and they could not keep flies out. The ADM stated cross-contamination (the unintentional transfer of harmful bacteria or other microorganisms [a living thing that is so small that it can only be seen with a microscope] from one object to another) could have occurred. During an interview on 11/8/24 at 3:20 p.m., with the Infection Preventionist (IP), the IP stated flies in Resident 40's room and in the lunchroom were an issue. The IP stated flies carry germs and they can cross-contaminate things. The IP stated residents at the facility were vulnerable. The IP stated the expectation for the facility is to be free from flies and for the fly traps to work all the time. The IP stated the facility needed a better plan to keep the flies from entering inside the facility. The IP stated flies in the facility increase resident's risk for infections. The IP stated the pest control program that was put in place was not effective. During an interview on 11/8/24 at 3:40 p.m., with the Maintenance Supervisor (MS), the MS stated there were a lot of flies in the facility on 11/5/24. The MS stated he called a pest control company to come in and they replaced nine fly traps that were not working in the facility. The MS stated the pest control they had in place was ineffective and the facility needed to have the pest control service company come in more often. During a review of the Facility's Map dated 11/8/24, the map indicated, .highlighted locations throughout the facility where 9 LED fly light trap bulbs (light that attracts flies, and they get trapped in the wall unit) had been replaced. During a review of facility's policy and procedure (P&P) titled, Sanitation and Infection Control- Subject: Pest Control, dated 2018, the P&P indicated, Policy: the facility will ensure a pest control prevention program provides . inspection, treatment and prevention of . insect infestation . pest control is designed to maintain a sanitary environment which prevents contamination transmission or spread of disease by insects . Procedures: . 11. It is recommended that a pest control company be retained on a monthly basis, or more often if necessary . 49949 2. During a review of Resident 23's Admission Record, (AR- a document containing resident demographic information and medical diagnosis) dated 11/8/24, the AR indicated, Resident 23 was admitted to the facility on [DATE]. Resident 23's diagnosis included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anemia (a condition where the body does not have enough healthy red blood cells), chronic kidney disease (CKD- a long-term condition that occurs when the kidneys are damaged and can't filter blood properly), bacteremia (the presence of bacteria in your blood) and pain. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function), dated 10/11/24, the MDS indicated Resident 23's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 12 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 23 was moderately impaired. During a concurrent observation and interview on 11/5/24 9:25 a.m., in Resident 23's room, two flies were on a curtain and a fly swatter was on the top of the nightstand. Resident 23 was asked why he had a fly swatter on the top of the nightstand and Resident 23 stated it was to kill the flies. Resident 23 stated he did not like the flies in the room and they were there often. During an interview with 11/7/24 at 4:30 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she has been employed at the facility for 11 months. CNA 4 stated during the summer the flies were more noticeable. CNA 4 stated it was not ok for flies to be in the room and flies were dirty. CNA 4 stated it was hard to keep flies out of the rooms. CNA 4 stated she has seen fly swatters in Resident 23's room multiple times. CNA 4 stated she would kill flies in Resident 23's room when she saw one. CNA 4 stated residents had complained about flies in the building. CNA 4 stated there were fly traps and fans to keep the flies out. CNA 4 stated flies were dirty, and caused infections and cross-contamination. During an interview on 11/8/24 at 11:16 a.m., with the Director of Nursing (DON), the DON stated the expectation was for the facility to be free of flies and insects. The DON stated flies in the facility could spread infections. The DON stated flies in the facility meant the pest control program they had in place was ineffective. During an interview on 11/8/24 at 2:31 p.m., with the Facility Administrator (ADM), the ADM stated flies in the facility were a constant problem. The ADM stated the flies were a legitimate concern for the facility and they could not keep the flies out. The ADM stated cross-contamination (the unintentional transfer of harmful bacteria or other microorganisms [a living thing that is so small that it can only be seen with a microscope] from one object to another) could have occurred. During an interview on 11/8/24 at 3:20 p.m., with the Infection Preventionist (IP), the IP stated flies in Resident 40's room and in the lunchroom during meals were an issue. The IP stated flies carried germs and they can cross-contaminate things. The IP stated residents at the facility were vulnerable. The IP stated the expectation for the facility was to be free from flies and for the fly traps to work at all times. The IP stated the facility needed a better plan to keep the flies from entering inside the facility. The IP stated flies in the facility increase resident's risk for infections. The IP stated the pest control program that was in place was not effective. During an interview on 11/8/24 at 3:40 p.m., with the Maintenance Supervisor (MS), the MS stated there were a lot of flies in the facility on 11/5/24. The MS stated he called a pest control company and they replaced nine fly traps that were not working in the facility. The MS stated the pest control that was currently in place was ineffective and the facility needed to have the pest control company come service more often. During a review of the Facility's Map dated 11/8/24, the map indicated, .highlighted locations throughout the facility where 9 LED fly light trap bulbs (light that attracts flies, and they get trapped in the wall unit) had been replaced. During a review of facility's policy and procedure (P&P) titled, Sanitation and Infection Control- Subject: Pest Control, dated 2018, the P&P indicated, Policy: the facility will ensure a pest control prevention program provides . inspection, treatment and prevention of . insect infestation . pest control is designed to maintain a sanitary environment which prevents contamination transmission or spread of disease by insects . Procedures: . 11. It is recommended that a pest control company be retained on a monthly basis, or more often if necessary . 48739 3. During a concurrent observation and interview on 11/5/24 at 11:54 a.m. with the CNA/RNA, in the Activities Room, flies were observed landing on Residents 15, 26, and 251's food and landing on the residents. The CNA/RNA stated residents eating in the Activities Room were eating there for restorative dining (a program that focuses on establishing a specific dining space for residents who require greater levels of supervision and assist with eating). The CNA/RNA stated she had a fly swatter to keep the flies off the residents. The CNA/RNA was observed swishing the fly swatter over Resident 15, 26, and 251's food while the residents were eating. The CNA/RNA stated flies should not have been in the room where Residents 15, 26, and 251 were eating. The CNA/RNA stated having flies in the room was not comfortable for the residents. The CNA/RNA stated flies could get germs on the resident's food and the residents could get sick. During a review of Resident 15's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information),), dated 11/8/24, the AR indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses of fracture of left femur (a break in the bone of the thigh) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 10/18/24, the MDS section C indicated Resident 15 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 15 was severely cognitively impaired. During a review of Resident 26's AR dated, 11/8/24, the AR indicated Resident 26 was admitted on [DATE] with diagnoses of fracture of lumbar vertebra, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and dysphagia (difficulty swallowing). During a review of Resident 26's MDS, dated [DATE], the MDS section C indicated Resident 26 had a BIMS score of 12, which indicated Resident 26 was moderately impaired. During a review of Resident 251's AR, dated 11/8/24, the AR indicated Resident 251 was admitted on [DATE] with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and dysphagia (difficulty swallowing). During a review of Resident 251's MDS, dated [DATE], the MDS section C indicated Resident 251 had a BIMS score of 3, which indicated Resident 251 was severely cognitively impaired. During a concurrent observation and interview on 11/5/24 at 12:12 p.m. with the Maintenance Assistant (MAINTA) in the Activities room, the MAINTA was observed checking the bug light on the wall The MAINTA stated the bug light was not on. During an interview on 11/07/24 at 5:02 p.m. with the Infection Preventionist (IP), the IP stated the maintenance department had a pest control company that performed pest control service on a regular schedule. The IP stated if anyone informed her or if she saw pests, she would inform the maintenance department. The IP stated flies were a problem for infection control. The IP stated flies put residents at risk for infection if the flies landed on the resident's food. The IP stated if the resident had a wound, the flies could land on the wound then land on other clean areas, exposing those areas to germs. The IP stated if flies landed on a resident's wound, they could lay eggs in the wound. The IP stated there should not be flies in the areas where residents were eating. During a review of the pest control company's documents titled, Service Report, dated 10/14/24, 9/30/24, and 8/22/24, the documents indicated, . fly light not working . recommend keeping doors closed when not in use to control flying activity entering facility . one fly light bulb that needs to be replaced . fly light not working . several fly lights were unplugged . During an interview on 11/8/24 at 3:29 p.m. with the Maintenance Supervisor (MS), the MS stated the fly bulbs had been out on the last three months of the pest control service reports. The MS stated the pest control program was ineffective. The MS stated the pest control company needed to come out to the facility more often to provide pest control service. During a review of the facility job description document titled, . Building & Maintenance Supervisor, dated 4/2013, the document indicated, . responsible for overall management of . maintenance . personnel to ensure a clean, safe and orderly living environment for residents . oversees . pest control . During a review of the facility's P&P titled, Pest Control, dated 5/2008, indicated, the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . maintenance services assist, when appropriate and necessary, in providing pest control services . 4. During a concurrent observation and interview on 11/7/24 at 10:56 a.m. with the Laundry Staff (LS) in the laundry room, two holes were observed in the lower back wall, open to the outside. The LS stated that the holes in the wall were not good. The LS added that if rodents or pests got into clean clothes, they could cause an infection risk to residents. During an interview on 11/7/24 at 5:02 p.m. with the Infection Preventionist (IP), the IP stated that maintenance had a regular company scheduled for pest control. The IP stated that if anyone informed her or if she saw anything related to pests, she would notify maintenance. The IP also stated that holes opening to the outside in the laundry room posed a risk for cross-contamination and infection to residents if rodents entered the room. During an interview on 11/8/24 at 3:29 p.m. with the Maintenance Supervisor (MS), the MS stated that the holes in the laundry room walls were discovered earlier that week when the laundry area was cleaned. The MS stated that there was not a work order for the repair of the holes. The MS stated that there was a risk associated with the holes opening to the outside because rodents could enter through them. The MS stated that rodents could cause cross-contamination in the laundry and pose an infection risk to residents. The MS stated that he had started the yearly inspection on 10/31/24. The MS stated that the board, which incompletely covered one of the holes, had been placed there approximately three to four months ago as a temporary fix. The MS stated that his expectation for the laundry area was for the holes to be properly covered to prevent anything from entering from the outside. During a review of the facility's policy and procedure (P&P) titled Maintenance Service, dated 12/2009, indicated that, . the maintenance department is responsible for maintaining the buildings, keeping the building in good repair and free from hazards, and providing routinely scheduled maintenance service to all areas. The maintenance director is responsible for maintaining the following records/reports: work order requests and maintenance schedules .

Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperatures in rooms occupied by 27 of 31 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 24, 26, 27, 28, 29 and 30, when the facility's HVAC (Heating,Ventilation and Air Conditioning - a system, machine, and technology that provides heating and cooling to residential and commercial buildings) was nonfunctional from 11/24/2020 to 12/5/2020 which caused the resident room's ambient (actual air temperature of an environment) temperatures to drop to 50.8- 67.6 degrees Fahrenheit (F) which is below the normal temperature range of 71 degrees to 81 degrees F. The facility's failures to promptly repair the HVAC system and failure to monitor the ambient room temperatures may have led to Residents 9, 14, 15, 24 and 29's unplanned hospitalization s on 12/2/2020, 12/4/2020, and 12/6/2020 due to fever, shortness of breath (SOB), cough, wheezing, and low oxygen (O2) saturation (measures the amount of hemoglobin {protein inside red blood cells that carries oxygen from the lungs to tissues and organs in the body}) and placed the health and safety of all residents at high risk for serious harm from respiratory illnesses such as cough, cold, flu, exacerbation of asthma, and progression of [MEDICAL CONDITION] (COVID-19 ([DIAGNOSES REDACTED]-CoV -2) - a contagious serious respiratory infection transmitted from person to person), pneumonia or [MEDICAL CONDITION]. Because of the serious potential harm and probable actual harm of suffering cold environmental temperatures measured below 71 degrees F for extended periods of time, risk of hypothermia (Hypothermia is defined by the National Institute on Aging, as when the body temperature drops below 96 degrees. Symptoms include slurred speech, sluggishness, confusion, dizziness, shallow breathing, unusual behavior, and a slow, irregular heartbeat), respiratory illnesses, hospitalization and/or death due to non-functioning heating system, an Immediate Jeopardy (IJ) situation was called under Code of Federal Regulations (CFR) 483.10(i)(1)-(7) for Safe/clean/Comfortable/ Homelike Environment and 483.25 for Quality of Care on 12/2/2020 at 2:35 p.m., onsite with the Administrator (ADM) and the Director of Nursing (DON). The facility submitted an acceptable IJ Action Plan {Version 8} on 12/8/2020 at 5:15 p.m. The IJ Action Plan included the following: 1) The thermostats were immediately regulated and adjusted to maintain a safe and comfortable temperature range of 71 to 81°F, 2) The HVAC was checked and repaired by a licensed/professional vendor to ensure the system functioned properly, 3) A monitoring tool was developed and used to ensure the ambient temperatures were within the required range of 71 degrees F to 81 degrees F at all times, 4) Staff were in-serviced regarding awareness and maintenance of safe and comfortable temperature levels for the residents at all times, and 5) Policies and Procedures (P & P) for maintaining the required room temperatures were developed and implemented. The components of the IJ Action Plan were validated onsite to have been fully implemented through observations, interviews, and record review. The IJ situation was removed on 12/9/20 at 5 p.m. with the ADM and the DON. Findings: On 12/1/2020 at 11:30 p.m., an unannounced onsite visit was made to investigate Complaint CA 661 regarding the residents being cold at night. During a review of the online weather report (Time and Date. com) indicated, Reedley California Weather: 12/1/2020 (6 pm-12 am) - High: 52 degrees F/Low: 41 degrees F . At 10:56 pm: 39 degrees F. During a concurrent observation and interview on 12/1/2020 at 11:42 p.m., with Licensed Vocational Nurse (LVN) 1, the ambient temperatures for the following rooms were tested using an infrared thermometer (hand held device shaped like a gun that measures ambient temperature by pointing in the air). LVN 1 stated Rooms (Rm) 9, 10, 11, 12, 14, 15 and 16 were designated as the facility's Red Zone, an isolation unit housing residents who were diagnosed with [REDACTED]. LVN 1 tested and validated the following ambient room temperatures were below the required 71-81 degrees F: Rm 1 occupied by Residents 16, 17, and 19 was 67.6 degrees F Rm 5 occupied by Residents 21, 22, and 24 was 64.2 degrees F Rm 6 occupied by Residents 26, 27, and 28 was 62.2 degrees F Rm 9 occupied by Residents 1, 2, and 3 (all three residents with COVID-19) was 62.2 degrees F Rm 10 occupied by Residents 4 and 5 (both with COVID-19) was 62.4 degrees F Rm 11 occupied by Residents 6, 7, and 8 (all three residents with COVID-19) was 59.8 degrees F Rm 12 occupied by Residents 9 and 10 (both with COVID-19) was 62.4 degrees F Rm 14 occupied by Residents 12 and 13 (both with COVID-19) was 59.2 degrees F Rm 15 occupied by Residents 14 (with COVID-19) was 50.8 degrees F Rm 16 occupied by Residents 11 & 15 (both with COVID-19) was 64.2 degrees F Rm 17 occupied by Resident 30 was 63.2 degrees F Rm 21 occupied by Resident 20 was 61 degrees F On 12/1/2020 at 11:55 p.m., during a telephone interview with the DON, the DON stated she was not aware the resident rooms were cold. She stated if no one complained about the cold, then she would not know about it. When asked what care interventions need to be provided to ensure the residents were safe and warm, the DON stated, They could turn up the heater. During a concurrent observation and interview on 12/2/2020 at 2:00 a.m., the thermostat in front of the COVID room was set at 70 degrees F. The thermostat on the East side was set at 65 degrees F. LVN 1 stated, all the thermostats had to be locked because the Maintenance Supervisor (MS) did not want the residents or staff to change the temperature setting to suit themselves. LVN 1 stated (Resident 1's name) had complained of severe cold over the past few days. LVN 1 stated staff were instructed to call the MS, DON, or the ADM when the temperature was cold. LVN 1 stated staff were instructed to turn the heater on only when or if the resident(s) complained of being cold. LVN 1 stated, at 12:05, she had adjusted the thermostats to increase the ambient room temperatures. At 12:58 a.m., LVN 1 re-tested the ambient room temperatures in Rm 1, 5, 6, 9, 10, 11, 12, 14, 15, 16, 17 and 21 with the infrared thermometer. LVN 1 stated the ambient room temperatures in the following rooms were still below the required 71-81 degrees F: Rm 1 (Residents 16, 17, and 19): 67.8 degrees F Rm 5 (Residents 21, 22, and 24): 65.8 degrees F Rm 6 (Residents 26, 27, and 28): 64.2 degrees F Rm 9 (Residents 1, 2, and 3): 58.4 degrees F Rm 10 (Residents 4 and 5): 51.8 degrees F Rm 11 (Residents 6, 7, and 8): 50 degrees F Rm 12 (Residents 9 and 10): 52 degrees F Rm 14 (Residents 12 and 13): 61 degrees F Rm 15 (Resident 14): 52.4 degrees F Rm 16 (Residents 11 & 15): 61.4 degrees F Rm 17 (Resident 30): 61.6 degrees F Rm 21 (Resident 20): 58.8 degrees F During an interview with the Maintenance Supervisor (MS) on 12/2/2020 at 2:12 p.m., the MS stated he did not know how often he had to check for ambient room temperatures. The MS stated the facility did not have an infrared thermometer and relied on the four thermostats to check the temperatures in the resident rooms and living spaces. The MS stated the facility did not have a system or logs to monitor ambient room temperatures. During a concurrent observation and interview on 12/3/2020 at 9:40 a.m., with the MS at the facility, the MS tested the ambient room temperatures using an infrared thermometer. The MS stated the ambient temperatures for the following rooms were still below the required 71-81 degrees F: Rm 6 (Resident 26, 27, and 28): 58 degrees F Rm 9 (Residents 1, 2, and 3): 66 degrees F Rm 10 (Residents 4 and 5): 67 degrees F Rm 11 (Residents 6, 7, and 8): 68 degrees F Rm 12 (Residents 9 and 10): 69 degrees F Rm 14 (Residents 12 and 13): 67 degrees F Rm 16 (Residents 11 & 15): 67 degrees F Rm 17 (Resident 30): 61.6 degrees F During an interview on 12/3/2020 at 11:30 a.m., the ADM stated the contractor/vendor (CV) was at the facility and had informed him the duct of the HVAC needed to be replaced. The ADM stated the (name of company) CV estimated the repair would take multiple days. The ADM stated the CV was currently working on buying the material to fix the duct system of the HVAC. During a concurrent interview and review of the facility's floor plan on 12/3/2020 at 1:50 p.m., with the MS the facilities, the MS stated there were two HVAC units serving Rm 1-7, one HVAC unit serving Rm 9-16, and one HVAC unit serving Rm 17-21. During a concurrent observation and interview on 12/4/2020 at 8:25 a.m., at the facility with the MS, the ambient room temperatures were tested using an infrared thermometer. The MS validated the ambient temperatures for the following rooms in the Red Zone were still below the required 71-81 degrees F: Rm 12 (Residents 9 and 10): 70 degrees F. Rm 14 (Residents 12 and 13): 69 degrees F. Rm 16 (Residents 11 & 15): 70 degrees F. During a concurrent observation and interview on 12/4/2020 at 9 a.m., at the facility with the MS, the ambient room temperatures were tested using an infrared thermometer. The MS stated the ambient temperatures for the following rooms were still below the required 71-81 degrees F: Rm 17 had a room temperature of 70 degrees F. Rm 19 had a room temperature of 68 degrees F. Rm 21 had a room temperature of 70 degrees F. During a concurrent observation and interview on 12/4/2020 at 9:20 a.m., with the Compliance Officer (CO) for the Office of Statewide Health Planning and Development (OSHPD), at the facility, the CO inspected the HVAC unit and determined that the East wing HVAC unit was not grounded and was installed without a permit. The OSHPD CO stated he had observed work on the duct system had started and was half way completed. The OSHPD CO stated the flex duct (a flexible plastic over a metal wire coil which connects the heating and cooling system ductwork into the air distribution) was not the correct material for the duct system and was only going to be acceptable as a temporary fix for the time being. The OSHPD CO stated the duct system would have to be replaced with hard flex, which was the appropriate material to use as a permanent fix. The OSHPD CO pointed at the removed parts of the duct system and stated the old duct system was dirty and was leaking, which could have caused the ambient temperatures to be below the required 71-81 degrees F. During a concurrent observation and interview on 12/4/2020 at 9:30 a.m., with the Project Manager (PM) of (name of private company), the PM stated the ducting material installed and were sealed with a flex duct was only good for temporary repair. The PM stated, the correct size for the insulating metal duct (metal ducts are more rigid due to the nature of steel, making them ideal to build an entire HVAC system) must be used to permanently repair the HVAC system. During a concurrent interview and record review on 12/4/2020 at 9:55 a.m., with the CV for {name of company}. The CV stated he was called by the facility on 11/24/2020 because the HVAC unit was not heating. The CV stated, on 11/24 the lower motor V- belt (most common type of belt used for power) was broken. The CV stated he replaced the blower motor V- belt and the HVAC was fixed. The CV stated on 11/ 0, he received a second call from the facility that another HVAC unit on the west wing was not maintaining heating temperatures. The CV stated the problem was a voltage drop (the amount of voltage loss that occurs through all or part of a circuit due to blockage or break). The CV stated he had fixed the voltage drop as well. The CV stated he received a third call on the evening of 12/1/2020, that the east wing HVAC was not heating. The CV stated he went to the facility on [DATE] and this time, the blower's motor switch was not working. The SM stated, even though he fixed the blower motor switch on 12/2/2020, the heating temperature was still not maintained so he started to replace the duct system. During an interview on 12/4/2020 at 4:20 p.m., the ADM and DON stated the repair work on the facility's HVAC ducting system had not been completed. The ADM and DON stated staff would be monitoring the ambient temperatures rooms in all the resident rooms. During an interview on 12/5/2020 at 9:40 a.m., the MS stated the duct system repair had been completed. The MS stated he had checked the ambient temperatures in rooms 9-16 and the temperatures were 75-77 degrees F. The MS stated the temperatures remained in the required range of 71-81 degrees F; and the rooms no longer needed to be heated by the portable heaters. During a concurrent interview and record review on 12/7/2020 at 8:00 a.m. with the DON; the DON stated the following five residents (Residents 9, 14, 15, 24 and 29) who were housed in the rooms in the RED ZONE had change of condition (fever, shortness of breath, wheezing, cough, and low oxygen (O2) saturations) and were sent to the hospital on 12/2, 12/4, and 12/6/2020: 1. During a review of Resident 9's face sheet (FS- a document containing resident profile information) indicated Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's Minimum Data Set (MDS, a resident assessment tool used to identify healthcare needs) Cognitive Patterns (processes that include thinking, knowing, remembering, judging, and problem-solving) dated 11/13/2020 indicated Resident 9 had impaired decision-making skills and required cues/supervision by staff. During a review of Resident 9's Nursing Notes (NN) dated 12/1/2020 at 4:38 p.m., the NN indicated, Resident was having a cough, rapid testing done {Rapid COVID test is administered at the point of care by throat or nasal swab by a medical assistant or primary care provider. The rapid [MEDICATION NAME] test can return results showing whether the patient is infected with acute COVID-19 the same day} and came back positive for COVID . 2. During a review of Resident 14's NN dated 12/4/2020 at 7:39 a.m., the NN indicated Resident's appetite noted to have decreased . Writer noted that the resident was having shortness of breath. Respirations noted to be 22 bpm (beats per minute) . Noted O2 saturation to be between 83-88 percent on room air . MD was made aware via phone and he gave an order to start the resident on O2 at 2 liters per minute via nasal cannula and to also send the resident to the ED as soon as possible . During a review of Resident 14's (Hospital name) Discharge Summary (DC summary) dated 12/13/2020, the DC Summary indicated .Chief complaint . Patient presents with Respiratory Short of Breath .Pt with increased SOB, positive COVID x 2 weeks. Does not use home oxygen . Admission Diagnoses: [REDACTED]. Result Date: 12/5/2020 . 3. During a review of Resident 15's FS dated 12/2/2020, the FS indicated Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 15's NN dated 12/2/2020 at 5:42 p.m., the NN indicated Around 1530 (3:30 p.m.) resident called this nurse and stated he was not feeling good. Resident noted to be getting out of breath. Checked the O2 sat and noted 85 percent on RA (room air) and respirations 22 on RA. Elevated the head of the bed and O2 at 2L via nasal cannula initiated. O2 went to 91%. Checked the vitals and noted B/P 204/102, P (pulse) 100 per minute, temp (temperature) 98.9 degrees F. Resident's both hands and both arms noted to be swollen. Called MD and received an order to send the resident out to the ED. During a review of Resident 15's NN dated 12/2/2020 at 5:42 p.m., the NN indicated . Response driven COVID-19 testing was done at the facility on 11/24/2020 .Received results on 11/28/2020. Resident is Negative for COVID-19. During a review of Resident 15's Patient Care Treatment (PCT) dated 12/2/220, the PCT indicated, Vital Signs .BP 206/124 .O2 Saturation: 93% . Chief Complaints Updated .Respiratory Dyspnea .12/3/2020 [MEDICAL CONDITION] Detected . During a review of Resident 15's DC Summary dated 12/10/2020, the DC Summary indicated, Discharge [DIAGNOSES REDACTED]. Pneumonia due to COVID 19 virus . 4. During a review of Resident 24's NN dated 12/6/2020 at 1:02 p.m., the NN indicated CNA informed writer that the resident's O2 saturation is 80 percent . O2 at 2l/min via nasal cannula applied to the resident . The resident noted to have SOB . Respiration was noted to be 33 breaths per minute . MD made aware . verbal order to send the resident to the E.R. (emergency room ) A.S.A.P (as soon as possible). During a review of Resident 24's NN dated 12/4/2020 at 4:12 p.m., the NN indicated Response driven COVID-19 testing was done at the facility on 11/24/2020. Received results on 11/28/2020. Resident is negative for COVID-19. During a review of Resident 24's NN dated 12/2/2020 at 2:19 p.m., the NN indicated, Response driven COVID-19 testing done 12/1/2020 by (facility name). Received results on 12/4/2020. Resident results are positive for COVID-19. During a review of Resident 24's Lab Results dated 12/6/2020, the Lab Results indicated .[DIAGNOSES REDACTED]-CoV-2 (COVID-19) . Abnormal . POSITIVE . During a review of Resident 24's ED Adult Triage Form (EDTF) dated 12/6/2020, the EDTF indicated, Chief complaint- triage: SOB . Focused Assessment: BIBA from SNF complaining of SOB, [MEDICAL CONDITION] . on 2L nasal cannula, (oxygen saturation) 80%, patient tested COVID 1 week ago. Enroute with EMS (emergency medical services) with minimal improvement saturation of 94% on 8 liters of oxygen per nasal cannula . During a review of Resident 24's History and Physical (H&P), dated 12/6/20 the H&P indicated Acute hypoxic [MEDICAL CONDITION] - secondary to COVID .pneumonia. Patient with initial saturations in the 70s - 80s at SNF, and in the mid-80s per EMS on 2 L. Requiring higher oxygen amounts, up to 6 L NC max. [MEDICAL CONDITION] possibly secondary to COVID pneumonia . Given recent positive COVID test, and initial symptoms classically associated with COVID, will treat [MEDICAL CONDITION] as result from COVID. However, patient's lungs did sound wet, and he has symptoms related to possible [MEDICAL CONDITION] exacerbation . During a review of Resident 24's Chest 1 View (X ray) dated 12/6/20, the X ray indicated Reason for the Exam SOB . Findings .Impression: [MEDICAL CONDITION] with interstitial [MEDICAL CONDITIONS]. 5. During a review of Resident 29's NN dated 12/2/2020 at 4:09 p.m., the NN indicated Response driven COVID-19 testing was done at the facility on 11/24/2020. Received results on 11/28/2020. Resident is Negative for COVID-19. During a review of Resident 29's NN dated 12/4/2020 at 5:27 a.m., the NN indicated The assigned CNA told this writer around 0145 (1:45 a.m.) that resident's oxygen level is 86 percent. This writer went to check immediately and resident noted to be wheezing. Oxygen was applied as per order. Rechecked O2 saturation after 15 minutes . noted to b 90 percent. This writer faxed MD regarding resident's condition. During a review of Resident 29's NN dated 12/4/2020 at 12:03 p.m., the NN indicated NOC nurse faxed to MD regarding resident condition. This writer checked the resident's oxygen level .86 percent .noted wheezing. Received fax back from MD with order to send out to hospital . During a review of Resident 29's PCT dated 12/4/2020, the PCT indicated, ED notes .Chief complaint Patient presents with Respiratory Short of Breath .12/4/2020 .Status: Final result COVID [DIAGNOSES REDACTED] COV 2 PCR: . Detected . During a review of Resident 29's DC summary dated 12/17/2020 , the DC Summary indicated, . chief compliant Patient presents with Respiratory Short of Breath from (facility) Sob, Low o2 sat 90-92 room air 96% on 4 L via nasal cannula .Admission Diagnoses: [REDACTED]. During a concurrent interview and record review on 12/7/2020 at 10:10 a.m., LVN 3 stated Resident 1 had complained of being cold when the temperatures dropped below 71 degrees F. Resident 1's face sheet (FS- a document containing resident profile information) indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, a resident assessment tool used to identify healthcare needs) Cognitive Patterns (processes that include thinking, knowing, remembering, judging, and problem-solving) dated 10/11/2020, indicated Resident 1's had a BIMS (Brief Interview for Mental Status) score of 15 of 15 points which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. LVN 3 stated she had not been given instructions on what to do to keep the residents warm when the temperatures dropped below 71 degrees F. During an interview on 12/9/2020 at 8:55 a.m., Resident 5 stated, I was using a small heater to keep warm. I am cold now, I didn't tell anyone but my arms and feet are cold . During a review of (name of weather service) forecast for 12/1/20 and 12/09/20, indicated outside temperatures in (area of the facility) reached a low of: 31 degrees F the night of 12/1/20 31 degrees F the night of 12/2/20 34 degrees F the night of 12/3/20 32 degrees F the night of 12/4/20 33 degrees F the night of 12/5/20 33 degrees F the night of 12/6/20 30 degrees F the night of 12/7/20 32 degrees F the night of 12/8/20 34 degrees F the night of 12/9/20 During a review of the facility's Policy and Procedure (P&P) titled, Quality of Life- Homelike Environment dated May 2017, the P&P indicated Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable and safe temperatures (71 F- 81 F) . During a review of job invoices dated on 11/24/2020 indicated two HVAC units had electrical problems, the job invoice dated 11/27/2020 indicated the HVAC unit serving Rm 9-16 had roasted wires and a broken blower V- belt, and the job invoice dated 11/27/20 indicated the HVAC units serving rooms 1-7 had voltage issues and the units were not maintaining the proper temperature. During a review of the CV (contractor/vendor) Air HVAC Service Order dated 11/24/20, the Service Order indicated, East side unit not heating found roasted wires and broken blower motor V- belt. Repaired wires and replaced V belt. During a review of the CV Air HVAC Service Order dated 11/27/20, the Service Order indicated Electrical problem in the system. Voltage drip is the problem. During a review of the CV Air HVAC Service Order dated 12/2/20, the Service Order indicated Found defective roll out switch and shortened wire of blower motor .Replaced roll out switch and repaired wires. During a review of the CV Air HVAC Service Order dated 12/4/20, the Service Order indicated East side replaced- Duct work with Flexible Duct- System is performing with proper Airflow and Cycled unit. During a review of OSHPD Construction Advisory Report (OSHPD Report) dated 12/4/2020, OSHPD Report indicated, .while on site noted the following: 1. The eastmost patient wing was supplied by a 6.5 ton Package HVAC unit which was gas fired for heating and electric for cooling. The package unit was located on the south side of the eastmost patient wing. The Installing contractor had recently made repairs to the package unit. The unit had been reported as having been inoperable for the last couple of weeks. The installing contractor had replaced about 50% of the supply ducting with flex ducting in order to stop excessive duct leakage. This work was performed at the direction of the Facility Administrator .There is some remaining duct leakage and I have authorized emergency replacement of supply ducting with flex ducting to minimize leakage and downtime while plans are developed by (name) Air Conditioning. This work is to be inspected by IOR It is also noted that this HVAC unit was installed without a building permit at time of installation. 2. The Installing contractor and Facility Administrator also showed a second 6.5 ton HVAC Package Unit installed on grade on the south side of the south wing adjacent to the eastmost patient wing. This Unit was also reported to have excessive duct leakage by the installing contractor. The administrator reported that this unit's operation was currently not creating a non-compliant heating situation in the area it served. This Package HVAC unit had also been installed without a building permit. 3. A Fire Alarm initiation and Local Fire response was noted as having happened. This issue may have been caused by failure of HVAC unit drive belt or dirty vents disturbed while working with them. This is not anticipated to be a chronic condition. 4. In summary, the new ductwork installation and Package units were installed without an OSHPD Building Permit which is not compliant with CAC 7-128 requirements. The facility is to address these installations through application for an OSHPD Building Permit charges may apply to work of OSHPD during resolution to point of obtaining an approved permit. At this time it appears interior temperatures are being adequately maintained. Installing contractor is to coordinate timing of duct replacement (temporary flex) and permanent hard duct installation and/or provide temp heating so as to maintain compliant patient temperature environment during the work. During a review of the facility's P&P titled, Maintenance Service dated December 2019, indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment The Maintenance Department is responsible for maintain the buildings, grounds and equipment in a safe and operable manner at all times . Functions of maintenance personnel include, but are not limited to Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, Maintaining the heat/ cooling system, plumbing fixtures, wiring, etc., in good working order, Establishing priorities in providing repair services, Providing routinely scheduled maintenance service to all areas .The Maintenance Director is responsible for developing and maintaining schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner . The Maintenance personnel shall follow the manufacturer's recommended maintenance schedule. During a review of the facility's P&P titled, Inspection of Heat/ Air- Conditioning Systems dated August 2008, the P&P indicated Our facility's heating and air- conditioning system shall be inspected at least semi- annually. Prior to the beginning of each heating and cooling season our facility's heating and air conditioning system shall be inspected for possible gas leaks, lines that have burst, etc. The Maintenance Department shall be responsible for such inspections, and shall have the authority to use local gas companies and/ or approved repairmen to assist in making such inspections when assistance is necessary .Maintenance Department is responsible for ensuring temperatures are safe, comfortable and within required range 71 to 81 degree F as evidenced by monitoring tool. During a review of online professional reference titled, Winter Wellness: Cold Weather and the Effects on Mental Health dated 12/17, found at (www.brookhavenretreat.com/cms) indicated, .The cold temperature itself can cause depression too. Cold weather keeps us from moving around and getting our blood flowing, which can lead to inflammation, and inflammation can signal the brain to become depressed. Cold temperatures also slow down the immune system's response time, making it harder to fend off germs . During a review of All Facilities Letter (AFL 13-31) sent to healthcare facilities from the California Department of Public Health Licensing and Certification titled, Winter Weather Emergency Preparedness Advisory dated 12/5/2013, indicated .Winter months bring weather that can rapidly create emergency and/or disaster-related conditions. Disaster plans must take all types of hazards into account, including the possibility of severe weather caused by freeze conditions and/or winter storms. Health care facilities are required by regulation to maintain their physical plant and all equipment in operational condition. If your facility is required to maintain an emergency power source, it must be fully tested and functional in order to ensure availability in the event of a power outage . During a review of the California Department of Public Health, Licensing and Certification Unit (CDPH L & C) - Intranet (local or restricted communications network) document titled, Winter Weather Health Tips, dated October 7, 2018, indicated The elderly and medically fragile are particularly susceptible to the cold. Persons with poor circulation, or who take medications that can interfere with the body's ability to regulate temperature, are at risk for hypothermia .Measures should be taken to trap existing warm air. If it appears, the loss of heat will be of significant duration, hang blankets over windows and doorways and move to a well insulated room.

Based on observation, interview, and record review, the facility failed to ensure that each resident received care and treatment to enable residents to maintain their highest practicable level of physical, mental, and psychosocial wellbeing, for 27 of 31 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 24, 26, 27, 28, 29 and 30), when licensed nursing staff did not conduct assessments to effectively identify and meet the needs of the residents when the ambient (actual air temperature of an environment) room temperatures had dropped to 50.8- 67.6 degrees Fahrenheit {a measure of temperature}(the normal temperature range is 71 degrees to 81 degrees F) due to a non functioning heating system. The facility's failures to promptly repair the HVAC (Heating,Ventilation and Air Conditioning - a system, machine, and technology that provides heating and cooling to residential and commercial buildings), failure to monitor the ambient room temperatures, failure to assess the resident's comfort and provide care interventions to keep the residents safe and warm may have led to Residents 9, 14, 15, 24 and 29's unplanned hospitalization s on 12/2/2020, 12/4/2020, and 12/6/2020 due to fever, shortness of breath (SOB), cough, wheezing, and low oxygen (O2) saturation (measures the amount of hemoglobin {protein inside red blood cells that carries oxygen from the lungs to tissues and organs in the body}) and placed the health and safety of all residents at high risk for serious harm from respiratory illnesses such as cough, cold, flu, exacerbation of asthma, and progression of [MEDICAL CONDITION] (COVID-19 ([DIAGNOSES REDACTED]-CoV -2) - a contagious serious respiratory infection transmitted from person to person), pneumonia or [MEDICAL CONDITION]. Because of the serious potential harm and probable actual harm of suffering cold environmental temperatures measured below 71 degrees F for extended periods of time, risk of hypothermia (medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature), respiratory illnesses, hospitalization and/or death due to non-functioning heating system, an Immediate Jeopardy (IJ)situation was called under Code of Federal Regulations (CFR) 483.10(i)(1)-(7) for Safe/clean/Comfortable/ Homelike Environment and 483.25 for Quality of Care on 12/2/2020 at 2:35 p.m., onsite with the Administrator (ADM) and the Director of Nursing (DON). The facility submitted an acceptable IJ Action Plan {Version 8} on 12/8/2020 at 5:15 p.m. The IJ Action Plan included the following: 1) The thermostats were immediately regulated and adjusted to maintain a safe and comfortable temperature range of 71 to 81°F, 2) The HVAC was checked and repaired by a licensed/professional vendor to ensure the system functioned properly, 3) A monitoring tool was developed and used to ensure the ambient temperatures were within the required range of 71 degrees F to 81 degrees F at all times, 4) Staff were in-serviced regarding awareness and maintenance of safe and comfortable temperature levels for the residents at all times, and 5) Policies and Procedures (P & P) for maintaining the required room temperatures were developed and implemented. The components of the IJ Action Plan were validated onsite to have been fully implemented through observations, interviews, and record review. The IJ situation was removed on 12/9/20 at 5 p.m. with the ADM and the DON. Findings: On 12/1/2020 at 11:30 p.m., an unannounced onsite visit was made to investigate Complaint CA 661 regarding the residents being cold at night. During a review of the online weather report (TimeandDate.com) indicated, Reedley California Weather: 12/1/2020 (6 pm-12 am) - High: 52 degrees F/Low: 41 degrees F . At 10:56 pm: 39 degrees F. During a concurrent observation and interview on 12/1/2020 at 11:42 p.m., with Licensed Vocational Nurse (LVN) 1, the ambient temperatures for the following rooms were tested using an infrared thermometer (hand held device shaped like a gun that measures ambient temperature by pointing in the air). LVN 1 stated Rooms (Rm) 9, 10, 11, 12, 14, 15 and 16 were designated as the facility's Red Zone, an isolation unit housing residents who were diagnosed with [REDACTED]. LVN 1 tested and validated the following ambient room temperatures were below the required 71-81 degrees F: Rm 1 occupied by Residents 16, 17, and 19 was 67.6 degrees F Rm 5 occupied by Residents 21, 22, and 24 was 64.2 degrees F Rm 6 occupied by Residents 26, 27, and 28 was 62.2 degrees F Rm 9 occupied by Residents 1, 2, and 3 (all three residents with COVID-19) was 62.2 degrees F Rm 10 occupied by Residents 4 and 5 (both with COVID-19) was 62.4 degrees F Rm 11 occupied by Residents 6, 7, and 8 (all three residents with COVID-19) was 59.8 degrees F Rm 12 occupied by Residents 9 and 10 (both with COVID-19) was 62.4 degrees F Rm 14 occupied by Residents 12 and 13 (both with COVID-19) was 59.2 degrees F Rm 15 occupied by Residents 14 (with COVID-19) was 50.8 degrees F Rm 16 occupied by Residents 11 & 15 (both with COVID-19) was 64.2 degrees F Rm 17 occupied by Resident 30 was 63.2 degrees F Rm 21 occupied by Resident 20 was 61 degrees F On 12/1/2020 at 11:55 p.m., during a telephone interview with the DON, the DON stated she was not aware the resident rooms were cold. She stated if no one complained about the cold, then she would not know about it. When asked what care interventions need to be provided to ensure the residents were safe and warm, the DON stated, They could turn up the heater. During a concurrent observation and interview on 12/2/2020 at 2:00 a.m., the thermostat in front of the COVID room was set at 70 degrees F. The thermostat on the East side was set at 65 degrees F. LVN 1 stated, all the thermostats had to be locked because the Maintenance Supervisor (MS) did not want the residents or staff to change the temperature setting to suit themselves. LVN 1 stated (Resident 1's name) had complained of severe cold over the past few days. LVN 1 stated staff were instructed to call the MS, DON, or the ADM when the temperature was cold. LVN 1 stated staff were instructed to turn the heater on only when or if the resident(s) complained of being cold. LVN 1 stated, at 12:05 a.m., she had adjusted the thermostats to increase the ambient room temperatures. At 12:58 a.m., LVN 1 re-tested the ambient room temperatures in Rm 5, 6, 9, 10, 11, 12, 14, 15, 16 and 17 with the infrared thermometer. LVN 1 stated the ambient room temperatures in the following rooms were still below the required 71-81 degrees F: Rm 1 (Residents 16, 17, and 19): 67.8 degrees F Rm 5 (Residents 21, 22, and 24): 65.8 degrees F Rm 6 (Residents 26, 27, and 28): 64.2 degrees F Rm 9 (Residents 1, 2, and 3): 58.4 degrees F Rm 10 (Residents 4 and 5): 51.8 degrees F Rm 11 (Residents 6, 7, and 8): 50 degrees F Rm 12 (Residents 9 and 10): 52 degrees F Rm 14 (Residents 12 and 13): 61 degrees F Rm 15 (Resident 14): 52.4 degrees F Rm 16 (Residents 11 & 15): 61.4 degrees F Rm 17 (Resident 30): 61.6 degrees F Rm 21 (Resident 20): 58.8 degrees F During an interview with the Maintenance Supervisor (MS) on 12/2/2020 at 2:12 p.m., the MS stated he did not know how often he had to check for ambient room temperatures. The MS stated the facility did not have an infrared thermometer and relied on the four thermostats to check the temperatures in the resident rooms and living spaces. The MS stated the facility did not have a system or logs to monitor ambient room temperatures. During a concurrent observation and interview on 12/3/2020 at 9:40 a.m., with the MS at the facility, the MS tested the ambient room temperatures using an infrared thermometer. The MS stated the ambient temperatures for the following rooms were still below the required 71-81 degrees F: Rm 6 (Resident 26, 27, and 28): 58 degrees F Rm 9 (Residents 1, 2, and 3): 66 degrees F Rm 10 (Residents 4 and 5): 67 degrees F Rm 11 (Residents 6, 7, and 8): 68 degrees F Rm 12 (Residents 9 and 10): 69 degrees F Rm 14 (Residents 12 and 13): 67 degrees F Rm 16 (Residents 11 & 15): 67 degrees F Rm 17 (Resident 30): 61.6 degrees F During an interview on 12/3/2020 at 11:30 a.m., the ADM stated the Contractor/Vendor (CV) was at the facility and had informed him the duct of the HVAC needed to be replaced. The ADM stated the (name of company) CV estimated the repair would take multiple days. The ADM stated the CV was currently working on buying the material to fix the duct system of the HVAC. During a concurrent interview and review of the facility's floor plan on 12/3/2020 at 1:50 p.m., with the MS the facilities, the MS stated there were two HVAC units serving Rm 1-7, one HVAC unit serving Rm 9-16, and one HVAC unit serving Rm 17-21. During a concurrent observation and interview on 12/4/2020 at 8:25 a.m., at the facility with the MS, the ambient room temperatures were tested using an infrared thermometer. Were retested . The MS validated the ambient temperatures for the following rooms in the Red Zone were still below the required 71-81 degrees F: Rm 12 (Residents 9 and 10): 70 degrees F. Rm 14 (Residents 12 and 13): 69 degrees F. Rm 16 (Residents 11 & 15): 70 degrees F. During a concurrent observation and interview on 12/4/2020 at 9 a.m., at the facility with the MS, the ambient room temperatures were tested using an infrared thermometer. The MS stated the ambient temperatures for the following rooms were still below the required 71-81 degrees F: Rm 17 had a room temperature of 70 degrees F. Rm 19 had a room temperature of 68 degrees F. Rm 21 had a room temperature of 70 degrees F. During a concurrent observation and interview on 12/4/2020 at 9:20 a.m., with the Compliance Officer (CO) for the Office of Statewide Health Planning and Development (OSHPD), at the facility, the CO inspected the HVAC unit and determined that the East wing HVAC unit was not grounded and was installed without a permit. The OSHPD CO stated he had observed work on the duct system had started and was half way completed. The OSHPD CO stated the flex duct (a flexible plastic over a metal wire coil which connects the heating and cooling system ductwork into the air distribution) was not the correct material for the duct system and was only going to be acceptable as a temporary fix for the time being. The OSHPD CO stated the duct system would have to be replaced with hard flex, which was the appropriate material to use as a permanent fix. The OSHPD CO pointed at the removed parts of the duct system and stated the old duct system was dirty and was leaking, which could have caused the ambient temperatures to be below the required 71-81 degrees F. During a concurrent observation and interview on 12/4/2020 at 9:30 a.m., with the Project Manager (PM) of (name of private company), the PM stated the ducting material installed and were sealed with a flex duct was only good for temporary repair. The PM stated, the correct size for the insulating metal duct (metal ducts are more rigid due to the nature of steel, making them ideal to build an entire HVAC system) must be used to permanently repair the HVAC system. During a concurrent interview and record review on 12/4/2020 at 9:55 a.m., with the CV for (name of company). The CV stated he was called by the facility on 11/24/2020 because the HVAC unit was not heating. The CV stated, on 11/24 the lower motor V- belt (most common type of belt used for power) was broken. The CV stated he replaced the blower motor V- belt and the HVAC was fixed. The CV stated on 11/ 0, he received a second call from the facility that another HVAC unit on the west wing was not maintaining heating temperatures. The CV stated the problem was a voltage drop (the amount of voltage loss that occurs through all or part of a circuit due to blockage or break). The CV stated he had fixed the voltage drop as well. The CV stated he received a third call on the evening of 12/1/2020, that the east wing HVAC was not heating. The CV stated he went to the facility on [DATE] and this time, the blower's motor switch was not working. The SM stated, even though he fixed the blower motor switch on 12/2/2020, the heating temperature was still not maintained so he started to replace the duct system. During an interview on 12/4/2020 at 4:20 p.m., the ADM and DON stated the repair work on the facility's HVAC ducting system had not been completed. The ADM and DON stated staff would be monitoring the ambient temperatures rooms in all the resident rooms. During an interview on 12/5/2020 at 9:40 a.m., the MS stated the duct system repair had been completed. The MS stated he had checked the ambient temperatures in rooms 9-16 and the temperatures were 75-77 degrees F. The MS stated the temperatures remained in the required range of 71-81 degrees F; and the rooms no longer needed to be heated by the portable heaters. During a concurrent interview and record review on 12/7/2020 at 8:00 a.m. with the DON; the DON stated the following five residents (Residents 9, 14, 15, 24 and 29) who were housed in the rooms in the RED ZONE had change of condition (fever, shortness of breath, wheezing, cough, and low oxygen (O2) saturations) and were sent to the hospital on 12/2, 12/4, and 12/6/2020: 1. During a review of Resident 9's face sheet (FS- a document containing resident profile information) indicated Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's Minimum Data Set (MDS, a resident assessment tool used to identify healthcare needs) Cognitive Patterns (processes that include thinking, knowing, remembering, judging, and problem-solving) dated 11/13/2020 indicated Resident 9 had impaired decision-making skills and required cues/supervision by staff. During a review of Resident 9's Nursing Notes (NN) dated 12/1/2020 at 4:38 p.m., the NN indicated, Resident was having a cough, rapid testing done {Rapid COVID test is administered at the point of care by throat or nasal swab by a medical assistant or primary care provider. The rapid [MEDICATION NAME] test can return results showing whether the patient is infected with acute COVID-19 the same day} and came back positive for COVID . During a review of Resident 9's NN dated 12/6/2020 at 7:37 p.m., the NN indicated that on 12/6/2020 at 4:00 p.m., Resident 9 had a temperature of 101 degrees F per (oral), pulse of 92 per minute, and respiration of 29 breaths per minute. Resident 9's physician ordered to send the resident to the emergency department (ED) and to start oxygen at 2 liters per minute via nasal (nose) cannula for comfort related to shortness of breath (SOB). During a review of Resident 9's Chest 1 View (X ray) dated 12/6/20, the X ray indicated, Reason for the Exam Dyspnea (difficulty of breathing) . IMPRESSION: Chronic lung changes with no definite acute focal consolidation(air that usually fills the small airways in your lungs is replaced with fluid) to suggest an acute cardiopulmonary (related to heart and lungs) process. During a review of Resident 9's, ED Adult Triage Form (EDTF) dated 12/6/2020, the EDTF indicated Chief complaint- triage: SOB . Focused Assessment: BIBA (brought in by ambulance) from SNF (Skilled Nursing Facility) for [MEDICAL CONDITION] (a dangerous condition that happens when the body doesn't get enough oxygen) .COVID positive . During a review of Resident 9's Lab Results dated 12/7/2020, the Lab Results indicated .[DIAGNOSES REDACTED]-CoV-2 (Covid 19 ) . Abn {abnormal} POSITIVE . (Positive results indicating the resident had [MEDICAL CONDITION]). 2. During a review of Resident 14's NN dated 11/26/2020 at 12:02 p.m., the NN indicated Resident moved from Rm 6-2 to Rm 17 due to cough, isolation precautions . Resident has a change of condition . feeling very weak, SOB, Resident has diarrhea noted. During a review of Resident 14's NN dated 11/28/2020 at 4:55 p.m., the NN indicated Response driven COVID-19 testing was done at the facility on 11/24/2020 by (facility name). Received results on 11/28/2020. Resident is Positive for COVID-19. During a review of Resident 14's NN dated 12/4/2020 at 7:39 a.m., the NN indicated Resident's appetite noted to have decreased . Writer noted that the resident was having shortness of breath. Respirations noted to be 22 bpm (beats per minute) . Noted O2 saturation to be between 83-88 percent on room air . MD was made aware via phone and he gave an order to start the resident on O2 at 2 liters per minute via nasal cannula and to also send the resident to the ED as soon as possible . During a review of Resident 14's Discharge Summary (DC summary) dated 12/13/2020, the DC Summary indicated .Chief complaint . Patient presents with Respiratory Short of Breath .Pt with increased SOB, positive COVID x 2 weeks. Does not use home oxygen . Admission Diagnoses: [REDACTED]. Result Date: 12/5/2020 . 3. During a review of Resident 15's FS dated 12/2/2020, the FS indicated Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident 15's NN dated 12/2/2020 at 5:42 p.m., the NN indicated Around 1530 (3:30 p.m.) resident called this nurse and stated he was not feeling good. Resident noted to be getting out of breath. Checked the O2 sat and noted 85 percent on RA (room air) and respirations 22 on RA. Elevated the head of the bed and O2 at 2L via nasal cannula initiated. O2 went to 91%. Checked the vitals and noted B/P 204/102, P (pulse) 100 per minute, temp (temperature) 98.9 degrees F. Resident's both hands and both arms noted to be swollen. Called MD and received an order to send the resident out to the ED. During a review of Resident 15's NN dated 12/2/2020 at 5:42 p.m., the NN indicated . Response driven COVID-19 testing was done at the facility on 11/24/2020 .Received results on 11/28/2020. Resident is Negative for COVID-19. During a review of Resident 15's PCT dated 12/2/220, the PCT indicated, Vital Signs .BP 206/124 .O2 Saturation: 93% . Chief Complaints Updated .Respiratory Dyspnea .12/3/2020 [MEDICAL CONDITION] Detected . During a review of Resident 15's DC Summary dated 12/10/2020, the DC Summary indicated, Discharge [DIAGNOSES REDACTED]. Pneumonia due to COVID 19 virus . 4. During a review of Resident 24's NN dated 12/6/2020 at 1:02 p.m., the NN indicated CNA informed writer that the resident's O2 saturation is 80 percent . O2 at 2l/min via nasal cannula applied to the resident . The resident noted to have SOB . Respiration was noted to be 33 breaths per minute . MD made aware . verbal order to send the resident to the E.R. (emergency room ) A.S.A.P (as soon as possible). During a review of Resident 24's NN dated 12/4/2020 at 4:12 p.m., the NN indicated Response driven COVID-19 testing was done at the facility on 11/24/2020. Received results on 11/28/2020. Resident is negative for COVID-19. During a review of Resident 24's NN dated 12/2/2020 at 2:19 p.m., the NN indicated, Response driven COVID-19 testing done 12/1/2020 by (facility name). Received results on 12/4/2020. Resident results are positive for COVID-19. During a review of Resident 24's Lab Results dated 12/6/2020, the Lab Results indicated .[DIAGNOSES REDACTED]-CoV-2 (COVID-19) . Abnormal . POSITIVE . During a review of Resident 24's ED Adult Triage Form (EDTF) dated 12/6/2020, the EDTF indicated, Chief complaint- triage: SOB . Focused Assessment: BIBA from SNF complaining of SOB, [MEDICAL CONDITION] . on 2L nasal cannula, (oxygen saturation) 80%, patient tested COVID 1 week ago. Enroute with EMS (emergency medical services) with minimal improvement saturation of 94% on 8 liters of oxygen per nasal cannula . During a review of Resident 24's History and Physical (H&P), dated 12/6/20 the H&P indicated Acute hypoxic [MEDICAL CONDITION] - secondary to COVID .pneumonia. Patient with initial saturations in the 70s - 80s at SNF, and in the mid-80s per EMS on 2 L. Requiring higher oxygen amounts, up to 6 L NC max. [MEDICAL CONDITION] possibly secondary to COVID pneumonia . Given recent positive COVID test, and initial symptoms classically associated with COVID, will treat [MEDICAL CONDITION] as result from COVID. However, patient's lungs did sound wet, and he has symptoms related to possible [MEDICAL CONDITION] exacerbation . During a review of Resident 24's Chest 1 View (X ray) dated 12/6/20, the X ray indicated Reason for the Exam SOB . Findings .Impression: [MEDICAL CONDITION] with interstitial [MEDICAL CONDITIONS]. 5. During a review of Resident 29's NN dated 12/2/2020 at 4:09 p.m., the NN indicated Response driven COVID-19 testing was done at the facility on 11/24/2020. Received results on 11/28/2020. Resident is Negative for COVID-19. During a review of Resident 29's NN dated 12/4/2020 at 5:27 a.m., the NN indicated The assigned CNA told this writer around 0145 (1:45 a.m.) that resident's oxygen level is 86 percent. This writer went to check immediately and resident noted to be wheezing. Oxygen was applied as per order. Rechecked O2 saturation after 15 minutes . noted to b 90 percent. This writer faxed MD regarding resident's condition. During a review of Resident 29's NN dated 12/4/2020 at 12:03 p.m., the NN indicated NOC nurse faxed to MD regarding resident condition. This writer checked the resident's oxygen level .86 percent .noted wheezing. Received fax back from MD with order to send out to hospital . During a review of Resident 29's PCT dated 12/4/2020, the PCT indicated, ED notes .Chief complaint Patient presents with Respiratory Short of Breath .12/4/2020 .Status: Final result COVID [DIAGNOSES REDACTED] COV 2 PCR: . Detected . During a review of Resident 29's DC summary dated 12/17/2020 , the DC Summary indicated, . chief compliant Patient presents with Respiratory Short of Breath from (facility) Sob, Low o2 sat 90-92 room air 96% on 4 L via nasal cannula .Admission Diagnoses: [REDACTED]. During a concurrent interview and record review on 12/7/2020 at 10:10 a.m., LVN 3 stated Resident 1 had complained of being cold when the temperatures dropped below 71 degrees F. Resident 1's face sheet (FS- a document containing resident profile information) indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, a resident assessment tool used to identify healthcare needs) Cognitive Patterns (processes that include thinking, knowing, remembering, judging, and problem-solving) dated 10/11/2020, indicated Resident 1's had a BIMS (Brief Interview for Mental Status) score of 15 of 15 points which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. LVN 3 stated she had not been given instructions on what to do to keep the residents warm when the temperatures dropped below 71 degrees F. During an interview on 12/9/2020 at 8:55 a.m., with Resident 5, Resident 5 stated, .I was using a small heater to keep warm. I am cold now, I didn't tell anyone but my arms and feet are cold . During a review of (name of weather service) forecast for 12/1/20 and 12/09/20, indicated outside temperatures in (area of the facility) reached a low of: 31 degrees F the night of 12/1/20 31 degrees F the night of 12/2/20 34 degrees F the night of 12/3/20 32 degrees F the night of 12/4/20 33 degrees F the night of 12/5/20 33 degrees F the night of 12/6/20 30 degrees F the night of 12/7/20 32 degrees F the night of 12/8/20 34 degrees F the night of 12/9/20 During a review of the facility's Policy and Procedure (P&P) titled, Quality of Life- Homelike Environment dated May 2017, the P&P indicated Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable and safe temperatures (71 F- 81 F) . During a review of the facility's P&P titled, Inspection of Heat/ Air- Conditioning Systems dated August 2008, the P&P indicated Our facility's heating and air- conditioning system shall be inspected at least semi- annually. Prior to the beginning of each heating and cooling season our facility's heating and air conditioning system shall be inspected for possible gas leaks, lines that have burst, etc. The Maintenance Department shall be responsible for such inspections, and shall have the authority to use local gas companies and/ or approved repairmen to assist in making such inspections when assistance is necessary .Maintenance Department is responsible for ensuring temperatures are safe, comfortable and within required range 71 to 81 degree F as evidenced by monitoring tool. During a review of online professional reference titled, Winter Wellness: Cold Weather and the Effects on Mental Health dated 12/17, found at (www.brookhavenretreat.com/cms) indicated, .The cold temperature itself can cause depression too. Cold weather keeps us from moving around and getting our blood flowing, which can lead to inflammation, and inflammation can signal the brain to become depressed. Cold temperatures also slow down the immune system's response time, making it harder to fend off germs . During a review of All Facilities Letter (AFL 13-31) sent to healthcare facilities from the California Department of Public Health Licensing and Certification titled, Winter Weather Emergency Preparedness Advisory dated 12/5/2013, indicated .Winter months bring weather that can rapidly create emergency and/or disaster-related conditions. Disaster plans must take all types of hazards into account, including the possibility of severe weather caused by freeze conditions and/or winter storms. Health care facilities are required by regulation to maintain their physical plant and all equipment in operational condition. If your facility is required to maintain an emergency power source, it must be fully tested and functional in order to ensure availability in the event of a power outage . During a review of the California Department of Public Health, Licensing and Certification Unit (CDPH L & C) - Intranet (local or restricted communications network) document titled, Winter Weather Health Tips, dated October 7, 2018, indicated The elderly and medically fragile are particularly susceptible to the cold. Persons with poor circulation, or who take medications that can interfere with the body's ability to regulate temperature, are at risk for hypothermia .Measures should be taken to trap existing warm air. If it appears, the loss of heat will be of significant duration, hang blankets over windows and doorways and move to a well insulated room.

Based on interview, and record review, the facility failed to ensure effective pain management was provided to 1 of 3 sampled residents (Resident 7) consistent with the facility's policy, resident care plan, and resident preferences when: 1. Licensed Nurses did not administer [MEDICATION NAME] (pain medication) medication consistent with physician's orders [REDACTED]. 2. Licensed Nurses did not review, acknowledge, or act on Resident 7's known [DIAGNOSES REDACTED]. 3. Licensed Nurses did not schedule a pain management consult appointment for a hip injection and sacroiliac joint (joint that connects spine to pelvis) injection for Resident 7 or provide Resident 7 with the use of a Geri chair (a medical clinical recliner chair designed to allow someone to get out of the confines of their bed and be able to sit comfortably in a variety of positions while being fully supported) for mobility per Resident 7's preference. 4. Licensed Nurses did not identify situations or interventions where an increase in Resident 7's pain was anticipated, as outlined in the facility's pain clinical protocol policy including Resident 7's need for pain intervention prior to transfer to a mechanical lift to transfer Resident 7 back to bed, prior to implementation of a Restorative Nursing Aide (RNA) (a certified nursing assistant (CNA) who has additional, specialized training in restorative nursing care. A restorative nurse's aide (RNA) helps patients gain an improved quality of life by increasing their level of strength and mobility) program, as well as prior to ambulating or repositioning. 5. Licensed Nurses did not attempt or document non-pharmacological (non-drug) interventions consistent with Resident 7's pain management care plan and physician's orders [REDACTED].>These failures resulted in Resident 7 experiencing pain and suffering from not receiving ordered pain medication and was transferred to an acute care hospital setting due to ineffective pain control and psychological harm, significantly affecting Resident 7's wellbeing. Because of the ineffective pain management by the facility, Resident 7's health and well-being was placed at risk for actual and potential harm. An Immediate Jeopardy (IJ) situation was called on 12/12/19 at 5:22 p.m. with the Administrator, Director of Nursing (DON), and Social Services Designee (SSD). Resident 7 was anxious, and experienced severe pain on 9/23/19 at a pain level scored 8 of 10 on a pain scale (a zero would be no pain and 10 worst pain imaginable) suffered from nausea and vomiting, and requested to be transferred to the hospital where he was admitted . The facility caused Resident 7 to have serious opiate (class of drugs to relieve pain) withdrawal symptoms by not providing prescribed [MEDICATION NAME] medication's, and necessitated a transfer to an acute care hospital on [DATE] that resulted in a 5-day hospitalization . Licensed Nurses displayed the behavior of not assessing and providing effective pain medication when Resident 7's pain levels were consistently documented as severe. Resident 7 suffered from extraneous pain as a result of inadequate assessment and failure to identify when to anticipate Resident 7 was in pain by licensed staff. The facility submitted and implemented a Plan of Removal to address the IJ situation. The IJ Plan of Removal was accepted on 12/14/19 and addressed in-service training and competencies of nursing staff to accurately assess Resident 7's pain. The Plan of Removal was verified to be implemented and the IJ was removed on 12/15/19 with the DON. Findings: 1. During a review of Resident 7's Minimum Data Set, (MDS) assessment, Section C- Cognitive Patterns, dated 11/24/19, the MDS assessment indicated, Resident 7 had the mental capacity to make medical decisions. Section C0500 of the MDS assessment indicated a Brief Interview Mental Status (BI[CONDITION]) score of 15 of 15. A score of 15 indicated no cognitive deficits. During an interview on 12/3/19 at 10:00 a.m., Resident 7, stated, .they took away my [MEDICATION NAME], I was getting it every 6 hours, took it away for a day and a half . I started throwing up blood and getting nausea and vomiting from withdrawal from not getting medicine . During a review of Resident 7's Order Summary Report, dated 12/3/19, the Order Summary Report indicated a physician's orders [REDACTED]. During an interview on 12/3/19 at 1:57 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 9/23/19, Resident 7 was not administered his routine [MEDICATION NAME] because the facility did not have any tablets on hand, and the insurance would not pay for the medication unless the physician sent in an approval. LVN 1 stated, I'm not sure about pain meds, if insurance not paying . for other meds, if insurance not paying, facility will pay for it . he (Resident 7) was having a tough time that's why he was sent to the hospital a day or two after . if resident doesn't get pain meds, they'll be in a lot of pain . During a review of Resident 7's Pain Management Care Plan (PM Care Plan), dated 8/21/19, the PM Care Plan indicated, To start [MEDICATION NAME] [MED] IR (immediate release) 45 mg p.o. (orally) every 6 hours routine. During a review of Resident 7's Medical Administration Record (MAR), dated 9/1/19 through 9/30/19, the MAR indicated [REDACTED]. During a review of Resident 7's Progress Notes, dated 9/23/19 at 4:32 a.m., the Progress Notes indicated, .Resident's [MEDICATION NAME] [MED] tablet 15 mg not available from . (name- pharmacy provider) two tablet(s) were left in card given to resident at 0000 (midnight). Called . and spoke to (pharmacy staff) as per (pharmacy) is waiting for MD's (Medical doctor-Physician's) authorization. Resident is aware of it. Will communicate with incoming nurse. During a review of Resident 7's Progress Notes, dated 9/23/19 at 5:16 a.m., the Progress Notes indicated, . med not available from (pharmacy). Per (Pharmacy) waiting for MD's authorization. Resident is aware. During a review of Resident 7's Progress Notes, dated 9/23/19 at 1:08 p.m., the Progress Notes indicated, .med is not available. Called (pharmacy) at (9:50 a.m.), said they are waiting for authorization from MD. MD notified at (10 a.m.). During a review of Resident 7's Progress Notes, dated 9/23/19 at 5:26 p.m., the Progress Notes indicated, .resident vomited recently, including medication [MEDICATION NAME] (anxiety medication). Resident requested another dose of [MEDICATION NAME], showing anxious behaviors due to awaiting of pain medication. MD notified of situation . During a review of Resident 7's Progress Notes, dated 9/23/19 at 10 p.m., the Progress Notes indicated, .medication not available, medication wasn't given . During a review of Resident 7's Progress Notes, dated 9/23/19 at 11:19 p.m., the Progress Notes indicated, .resident was reportedly vomiting the entire day of 9/23/19 and in pain. Resident left on gurney (stretcher on wheels for transporting patients) with paramedics. MD notified of situation. During a review of Resident 7's Progress Notes, dated 9/28/19 at 6:11 p.m., the Progress Notes indicated, The resident came back in stable condition around 1540 (3:40 p.m.) . During a concurrent interview and record review on 12/3/19 at 3:09 p.m., with the DON, Resident 7's MAR, dated 9/1/19 through 9/30/19 was reviewed. The DON validated Resident 7 was not administered 4 doses of routine [MEDICATION NAME] as ordered by the physician on 9/23/19 and was sent to the hospital for 5 days as a result of his pain not being managed at the facility. The DON stated, . when insurance doesn't cover resident, we do facility pay . we tell pharmacy to deliver and facility will pay for 2 to 3 days until we get prior auth. (authorization by physician to insurance) so patient doesn't have to suffer for not getting pain medication . During a follow up interview on [DATE] at 1:30 p.m., with Resident 7, when asked about the severity of his pain, Resident 7 stated, .I didn't get pain meds, had to go to hospital for 5 days . my pain was very very high, and I felt terrible . During a review of Resident 7's clinical record, titled, Discharge Summary Report (DS Report), dated 9/28/19, the DS Report indicated, Patient has chronic pain and opioid (class of drugs to relieve pain) dependence. Skilled nursing facility ran out of [MEDICATION NAME]. Patient developed nausea and vomiting, diarrhea. Patient also had one bout of upper GI (gastrointestinal-passage from mouth to anus) bleeding. He was brought to the ER (emergency room ) for evaluation. Patient was hydrated with IV (intravenous- administered in veins) fluids. He was started on [MEDICATION NAME], antiemetics (anti-vomiting), [MED] (medication for acid reflux) (heartburn). During a telephone interview on [DATE] at 10:36 a.m., with Physician 1, Physician 1 stated, That's a problem with facility, my patient needs medication . facility can override cost and give medication . technically resident needs pain (medication) and physician not there to sign paperwork . if you have patient, you have to give medication, patient should get medicine as ordered . I have spoken with them in facility . During an observation on 12/12/19, at 4:17 p.m., a narcotic e-kit (kit containing medications for emergency use, these narcotic medications can affect the mind and cause sleepiness) was observed in the medication cart. The narcotic e-kit contained 6 tablets of [MEDICATION NAME] [MED] IR 15 mg tablets. During an interview on 12/12/19 at 4:22 p.m., with the DON, the DON stated, I didn't know nurses was calling pharmacy for medication, wasn't here until next day when I came to work .No, not ok for resident to go one day without medication . I have no idea why they didn't use the e-kit, they know . The DON validated the narcotic e-kit contained [MEDICATION NAME] [MED] IR 15 mg tablets and was available to be used by licensed staff. During a telephone interview on 12/13/19 at 11:54 a.m., with the Pharmacy Biller (PB), when asked about the facility's process for providing medication to residents awaiting prior authorization, the PB stated, At that time (9/23/19) we did not send anything to facility unless they approved it . When asked if facility called pharmacy for authorization to access [MEDICATION NAME] 15mg IR tablet for Resident 7, the PB stated, I don't see where they billed for an e-kit, there would be an e-kit charge, I see no record . During a review of the pharmacy's Electronic Shipping Manifest (Manifest) dated 9/22/19, the Manifest indicated, one narcotic e-kit containing [MEDICATION NAME] 15mg IR tablets, was delivered to the facility on [DATE] at 2:11 p.m. During a telephone interview on 1[DATE] at 11:24 a.m., with Pharmacist 1, Pharmacist 1 stated [MEDICATION NAME] 15 mg IR was in the facility's e-kit. Pharmacist 1 stated the narcotic e-kit was replaced weekly and had been replaced on 9/22/19. Pharmacist 1 validated there was no record [MEDICATION NAME] 15 mg IR was accessed from the narcotic e-kit replaced on 9/22/19. During a review of the pharmacy's New After Hours Log (Log) dated 9/23/19, the Log indicated, medication request .needing a new rx (prescription), per nurse pt (patient) is out. Offered to see if on call is able to call MD for a verbal. Per nurse (Physician 1) will not answer at this hour, will have morning nurse follow up with pharmacy in the am. During a telephone interview on 1[DATE] at 12:05 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she worked the morning shift on 9/23/19 from 6:30 a.m. until 3 p.m. LVN 1 stated, On that day I called pharmacy to see what was going on, they sent a form that insurance wasn't covering . I wasn't aware that we could use e-kit for routine orders too, it didn't come to my mind and pharmacy didn't mention . During a telephone interview on 1[DATE] at 1:50 p.m., with LVN 6, LVN 6 stated she was the overnight nurse caring for Resident 7 from 9/22/19 to 9/23/19. LVN 6 stated, I was only left with 2 tabs (tablets) for midnight and I gave him (Resident 7) a dose and called pharmacy regarding medication. They said they're waiting on doctor authorization and I put in notes. They did offer to call doctor, I was concerned doctor will not answer, it was really late at night .I didn't ask about the e-kit at that time either. It didn't come up in my mind. when next dose was due at 6 a.m., when I went to told him we were out of medication, he told me, 'I still have pain.' During an interview on 1[DATE] at 2:23 p.m., with the DON, the DON stated LVN 6 should have had the pharmacy call the doctor. The DON stated, It's his choice if he answers or not and pharmacy would have notified nurse if doctor didn't answer . nurses need to check e-kit if medication is in there and call pharmacy, they know they need to get authorization code . During a review of the facility's policy and procedure, Emergency Pharmacy Service and Emergency Kits (E-Kits (Emergency PS & E-Kits), dated 9/10, the Emergency PS & E-Kits indicated, If an emergency verbal order is required the pharmacist/prescriber contact can occur either: 1. By the facility nurse contacting the pharmacy to notify there is a need to withdrawal a controlled medication from the emergency kit (EDK) and provides prescriber contact information so that the pharmacist can contact the prescriber directly. 2. By the facility nurse requesting prescriber contact pharmacy directly to give verbal emergency order and provide prescriber with pharmacy contact information. Once the pharmacist receives the valid emergency verbal authorization, the pharmacist will contact facility to notify facility nurse of: * authorization to access emergency kit * specific prescription details *number of authorized entries to E-kit * number of doses per entry to E-kit If hard copy Prescriber signed prescription is available: 1. Nurse will contact pharmacist to communication need to access E-kit . During a review of the facility's document, Floor Nurse Job Description, revised 4/13, the Floor Nurse Job Description indicated, Prepare and administer medications as ordered by the physician. 2. A review of Resident 7's admission records indicated Resident 7 had admission [DIAGNOSES REDACTED]. During a review of Resident 7's Physician Office Visit Record dated 4/4/18, the Physician Office Visit Record indicated, CT scan of the abdomen and pelvis performed at (hospital) on November 4, 2017 revealed multilevel [MEDICAL CONDITION] (irreversible loss of function) changes of the spine. Mild [MEDICAL CONDITION] [CONDITION] (bone in spine becomes displaced and moves forward or backward irreversibly) at L5-L1 (Lumbar 5-Lumbar 1 -lower backbones of the spine). Avascular necrosis (death of bone tissue due to a loss of blood supply, can cause bone to collapse) of the femoral heads bilaterally (highest parts of both thigh bones), right greater than left. Mild collapse of the articular surface (surface of bone or cartilage) of the right femoral head (bony knob of thigh bone) . During an interview on 12/3/19 at 10:50 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated, He (Resident 7) doesn't want to shower, doesn't want bed bath, doesn't want to be repositioned, he says no, hip hurts . During an interview on 12/3/19 at 10:59 a.m., with Resident 7, Resident 7 stated, I don't like to be moved when I'm in pain, it hurts . During a review of Resident 7's Pain Management Care Plan (PM Care Plan) dated [DATE], the PM Care Plan indicated, Interventions: Document non-pharmacological interventions prior to administration of PRN (as needed) medications as follows: ([MEDICATION NAME] (pain) interventions) 1) Repositioning 2) Calm/Quiet Environment, Dim Lighting 3). Hot/Cold Application 4) Relaxation Techniques 5) Distraction 6) Music 7) Massage 8) Other/see nurses notes as needed. During a concurrent interview and PM Care Plan on 12/3/19 at 11:24 a.m., with LVN 1, LVN 1 confirmed Resident 7's non-pharmacological interventions for pain management. LVN 1 stated, He (Resident 7) doesn't want to be moved . yeah if he doesn't want to be moved . intervention (repositioning) wouldn't be effective . During a review of Resident 3's PM Care Plan dated [DATE], the PM Care Plan indicated, Interventions: Document non-pharmacological interventions prior to administration of PRN (as needed) medications as follows: ([MEDICATION NAME] (pain) interventions) 1) Repositioning 2) Calm/Quiet Environment, Dim Lighting 3). Hot/Cold Application 4) Relaxation Techniques 5) Distraction 6) Music 7) Massage 8) Other/see nurses notes as needed. During a review of Resident 5's PM Care Plan dated 11/23/19, the PM Care Plan indicated, Interventions: Document non-pharmacological interventions prior to administration of PRN (as needed) medications as follows: ([MEDICATION NAME] (pain) interventions) 1) Repositioning 2) Calm/Quiet Environment, Dim Lighting 3). Hot/Cold Application 4) Relaxation Techniques 5) Distraction 6) Music 7) Massage 8) Other/see nurses notes as needed. During a concurrent interview and record review on 12/3/19 at 1:34 p.m., with LVN 1, the PM Care Plan for Residents 3, 5, and 7 was reviewed on 12/3/19. LVN 1 validated the non-pharmacological interventions for Residents 3, 5 and 7 were identical. LVN 1 stated that for Resident 7, . repositioning wouldn't work for him because he doesn't like to be moved . they (non-pharmacological interventions) should be more specific to what interventions would work for them (residents) . During a concurrent interview and record review PM Care Plan on 12/3/19 at 2:44 p.m., with the DON, the DON validated non-pharmacological interventions for Residents 3, 5 and 7 were identical and not individualized for each resident. DON stated, That's the standard we have. During an interview on [DATE] at 1:30 p.m., with Resident 7, when asked if non-pharmacological interventions indicated in care plan were his preference, Resident 7 stated, four of them (IDT- interdisciplinary team (care team that meets to review, discuss, and make recommendation about care of resident) meeting) come in room to gang up on me, don't ask me what I want to relieve pain aside from medications . During a review of the facility's policy and procedure (P&P) titled, Care Plans- Comprehensive revised 12/10, the P&P indicated, Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. developing interventions that are targeted and meaningful to the resident . 3a. During an interview on 12/3/19 at 10:50 a.m., with CNA 2, CNA 2 stated, I'm not sure why he's here, something with his hips, something is wrong with his bones, he can't really stand up and walk . he doesn't want to shower, doesn't want bed bath, doesn't want to be repositioned, he says no hip hurts, doesn't want to change clothes or pad, he asks for wash cloth to wipe his face and hands . he doesn't want to get up. I don't really know about care plan but to transfer him when they do deep cleaning in the rooms, I think they give him something for pain, maybe [MEDICATION NAME] . we are supposed to chart on computer so you guys can see everything he doesn't want to do. He has a wheelchair by his bedside to get around . During a concurrent observation and interview on 12/3/19 at 10:59 a.m., with Resident 7 in his bedroom, a wheel chair was observed against the wall on the left side of Resident 7's bed. When asked about the wheel chair, Resident 7 indicated he had notified staff about his inability to use the wheelchair due to pain in his back and hip. Resident 7 stated, They know I can't use a wheelchair and have to use a Geri chair (Geri chair- large, padded, comfortable reclining chair with casters designed to allow patients who cannot walk, to get out of a bed and sit comfortably while being fully supported and transported within a facility), better for my pain control . During a concurrent interview and record review on 12/3/19 at 11:24 a.m., with LVN 1, Resident 7's Order Summary Report, dated 12/3/19 was reviewed. The Order Summary Report indicated Resident 7 did not have an order for [REDACTED]. LVN 1 validated Resident 7 did not have an order for [REDACTED].>During a concurrent interview and record review on 12/3/19 at 11:47 a.m., with the DON, Resident 7's Care Plan, undated was reviewed. The DON was unable to provide documentation of a care plan addressing the use of a Geri chair for Resident 7. The DON validated Resident 7 did not have a care plan for the use of a Geri chair. The DON stated, Yes, there should be a care plan for the use of a Geri chair so nurses know to offer resident. The DON also validated Resident 7 did not have an active order for a Geri chair, and a new order was initiated a few minutes prior, at 11:45 a.m. During an interview on [DATE] at 1:30 p.m., with Resident 7, Resident 7 stated he was able to use a walker until approximately 5 months prior. Resident 7 stated, .my back and hip hurt so bad, I can't sit in a wheelchair at all .I sat in the wheelchair for 5 hours going to a doctor appointment, waiting in doctor's office and coming back . During an interview on [DATE] at 2:48 p.m., with the DON, the DON stated, Yes he (Resident 7) told us he can't use wheelchair, we have Geri chair but he wants a special one, I will follow up on where we are. 3b. During an interview on 12/3/19 at 11:55 a.m., with the DON, the DON indicated Resident 7 had a pain management consult and was being seen by Physician 2 at his office, outside the facility. During a concurrent interview and record review of Resident 7's Progress Notes, on 12/3/19 at 12:20 p.m., with the Social Service Designee (SSD), the SSD indicated Resident 7 was being seen by Physician 2, who was a specialist in back and neck pain management. The SSD stated Resident 7 did not have medical insurance and could not go to appointments from 12/13/18 to 3/13/19. During a review of Resident 7's Progress Notes, the Progress Notes indicated, Resident 7 had been seen by Physician 2's office on 4/4/18, 9/27/18, 10/1/18, 11/6/18, and 4/10/19. The Resident 7's Progress Notes also indicated Resident 7 had requested that facility schedule an appointment for pain management on 9/30/19. An appointment was made for 10/15/19 for Resident 7 to be administered a pain injection and follow up with Physician 2 on 11/6/19. During a concurrent interview and record review on 12/3/19 at 3:04 p.m., with the DON, Resident 7's PM Care Plan was reviewed. The DON was unable to provide a care plan addressing the administration of pain injections to Resident 7 outside of the facility. The DON stated, . he didn't receive injections here, so I didn't care plan for that . yes, should be included in care plan . During a record review of the Progress Notes indicated, 4/4/18 13:56, Resident (7) left for an appt. (appointment with Physician 2) with staff . 9/27/18 17:15 (5:15 p.m.) Resident (7) came back from his appt. with (Physician 2) . 10/1/18 18:04 (18:04 p.m.) Resident (7) came back . procedure that the resident went to the office for was not done . 11/6/18 14:14 (2:14 p.m.) Resident (7) came back at 14:10 (2:10 p.m.) . will be S/P (status [REDACTED]. 4/10/19 9:27 Resident (7) . at 0920 (9:20 a.m.) for an appt. at chronic pain clinic . 5/3/19 0054 (12:54 a.m.) Around 23:45 (11:45 p.m.) this resident (7) called this writer about having severe pain in his right leg and hip .resident was continuously (sp)c/o (chief complaint) pain with pain scale of 10/10 and requested this writer to go out to hospital. Resident stated 'this pain is worse and I can't take it anymore.' This writer called MD and go an order (sp) to send this order to send this resident to hospital (sp) . 6/6/19 12:44 (p.m.) this writer received a phone call from (Physician 2's) office where resident has his pain injection .wanted to schedule appointment for resident to have injections on [DATE] .Resident (7) said I will let you know when I can go. 9/30/19 Resident (7) requested for this writer to call (Physician 2) to schedule appointment for pain management injections. This writer was able to get resident appointment with (Physician 2) for pain injections on 10/15/19. 10/14/19 16:10 (4:10 p.m.) this writer was informed by the charge nurse that Resident (7) appointment at (surgery center) called and cancel resident appointment . SSD indicated the appointment on 10/14/19 was cancelled because Resident 7's appointment had been scheduled at a different surgery center that did not accommodate residents who were unable to walk. SSD confirmed Resident 7 had previously been seen at a surgery center that accommodated residents who were unable to walk. The SSD confirmed it had been over 2 months since Resident 7 requested that the facility schedule an appointment for pain management and acknowledged the facility had not followed up to reschedule the appointment for Resident 7. During a review of Resident 7's Pain Management Care Plan (PM Care Plan), the PM Care Plan indicated, . scheduled for pain injections with pain management (Physician 2) on 10/15/19 at surgery center, refusing to go there too . During a concurrent interview and record review on 12/3/19 at 2:52 p.m., with the DON, Resident 7's Progress Notes from May 2019 to December 2019 were reviewed. The DON was unable to find documentation that Resident 7 had refused to go to his pain management appointment on 10/15/19. The DON validated Resident 7 had requested that the facility schedule an appointment for pain management on 9/30/19. The DON also confirmed the facility had not followed up to reschedule the appointment for Resident 7 after it was cancelled by the surgery center. The DON stated, If appointment is cancelled, facility should follow up to reschedule .it affects way resident pain is managed . During a telephone interview on [DATE] at 10:32 a.m., with Physician 1, Physician 1 stated, It's not his (Resident 7) fault, they (facility) should have rescheduled appointment for pain injection . 4a. During a review of Resident 7's MDS, dated [DATE], the MDS indicated, Resident 7 had limitation that interfered with daily functions or placed resident at risk of injury and was impaired on both sides in his lower extremity (hip, knee, ankle, foot). During an interview on 12/3/19 at 10:33 a.m., with CNA 1, CNA 1 stated, (Resident 7) is very lazy, doesn't want to get up all at, doesn't even take shower . During an interview on 12/3/19 at 10:59 a.m., with Resident 7, Resident 7 indicated he did not want to get out of bed because he was in pain. Resident 7 stated, .they have to use (mechanical lift) (mechanical device to lift patients safely) to get me out of bed and it hurts a lot . If I want to get up, they will give me liquid [MEDICATION NAME], helps for about an hour then I'm in pain again, from being in Geri chair and getting back in (mechanical lift) . no pain meds when getting back in (mechanical lift) . I don't like to be moved when I'm in pain, it hurts. During a concurrent interview and record review of Resident 7's Order Summary Report, dated 12/3/19, on 12/3/19 at 11:07 a.m., with LVN 1, LVN 1 stated, . (Resident 7) started getting into Geri chair for deep cleaning when liquid [MEDICATION NAME] offered . LVN 1 validated Resident 7 did not have an order for [REDACTED].can anticipate he's going to have pain, if you ask him if he's in pain . 4b. During an interview on [DATE] at 1:30 p.m., with Resident 7, Resident 7 stated, Both of my hips are dying, they don't understand it's getting worse .the way they talk, they say that you could do it if you really wanted to . I say it's getting worse and they say you just don't want to do it . I'm afraid it's not getting better, it's getting worse, I feel terrible . I'm kinda in a catch 22, ortho doctor said I need to walk if I need hip replacement but I can't walk because I'm in too much pain . During a review of Resident 7's Order Summary Report, dated 12/3/19, the Order Summary Report indicated a physician's orders [REDACTED]. During an interview on [DATE] at 2:33 p.m., with RNA 1, RNA 1 stated, He's (Resident 7) supposed to do range of motion but he refuses to do them, he says, You don't understand I'm in pain . I go at different times but he has the same excuse, 'I'm in a lot of pain' . I don't know what time they pass pain meds, I go at different times but it doesn't change . he always says no, I told the nurses . During a concurrent interview and record review on [DATE] at 3:10 p.m., with the DON, Resident 7's Progress Notes from May 2019 to December 2019 were reviewed. The DON was unable to provide documentation that nursing staff had identified or addressed Resident 7's need for pain intervention prior to getting back in the mechanical lift (used to assist resident to transfer from one surface to another) to get back to bed, prior to RNA program, as well as prior to ambulating or repositioning. The DON validated nurses had not followed up with Resident 7's physician regarding pain interventions relating to Resident 7 ambulating, repositioning, getting back in the mechanical lift to get back to bed, or prior to RNA program. During an interview on [DATE] at 10:32 a.m., Physician 1 stated, Resident (7) told me when he gets in chair pain increases so I ordered liquid [MEDICATION NAME] . nobody told me about pain that he experiences getting back in bed, or refusing to do RNA because of pain . they (staff) never came to me to say he's in pain or do something different . During a review of Resident 7's Progress Notes dated 10/2/19 at 12:31 p.m. and signed by the DON, the Progress Notes indicated, IDT (interdisciplinary team- care team coordinating assessment and care of resident) met with resident in room because resident refuses to get up to attend the care meeting. Discussed all the options to get up start with 20 minutes and then gradually increase the time. Per resident he is not feeling well and he recently came from hospital .Every time staff reaches him to get out of bed, resident has some kind of excuse .resident keep asking for medications for any little thing but wont, get out of bed at all . go in room to chat and resident is talking/laughing with peers or most of the time laying in bed with eye mask on. No s/sx (signs/symptoms) of pain/discomfort noted. No moaning/groaning noted. No facial expressions noted. Keep asking for pain meds. MD (physician) is aware of him. No matter ho

Based on observation, interview, and record review, the facility failed to ensure sufficient preparation and orientation for a safe and orderly discharge from the facility for four of 27 residents (Resident 1, 2, 3, and 7) when: Resident 1 was discharged from the Skilled Nursing Facility (SNF) 1 without family support and into a situation that previously required Adult Protective Services (APS) intervention, without ensuring physician ordered medical services and equipment were in place. Upon discharge, Resident 1's family member refused entry into the home and 911 was called. Resident 1 experienced emotional and physical distress that required intervention by local police and the fire department and subsequent transfer of Resident 1 to the acute care hospital (ACH) by ambulance. Resident 2 was discharged from SNF 1 where he was assessed to require 24 hour nursing care and insulin (hormone that lowers blood sugar levels) injections four times a day to treat his medical condition, to a room and board (R&B, a home that provides food and lodging, and requires residents to be independent) which did not have staff on duty 24 hours a day or staff who could administer injections; the R&B only provided a room and meals. The owner of R&B 1 stated Resident 2 required a higher level of care than what could be provided at R&B 1 and transferred Resident 2 to R&B 2 (also a home which only provides meals and a room). Resident 2 later fell at R&B 2 and suffered a fractured (broken) left hip which required surgical intervention. SNF 1 did not verify the services required on discharge were provided by R&B 1 and incorrectly identified the R&B as a Board and Care (B&C- licensed homes staffed with caregivers 24 hours a day/seven days a week) and as an Assisted Living (housing for elderly or disabled that provides nursing care, housekeeping, and prepares meals). Resident 3, who had resided in SNF 1 for 1458 days and suffered from dementia (disorder causing decline in memory, reasoning and judgement and poor safety awareness) was discharged from SNF 1, where he was assessed to require 24 hour nursing care and extensive staff assistance for all activities of daily living, to R&B 1, where 24 hour care and supervision were not provided, placing Resident 3 at risk of harm and injury. The owner of R&B 1 stated Resident 3 required a higher level of care than what could be provided at R&B 1 and transferred Resident 3 to R&B 2. The facility did not verify the services required on discharge were provided by R&B 1 and incorrectly identified the R&B as a B&C and as an Assisted Living facility The survey findings validated an Immediate Jeopardy at the Code of Federal Regulations (CFR) 483.15(c)(7) Orientation for Transfer or Discharge, F204 with a scope and severity of K (more than a limited number of individuals affected; Immediate Jeopardy (IJ), a situation in which immediate corrective action is necessary because the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility). Because of the actual serious harm related to the unsafe discharge of Resident 1 and Resident 2, and the serious potential harm of the unsafe discharge of Resident 3, an IJ situation was called on 5/3/17 at 11 a.m. with the Administrator (Adm), Assistant Administrator (AA), Director of Nursing (DON) and Social Services Designee (SSD). On 5/4/17 at 11 a.m., the Adm presented an acceptable Action Plan addressing the IJ situation. The action plan consisted of the following elements: (1) Establishment of criteria for review by the Interdisciplinary Team (IDT, team of health care providers that plan resident care including licensed nurses, Social Services and facility Administrators) prior to resident discharge. The review would include assessment of resident needs to ensure appropriate placement with adequate services to meet resident needs, ensuring the discharge is safe, obtaining physician orders [REDACTED]. IDT to ensure all residents will be provided, educated, and assisted with the appeal process if they do not agree with the discharge and the Ombudsman will be contacted for any resident who is unable to make decisions and has no responsible party. (2) Revision of the facility Notice Before Transfer form to include the right to appeal the discharge and the process to appeal a discharge. (3) Establishment of a process to verify the facility residents are discharged to a properly licensed facility that has the ability to meet the needs of the resident. (4) Arrangement for training on the discharge process, IDT process and Quality Assurance process through Health Services Advisory Group. On 5/5/17 at 3:05 p.m., the surveyor met with the Adm, DON, and SSD. The facility demonstrated that all the elements of the Action Plan that addressed the immediacy had been implemented and the IJ was removed on 5/5/17 at 3:05 p.m. with the Adm, DON and SSD present. Resident 7 was discharged into the care of the owner of R&B 1. The owner of R&B 1 was unable to provide care for Resident 7 and transferred Resident 7 to R&B 3 which was owned by a different provider. R&B 1 and R&B 3 were homes that provided a room and meals. No skilled nursing services or 24 hour care givers were available at R&B 1 or R&B 3.The owner of R&B 3 was unable to provide the level of care required by Resident 7. The owner of R&B 3 stated Resident 7's friend removed Resident 7 from R&B 3 and her whereabouts is unknown. The facility did not verify the services required for Resident 7 were available at R&B 2 and placed Resident 7 at risk for harm from inadequate care. Findings: For Resident 1: Resident 1's face sheet (document containing resident personal information) indicated Resident 1 was [AGE] years old and was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS) (a resident assessment tool) assessment, dated 8/24/16, indicated Resident 1 had no cognitive (memory) impairment. The MDS assessment indicated Resident 1 did not ambulate (walk) and required total staff support in bed mobility, transfers from bed to wheelchair, locomotion while in wheelchair, dressing, toilet use, personal hygiene and bathing. Administrative document review, untitled and dated 10/6/16, indicated a typed written 30 day discharge notice addressed to Resident 1. The letter indicated, Hand delivered to (Resident 1) at (the facility) .Copy to (Family Member (FM) 1) .You are hereby given a 30 Day notice of discharge from (facility) .because you have not been paying your share of cost. Your Medical (Medi-Cal) determined share-of-cost is $2,269 per month. Your current bill is $11,649.63. You will be discharged on [DATE] unless your bill is paid in full and/or a satisfactory repayment plan is established prior to that time. Your bill will increase by $2,269 plus interest by that date. You will be discharged to your home with your (FM 1). We will assist you in setting up in-home care if you desire. You have all your mental capacities and even with certain physical limitations you should be able to function at home with some in-home supportive services . On 11/10/16 at 9:40 a.m., during an interview and concurrent clinical record and administrative document review, the AA stated Resident 1 was discharged from the facility on 11/7/16. The AA stated, We provided transportation to her (Resident 1's) home. (FM 1) refused to open the gate to let her come in. The AA stated she and the Adm drove to Resident 1's house after Resident 1's transport driver informed them FM 1 would not let Resident 1 inside the home. The AA stated FM 1 yelled and cursed at them, and refused to open the gate. The AA stated, We offered to let him pay the bill. The AA stated FM 1 stated he paid the utility bill with Resident 1's money; he took care of her house and could not take care of her. The AA stated while the situation with FM 1 yelling and the facility staff responding took place, Resident 1 complained she didn't feel well, so she (the AA) called 911 (the emergency response phone number). The AA stated two policemen and three or four firemen responded to the 911 call and the AA and the Adm then left Resident 1 at her house. The AA stated, We were told we were free to go. We left. (FM 1) was in the house. The resident (Resident 1) was at the gate with officers, and the paramedics were taking her (Resident 1) to the hospital .She (Resident 1) said she knew the law. She didn't believe she would be kicked out. The AA stated FM 1 had not answered phone calls from the facility prior to Resident 1's discharge and had not participated in Resident 1's discharge planning. Resident 1's ACH clinical record titled, ED (emergency department) Provider Notes dated 11/7/16, indicated, Chief Complaint .patient was kicked out of SNF (SNF 1), PD (police department) states home is unfit for patient to live in XXX[AGE] year old was left in front of her house and FPD (local PD) stated her house is unfit to live in, therefore was transported to the hospital . Resident 1's ACH clinical record titled, Acute Care Physical Therapy Initial Assessment and discharge date d 11/8/16, indicated, .Summary/Analysis of examination: The patient .who presents for placement due to unsafe living conditions at her home. She (Resident 1) demonstrates weakness about all extremities with right [MEDICAL CONDITION] (paralysis of one side of the body) consistent with previous stroke [AGE] years ago. She required maxA ( maximum assistance) to complete bed mobility and transfer tasks .She exhibits excessive extensor tone (muscle tightness) about BLE (both lower extremities) which made stand pivot transfers difficult to complete .Recommend disposition to long term SNF when medically cleared .Nursing staff to assist patient with bed mobility .Most appropriate from 2 person stand pivot transfer versus lift (mechanical device to lift patient out of bed and transfer to chair) transfer for patient and caregiver safety . Resident 1's ACH clinical record titled, Case Manager Addendum dated 11/7/16, indicated, .Per medical record review - she was an APS case 05/10/16 - APS report filed by PD due to unsanitary living conditions and suspicion of abuse/neglect. Pt (patient) with a past medical history of [REDACTED]. In (identity of facility) ED pt was noted to have hair soiled with feces, small cockroaches on her, and multiple wounds. Wound on right foot found to have maggots. Report received by APS from PD that pts home is uninhabitable and that (FM 1) appears to have his own medical conditions and cannot care for pt . Resident 1's clinical record titled, . EMS (emergency medical services) dated 5/8/16, indicated, XXX[AGE] year old female .found laying on the floor by (FM 1), c/o (complaint of) possible fall unknown how long pt (patient) has been on floor .firemen on scene stated, The inside of the house is not livable, I (captain) called .PD to come out and start an APS case, the pt cannot take care of herself and when you see her inside (home) you'll see what I mean. (FM 1) was on scene in the house, (FM 1) stated, I have been at the hospital; for the past 4 days .I don't know how long she has been on the floor. Pt .completely soiled head to toe, coffee ground emesis (vomit) inside the pt mouth/on arms/shirt, diaper full leaking out, cockroaches crawling all over the pt . On 11/15/16 at 1 p.m., during an interview and concurrent clinical record review, the SSD stated there were allegations of abuse at Resident 1's home prior to her admission to SNF 1. The SSD stated Resident 1 did not have a safe discharge. The SSD stated there were issues surrounding APS. The SSD stated, When we talked to her, she wanted to go home .she hadn't seen (FM 1) in six months. The SSD stated FM 1 did not participate in discharge planning. The SSD stated medical equipment was required for home care, which needed to be arranged prior to Resident 1's discharge. The SSD stated Resident 1 was bed and wheel chair bound, and Resident 1 had not walked during her stay at the facility. The SSD stated Resident 1's physician ordered a hospital bed, a wheelchair, a mechanical lift, a bedside commode (portable bedside toilet) and a shower chair for home use. The SSD stated there was no validation the items had been delivered to the house or would be able to be acquired with Resident 1's insurance. The SSD stated, There was no reason to expect (FM 1) would cooperate. I knew it was an unsafe discharge. I didn't have access to her house. I didn't know if she had medical equipment. The SSD stated, A 30 day notice (notice of transfer/discharge) was given for failure to pay. The SSD stated Resident 1's discharge Was up to the Administrator. Resident 1's Progress Note, entered by the SSD, dated 6/7/16 at 2:13 p.m., indicated, This writer contacted the Adult Protective Services to confirm if there is an open case. Spoke with (worker's name) and he said yes the case is still open . An additional Progress Note, entered by SSD, dated 8/23/16 at 11:31 a.m., indicated, It is uncertain if returning to her home would be a safe discharge. Adult Protective Services were involved. This writer has left many messages for (FM 1) and he does not return the calls . On 4/13/17 at 9 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 was discharged home on[DATE] at 2 p.m. LN 1 stated Resident 1 did not want to sign for her discharge. LN 1 stated Resident 1 looked angry and later began to cry. LN 1 stated the Adm and the AA spoke to Resident 1 about her discharge taking place on 11/7/16, and told her she needed to sign the discharge papers. LN 1 stated Resident 1 had wounds on her right foot. LN 1 could not explain what type of wounds. LN 1 stated Resident 1 required daily wound care to her right foot toes. LN 1 stated she did not think Resident 1 could perform her own wound care. LN 1 stated she did not know what date the home health agency would follow up with Resident 1 for the wound care. LN 1 stated she did not think Resident 1 had a safe discharge home. Resident 1's clinical record titled Surgical Consent dated 10/27/16, indicated, Consultation for wound on right medial (inner side) foot .Subcutaneous (under the skin) tissue debridement (removal) performed by surgical excision (cutting out) of devitalized (dead) subcutaneous tissue .The pre-op (before procedure) wound area was 1.5 centimeters (cm-metric unit of measurement) X (by) 1.5 cm X .3 cm .The post op (after procedure) was 1.5 cm X 1.5 cm X .3 cm .DRESSING USED: Santyl (topical medication used to remove dead tissue)/ Calcium alginate (absorbent dressing). The patient has a wound located at the right medial foot .wound debrided today was at the right medial foot. For this wound there was evidence of tissue breakdown requiring aggressive management and may require future debridement .No guarantee for wound healing can be made given the patient risk factors and [DIAGNOSES REDACTED]. Resident 1's clinical record titled Pressure and Vascular Ulcer Log dated 11/2/16, indicated, R (right) medial foot wound 2 cm X 1.9 cm X .2 . Resident 1's physician orders [REDACTED]. Resident 1's clinical records titled, Video Swallow Evaluation dated 9/28/16, indicated, History of Silent aspiration (food or fluids enter the lungs) and dysphagia (difficulty swallowing) .With thin liquids, premature spillage (food or liquid swallowed escapes from the mouth and reaches the pharynx (throat) before the swallow starts) is seen into the piriforms (located in the pharynx are narrow hollowed areas) .Premature spillage is seen which may predispose to future episodes of aspiration .No aspiration or penetration with nectar or dry solids . Resident 1's clinical record titled, Order Summary Report dated 11/7/16, indicated Resident 1 had a physician ordered Mechanical Soft Diet (diet consisting of easy to swallow foods including ground meats and soft cooked diced vegetables and fruits), Nectar consistency (thick liquids). On 4/13/17 at 10:40 a.m., during an interview and a concurrent record review, the Director of Nursing (DON) stated Resident 1 was on a mechanical soft diet and required thickened liquids (liquids with an added unflavored powder used to thicken the consistency for those with swallowing problems) due to her dysphagia. The DON stated Resident 1 was seen by the speech therapist (ST) who determined Resident 1 needed to remain on nectar thick liquids to prevent aspiration of liquid into the lungs. The DON stated she did not know if Resident 1 could cook. The DON stated she did not know who would prepare Resident 1's meals at home or if Resident 1 knew how to thicken her liquids. The DON stated she did not know if Resident 1 was discharged with thickener because it was not reflected in Resident 1's clinical notes. The DON stated the SSD made all of the arrangements for the discharge and determined what support system existed for the residents being discharged . The DON stated she did not know FM 1 was not involved in the care of Resident 1. The DON stated she was unsure if Resident 1 demonstrated the ability to perform her wound treatment. The DON stated she was not aware APS was involved prior to Resident 1's admission. The DON stated, I don't think it was a safe discharge. On 4/13/17 at 11:30 a.m., during an interview, the AA stated she believed Resident 1 received a safe discharge. The AA stated Resident 1 wanted to be discharged from the facility. The AA stated Resident 1 was left on her (Resident 1's) property. The AA stated FM 1 was in Resident 1's house and the police officers were present. The AA stated, We had already lost a lot of money from her (Resident 1) nonpayment. The AA stated she was aware of APS involvement and she couldn't say whether or not it was appropriate for Resident 1 to return to the same previous living arrangements. The AA stated she was not aware of any regulation requiring facilities to ensure a safe discharge. Review of Resident 1's Physician order [REDACTED]. On 11/15/16 at 9:40 a.m., a telephone interview with the Staffing Supervisor (SS) of a company which provided companion care services and activities of daily living assistance was conducted. The SS stated he visited Resident 1 on 10/25/16 at SNF 1 to discuss services that his company could provide to Resident 1 after discharge from the facility. The SS stated the around the clock companion care ordered by Resident 1's physician was not covered by Resident 1's insurance. Resident 1 would have to pay privately for the 24 hour companion services and activities of daily living assistance. The SS stated Resident 1 informed him on 10/25/16 that private pay was an issue for her; she did not have the money to pay for the services. The SS stated Resident 1 did not have 24 hour companion services or activities of daily living assistance arranged for her discharge home due to her refusal of services related to inability to pay. On 11/15/16 at 1 p.m., during an interview, the SSD stated she was aware the 24 hour companion care services and activities of daily living were not covered by Resident 1's insurance and required Resident 1 to pay with private funds. The SSD stated she was not aware Resident 1 had declined the services due to inability to pay for around the clock companion care. On 4/13/17 at 2:45 p.m., during a telephone interview, the home health agency Adm (HHA ADM) stated the agency received orders for physical therapy and a home safety evaluation only. The HHA ADM stated, When we reviewed it (the orders), it looked like we would require more assistance and a nurse to follow. The nurse was scheduled for visit on 11/9/16 (Two days after the discharge from SNF 1 occurred). Resident 1's clinical record from the home health agency titled, Patient Communication dated 11/6/16, indicated, Patient referral from (facility) for discharge on 11/7 to home, includes medication training and wound care. Should RN (registered nurse) open to Home health? This patient is scheduled for PT (physical therapy home safety evaluation) on 11/9/16 . On 4/13/17 at 9:55 a.m., during an interview and concurrent record review, the SSD stated home health services were offered to Resident 1 on 10/6/16. The SSD stated, home health would complete an evaluation for home safety, medication training, and wound care. The SSD stated she did not contact the home health agency to coordinate or assist Resident 1 in arranging the first visit to ensure Resident 1 was safe. The SSD stated she did not know when the home health agency would follow up with Resident 1. The SSD stated Resident 1 did not have a supportive family unit working toward Resident 1's discharge. The SSD stated she made no attempt to contact APS prior to Resident 1's discharge to inquire about the previous APS case regarding Resident 1's home situation. The SSD stated she did not review the discharge instructions prior to Resident 1's discharge home. The SSD stated Resident 1 should not have been discharged to the same living conditions that existed prior to her admission to the facility. On 4/19/17 at 10:40 a.m., during a telephone interview, the durable medical equipment assistant (DMEA) stated the facility notified the equipment company by facsimile (fax) on 11/4/16 of the durable medical equipment (DME) need for Resident 1 at home. The DMEA stated, It looks like they ordered a manual wheelchair, oxygen, commode, hospital bed, a mechanical lift and a shower chair. The wheelchair was not going to be covered (by Resident 1's insurance). We needed additional documentation, more supporting notes and oxygen levels. The facility never responded, and they didn't call to make any arrangements. The DMEA stated the additional documentation was requested from the facility on 11/14/16 seven days after Resident 1 was discharged from the facility and ten days after the initial durable medical equipment was ordered. On 4/19/17 at 11:05 a.m., during a telephone interview, the DME supervisor (DMES) stated, It (the DME order) shows that we needed additional documentation to be able to determine if the DME ordered would be delivered. There are strict guidelines and the need (requires) to be supported with documentation. We did not receive it. It also looks like the form was left incomplete. We need patient height, patient weight, length of need and prognosis. Resident 1's clinical record titled, MULTI-DISCIPLINARY DISCHARGE SUMMARY (document that contains resident discharge assessment and plan) dated 11/7/16, contained an incomplete discharge summary. The document did not list a discharge diagnosis; under Nutritional Status Special Needs (including Preferences and Restrictions) did not list Resident 1's mechanical soft diet orders or need for nectar thick liquids. The document indicated an incomplete Nutritional Intake and Eating Habits. The document lists weakness under Joint Motions Disorders. The document listed Rt (right) foot open wound and Dressing changed q (every) day under TREATMENTS AND OR PROCEDURES. The document had incomplete entries under Procedures, Rehabilitation Potential, Discharge Potential, Activity Interest, Activity Potential and Activity Participation. The document was missing signatures and names of persons who completed the forms. The document was not signed by Resident 1 in the space that indicated, Resident Signature. On 4/18/17 at 10:20 a.m., during an observation and concurrent interview, Resident 1 was alert and sitting up in bed in SNF 2. Resident 1's fingers of her right hand were stiff and drawn in toward her palm. Resident 1 demonstrated difficulty moving her fingers. When asked about her discharge from SNF 1, Resident 1 stated she had been upset about the discharge. Resident 1 stated she had not been shown how to take care of her right foot wound. Resident 1 stated she would not have been able to care for her foot wound due to her limited mobility with her right hand and fingers. Resident 1 stated, (FM 1) is unable to care for me at home. He has been in and out of the hospital .My house has no electricity and no running water or heat .The manager (Adm) at the facility accused me of being a thief because I didn't give them my pension .I wanted to explain that (FM 1) was using my money to pay for my taxes and my bills plus the utilities. I was not stealing from them. Resident 1 stated, I was sad by the entire thing. I was stuck between a rock and a hard place. They were calling me a thief and accusing (FM 1) of stealing from me, but what would they have done. I felt horrible that I was kicked out of the facility and not let into my house, but (FM 1) is also ill himself. I wanted to be taken away (by the paramedics). On 4/18/17 at 12:05 p.m., during an interview, the Adm stated, I feel it was a safe discharge because (Resident 1) was never left in an unsafe situation. The cops were present .she (Resident 1) was on her property and (FM 1) was not letting her in her home. He refused to open the gate. The Adm stated, You can talk to (SSD) but (FM 1) and (Resident 1) were both in agreement to discharge home. The Adm stated Resident 1, Complained about being on a mechanical soft diet. I told her that she could go home and eat whatever she wanted. The Adm stated he assumed Resident 1 had a blender to prepare the mechanical soft diet because Resident 1 said she, had everything at home. The Adm stated he believed Resident 1 could prepare her own meals. The Adm stated he didn't think he called Resident 1 a thief. The Adm stated, Putting it into perspective, I told her the money belonged in the facility and she was stealing from the facility. The Adm stated he knew APS had a closed case on Resident 1 involving (FM 1). On 4/19/17 at 3:10 p.m., during a telephone interview, with APS supervisor (APSS) 1 and APSS 2, APSS 1 stated he was familiar with Resident 1's APS case of 5/10/16. APSS 1 stated Resident 1 should have never been discharged back to those conditions. APSS 2 concurred with APSS 1's discharge assessment. Administrative document review of a type written letter, untitled, dated 3/30/17, indicated, We reviewed the regulation, there is no place where it says Safe Discharge Please provide us the regulation that requires the policy for safe discharge. Notwithstanding the above we contend that this was a safe discharge in as much as we completed all the requirements for a discharge but when (FM 1) refused to allow her back into her own home a medical transport was summoned to take to the hospital so (Resident 1) was never in an unsafe situation . The letter was signed by the Adm. Administrative document review of a type written letter, untitled, dated 4/14/17, indicated, .(Resident 1) postponed the inevitable numerous times as should be apparent by how high we allowed her bill had become. She broke down crying when the time of her discharge became a reality as probably anyone would. The fact that she ultimately had to be issued a 30 day notice naturally brought into play a conflictual situation which came to a head at the moment of her discharge. Staff also reported .about a safe discharge. Naturally a safe discharge is always in everyone's best interest however we have been unable to find a regulation which requires a safe discharge. My comment is if you are aware of a safe discharge regulation .please share it with us .In addition we would like an explanation of how this could be considered an unsafe discharge. For all practical purposes (Resident 1) was actually discharged to the hospital with a visit in between to see her home and her (FM 1), (Resident 1) was never not safe . The letter was signed by the Adm. Review of facility policy and procedure titled, Discharge Summary and Plan, dated revised 2010, indicated, .When the facility anticipates a resident's discharge to a private residence .a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. For Resident 2: Resident 2's face sheet indicated Resident 2 was [AGE] years old at the time of discharge from SNF 1. He was admitted to the facility on [DATE] and resided in the facility a total of 761 days. Resident 2's [DIAGNOSES REDACTED]. The face sheet indicated Resident 2's family member, FM 2, was the Responsible Party (RP) to be contacted for notifications regarding Resident 2's care. Resident 2's MDS, dated [DATE], indicated Resident 2 had moderately impaired cognitive function (poor decision making, cues and supervision required) and was totally dependent on staff for toilet use and bathing. Resident 2's physician's orders [REDACTED]. Resident 2's SNF 1 care plan, dated 1/5/15, indicated, Residents condition requires long-term care. Resident requires 24/7 (24 hours per day, seven days per week) nursing care . The care plan, dated 1/29/15, indicated, Resident is at risk for elopement (leaving the facility without permission or supervision) .wandering with poor safety awareness . The care plan, dated 1/15/15, indicated, The resident uses physical restraints WanderGuard (alarmed device to alert staff when resident wandered near an exit door) . The care plan, dated 1/12/15, indicated the resident was Spanish speaking. Resident 2's physician's orders [REDACTED]. Resident 2's physician discharge order, dated 2/2/17, indicated, May discharge to (R&B 1) on 2/3/17 with medications, home health R.N. evaluation, wheelchair, and P.T (physical therapy). The physician order [REDACTED]. Resident 2's face sheet indicated Resident 2 was discharged on [DATE] (to R&B 1). On 4/28/17 at 9 a.m., a telephone interview with a Social Worker for the (name of county) Department of Social Services (SWFDSS) was conducted. The SWFDSS stated Resident 2 was discharged from SNF 1 to the care of R&B 1 on 2/4/17. The SWFDSS stated the owners of R&B 1 transferred Resident 2 to the care of R&B 2 (owned and operated by different people at another location). The owner of R&B 2 applied for In-Home Supportive Services (IHSS - subsidized in-home care) for Resident 2. The SWFDSS stated she was involved in screening residents for IHSS care. The SWFDSS stated she was contacting APS regarding concern of appropriate placement of Resident 2 in a room and board facility. On 4/28/17 at 1:45 p.m., during an interview, the DON stated she was aware the AA made the decision to discharge Resident 2 to a place the AA called an Assisted Living (housing for elderly or disabled that provides nursing care, housekeeping, and prepares meals). The DON stated she was not aware of the difference in the level of services provi(TRUNCATED)

Based on observation, interview and record review, the facility failed to provide 3 of 27 sampled residents (Resident 1, Resident 2, Resident 3) or their Responsible Party (RP) a 30 day notice of discharge that included the right to appeal the discharge to the State. This failure denied Resident 1, Resident 2, Resident 3 and their RP of the right to appeal the discharge and resulted in unsafe discharges when: 1. Resident 1 was discharged into a situation that previously required Adult Protective Services (APS) intervention and experienced emotional and physical distress that required intervention by local police and fire departments and ultimate transfer of Resident 1 to the acute care hospital (ACH) by ambulance. 2. Resident 2 was transferred to a lower level of care without notification of his RP prior to the transfer, and later fell in the less supervised setting and suffered a fractured (broken) hip that required surgical intervention. 3. Resident 3, who suffered from dementia (disorder causing progressive loss of memory, judgement and reasoning ability), and was unable to make reasonable independent decisions, was transferred to a lower level of care without prior notification of an advocate (in the absence of a family member to act as the RP) of the right to appeal the transfer in his behalf, placing Resident 3 at risk of harm and injury. Findings: 1. Resident 1's face sheet (a document containing resident personal information) indicated Resident 1 was admitted to the Skilled Nursing Facility (SNF) 1 on 5/17/16. Resident 1's [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS) (a resident assessment tool) assessment, dated 8/24/16, indicated Resident 1 had no cognitive (memory) impairment. The MDS assessment indicated Resident 1 did not ambulate (walk) and required total staff support in bed mobility, transfers from bed to wheelchair, locomotion while in wheelchair, dressing, toilet use, personal hygiene and bathing. Administrative document review, untitled and dated 10/6/16, indicated a typed written 30 day notice of discharge addressed to Resident 1. The letter indicated, Hand delivered to (Resident 1) at (the facility) .Copy to (Resident 1's Family Member (FM) 1) .You are hereby given a 30 Day notice of discharge from (facility) .because you have not been paying your share of cost. Your Medical determined share-of-cost is $2,269 per month. Your current bill is $11,649.63. You will be discharged on [DATE] unless your bill is paid in full and/or a satisfactory repayment plan is established prior to that time. Your bill will increase by $2,269 plus interest by that date. You will be discharged to your home with (FM 1). We will assist you in setting up in-home care if you desire. You have all your mental capacities and even with certain physical limitations you should be able to function at home with some in-home supportive services . On 11/10/16 at 9:40 a.m., during an interview and concurrent clinical record and administrative document review, the Assistant Administrator (AA) stated Resident 1 was discharged from the facility on 11/7/16. The AA stated, We provided transportation to her (Resident 1's) home. Her (FM 1) refused to open the gate to let her come in. The AA stated she and the facility Administrator (Adm) drove to Resident 1's house after Resident 1's transport driver informed them FM 1 would not let Resident 1 inside the home. The AA stated FM 1 yelled and cursed at them, and refused to open the gate. The AA stated, We offered to let him pay the bill. The AA stated FM 1 stated he paid the utility bill with Resident 1's money; he took care of her house and could not take care of her. The AA stated while the situation with FM 1 yelling and the facility staff responding took place, Resident 1 complained she didn't feel well so she (the AA) called 911 (the emergency response phone number). The AA stated two policemen and three or four firemen responded to the 911 call and the AA and the Adm then left Resident 1 at her house. The AA stated, We were told we were free to go. We left. (FM 1) was in the house. The resident (Resident 1) was at the gate with officers, and the paramedics were taking her (Resident 1) to the hospital. She (Resident 1) said she knew the law. She didn't believe she would be kicked out. The AA stated FM 1 had not answered phone calls from the facility prior to Resident 1's discharge and had not participated in Resident 1's discharge planning. On 11/15/16 at 1 p.m., during an interview and concurrent clinical record review, the Social Services Designee (SSD) stated there were allegations of abuse at Resident 1's home prior to her admission to the facility. The SSD stated Resident 1 did not have a safe discharge to her home on 11/7/16. The SSD stated there were issues surrounding APS. The SSD stated, When we talked to her, she wanted to go home .she hadn't seen (FM 1) in six months. The SSD stated FM 1 did not participate in discharge planning. The SSD stated medical equipment was required for home care, which needed to be arranged prior to Resident 1's discharge. The SSD stated Resident 1 was bed and wheel chair bound, and Resident 1 had not walked during her stay at the facility. The SSD stated Resident 1's physician ordered a hospital bed, a wheelchair, a mechanical lift, a bedside commode (portable bedside toilet) and a shower chair for the home. The SSD stated there was no validation the items had been delivered to the house or would be able to be acquired with Resident 1's insurance. The SSD stated, There was no reason to expect (FM 1) would cooperate. I knew it was an unsafe discharge. I didn't have access to her house. I didn't know if she had medical equipment. The SSD stated, A 30 day notice was given for failure to pay (her facility bill). Resident 1's ACH clinical record titled, ED (emergency department) Provider Notes dated 11/7/16, indicated, Chief Complaint .patient was kicked out of SNF, PD (police department) states home is unfit for patient to live in XXX[AGE] year old was left in front of her house and FPD (local PD) stated her house is unfit to live in, therefore was transported to the hospital . Resident 1's ACH clinical record titled, Case Manager Addendum dated 11/7/16, indicated, .Per medical record review - she (Resident 1) was an APS (Adult Protective Services) case 05/10/16 - APS report filed by PD (police department) due to unsanitary living conditions and suspicion of abuse/neglect. Pt (patient) with a past medical history of [REDACTED]. In (ACH) ED (emergency department) pt was noted to have hair soiled with feces, small cockroaches on her, and multiple wounds. Wound on right foot found to have maggots. Report received by APS from PD that pts home is uninhabitable and that (FM 1) appears to have his own medical conditions and cannot care for pt . Resident 1's Progress Note entered by the SSD, dated 6/7/16 at 2:13 p.m., indicated, This writer contacted the Adult Protective Services to confirm if there is an open case. Spoke with (worker's name) and he said yes the case is still open . An additional Progress Note, entered by SSD, dated 8/23/16 at 11:31 a.m., indicated, It is uncertain if returning to her home would be a safe discharge. Adult Protective Services were involved. This writer has left many messages for her (FM 1) and he does not return the calls . On 4/13/17 at 9 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 was discharged home on[DATE] at 2 p.m. LN 1 stated Resident 1 did not want to sign for her discharge. LN 1 stated Resident 1 looked angry and later began to cry. LN 1 stated the Adm and the AA spoke to Resident 1 about her discharge taking place on 11/7/16 and told her she needed to sign the discharge papers. On 4/18/17 at 10:20 a.m., during an observation and concurrent interview in SNF 2, where Resident 1 was transferred to after discharge from her stay at the ACH. Resident 1 was alert and sitting up in bed. Resident 1's fingers of her right hand were stiff and drawn in toward her palm. Resident 1 demonstrated difficulty moving her fingers and stated she would not have been able to take care of her foot wound at home due to the limited mobility in her hand and fingers. Resident 1 stated, My (FM) is unable to care for me at home. He has been in and out of the hospital .My house has no electricity and no running water or heat .The manager (Administrator) at the facility accused me of being a thief because I didn't give them my pension .I wanted to explain that my (FM) was using my money to pay for my taxes and my bills plus the utilities. I was not stealing from them. Resident 1 stated, I was sad by the entire thing, I was stuck between a rock and a hard place. They were calling me a thief and accusing (FM 1) of stealing from me, but what would they have done. I felt horrible that I was kicked out of the facility and not let into my house, but my (FM) is also ill himself. I wanted to be taken away (by the paramedics to the acute hospital). On 4/18//17 at 10:55 a.m., during an interview, Resident 1 stated the facility did not offer her the right to appeal the discharge. Resident 1 stated, They wanted me out of there. On 4/18/17 at 12:05 p.m. during an interview and concurrent administrative document review, the Adm stated the facility gave Resident 1 a 30 day discharge notice on 10/6/16. The Adm stated the discharge notice did not indicate Resident 1's right for an appeal. The Adm stated the discharge notice did not have information on how to request an appeal. The Adm stated, All I can say is that I'm sure we told her, but we don't have to show that in the letter (30 day discharge notice). Administrative document review, untitled, dated 4/14/17, indicated .(Resident 1) postponed the inevitable numerous times as should be apparent by how high we allowed her bill had become. She broke down crying when the time of her discharge became a reality as probably anyone would. The fact that she ultimately had to be issued a 30 day notice naturally brought into play a conflictual situation which came to a head at the moment of her discharge. Staff also reported .about a safe discharge. Naturally a safe discharge is always in everyone's best interest however we have been unable to find a regulation which requires a safe discharge . 2. Resident 2's face sheet indicated Resident 2 was [AGE] years old at the time of discharge from SNF 1. Resident 2 was admitted to the facility on [DATE] and resided in the facility a total of 761 days. Resident 2's [DIAGNOSES REDACTED]. Resident 2's face sheet indicated Resident 2's family member (FM) 2 was the Responsible Party (RP) to be contacted for notifications regarding Resident 2's care. Resident 2's MDS, dated [DATE], indicated Resident 2 had moderately impaired cognitive function (poor decision making, cues and supervision required) and was totally dependent on staff for toilet use and bathing. Resident 2's physician's orders [REDACTED]. Resident 2's care plan, dated 1/5/15, indicated, Residents condition requires long-term care. Resident requires 24/7 nursing care . Resident 2 was discharged on [DATE] to Room and Board (R & B ) 1, an unlicensed facility that provides meals and lodging but does not provide skilled nursing care or 24 hour supervision and care. Resident 2's care plans from SNF 1 did not indicate an improvement of function or capabilities or improved mental and physical abilities had occurred during his stay in the SNF. On 5/1/17 at 3:10 p.m., Resident 2 was observed in a room at the ACH. The ACH record indicated Resident 2 arrived to the ACH on 4/28/17 at 11:18 a.m., and the reason for admission was Left Femoral Neck (hip) Fx (fracture). The record indicated, Spanish speaking only. Caregiver found pt (patient) on the floor next to his bed (in R & B 2). The record indicated Resident 2 had undergone surgery 4/29/17, to repair the left [MEDICAL CONDITION]. The ACH Interpreter services were engaged to attempt to communicate with Resident 2. Resident 2 did not make eye contact or make any other recognizable attempts at verbal or nonverbal communication. On 5/2/17 at 11:12 a.m., during an interview and concurrent record review, the SSD stated, .No 30 day notices (30 day advance notice of discharge including the right to appeal the discharge) were given . a letter was sent to (FM 2), but after the fact (3 days after the discharge from the SNF had taken place). On 5/2/17 at 4:45 p.m., an interview and concurrent record review with the Director of Nursing (DON) was conducted. The DON stated Resident 2's condition had not significantly improved during his stay in the SNF, and he was not ready for discharge to a R&B on 2/4/17. On 5/11/17 at 8:10 a.m., a telephone interview with FM 2 was conducted. FM 2 stated he understood his father was supposed to be in a skilled nursing facility, but they (the facility) put his father in a group home without his knowledge. FM 2 asked, Why would they move him without talking to me? FM 2 stated when he learned his father was no longer at the facility; he waited three days to learn his father's location. FM 2 stated when he was finally able to locate and visit his father; he realized his father was not getting the care he needed and deserved, and that there were no Spanish speaking individuals to communicate with his father. FM 2 started to sob and stated, I had never in my life seen my father with a beard. I did not know what to do. Then, I heard he fell and hurt himself . On 5/16/17 at 9:50 a.m., during a telephone interview, the owner of R&B 1 stated he transferred Resident 2 to R&B 2. The owner of R&B 1 stated Resident 2 fell too much and needed a higher level of care than he could provide at R&B 1. The owner of R&B 1 stated, I kept an eye on (him) for half a month. On 5/16/17 at 1:55 p.m., a telephone interview with Resident 2's physician, MD 1, was conducted. MD 1 stated, I understood (Resident 2) was discharged to an Assisted Living facility. This patient has dementia, severe dementia. Not able to go to an R&B. R&B residents must be independent. This resident was not independent. The social worker should arrange a safe discharge. Physicians depend on that. We just sign the paperwork. On 5/16/17 at 3:35 p.m., an interview and concurrent record review with the Adm was conducted. The Adm stated, We didn't do everything right . 3. Resident 3's face sheet indicated Resident 3 was [AGE] years old at the time of discharge from SNF 1. Resident 3 was admitted to the facility on [DATE] and resided in the facility a total of 1458 days. The face sheet indicated Resident 3 was his own RP. Resident 3's [DIAGNOSES REDACTED]. Resident 3's physician order, dated 1/14/15, indicated a pureed (modified texture), no added salt diet, due to the [DIAGNOSES REDACTED]. skills for daily decision making were moderately impaired - decisions poor; cues/supervision required. The same MDS indicated Resident 3 required extensive assistance for dressing, toilet use, personal hygiene and bathing. Resident 3's care plan, last revision dated 1/16/17, indicated, Resident's condition requires long-term care. Discharge to community not feasible, Resident requires 24/7 nursing care . Resident 3's discharge to R&B 1 occurred on 2/3/17. Resident 3's care plans did not indicate an improvement of function or capabilities or improved mental and physical abilities had occurred during his stay in the SNF. On 4/28/17 at 9 a.m., a telephone interview with a Social Worker for the (name of county) Department of Social Services (SWFDSS) was conducted. The SWFDSS stated Resident 3 was discharged from the SNF to the care of R&B 1 on 2/4/17. The SWFDSS stated the owners of R&B 1 transferred Resident 3 to the care of R&B 2 (owned and operated by different people at another location). The SWFDSS stated the owner of R&B 2 applied for In Home Supportive Services (IHSS) for Resident 3.The SWFDSS stated Resident 3 had dementia and no family or support system available to ensure his needs were met. The SWFDSS stated she had contacted APS regarding concern over the questionable appropriateness of current placement in an R&B On 5/1/17 at 11:15 a.m., R&B 2 was visited. A woman that identified herself as a resident allowed surveyors to enter, and she phoned the owner. There were no care givers present. Resident 3 was observed in the back bedroom, sitting on the side of the bed eating breakfast cereal (Cheerios in milk) and a banana. Resident 3 had milk puddled around his mouth, in his full, bushy beard, and there was a distinct smell of urine about him. Resident 3 did not respond when he was spoken to and did not acknowledge surveyors' presence or make eye contact or make any recognizable attempts at verbal or nonverbal communication. On 5/2/17 at 11:12 a.m., during an interview and concurrent record review, the SSD stated, No 30 day notices were given . (to Resident 3). On 5/2/17 at 2 p.m., the Adm stated Resident 3's name was brought up in a morning meeting regarding discharge from SNF 1 to R&B 1 and there was no objection to Resident 3's discharge. The Adm stated the SSD finds placement and the Interdisciplinary Team (IDT, a team of healthcare providers who meet to review and revise resident care plans) has an opportunity to object to the placement. The Adm stated the IDT was made up of the Adm, the AA, the SSD, and the DON. On 5/2/17 at 4:45 p.m., an interview and concurrent record review with the DON was conducted. The DON stated Resident 3's condition had not significantly improved during his stay in the SNF, and he was not ready for discharge to a R&B on 2/4/17. On 5/16/17 at 9:50 a.m., during a telephone interview, the owner of R&B 1 stated he transferred Resident 3 to R&B 2. The owner of R&B 1 stated Resident 3 started hitting people and needed a higher level of care than he could provide at R&B 1. The owner of R&B 1 stated, I kept an eye on (him) for half a month. On 5/16/17 at 2:30 p.m., a telephone interview with Resident 3's physician, MD 2, was conducted. MD 2 stated, I am not sure what drove the discharge. MD 2 stated (Resident 3) required the same level of care (after discharge as was provided in SNF 1). MD 2 stated she went with the recommendation of the facility staff regarding Resident 3's discharge from SNF 1 on 2/3/17. On 5/16/17 at 3:35 p.m., an interview and concurrent record review with the Adm was conducted. The Adm stated, We didn't do everything right .

Based on observation, staff and family interview, clinical record and administrative document review, the facility failed to provide the necessary care for one of 15 sampled residents (Resident 1) when: 1. Provision of a very low calorie diet was not evaluated by nursing staff as a cause for the Resident's significant weight loss. 2. Resident 1's condition and plan of care was not effectively communicated between facility and hospice staff. These failures resulted in a significant weight loss for Resident 1 and placed Resident 1 at risk for further decline. Findings: 1. On 6/30/14 at 1:10 p.m., during an observation in Resident 1's room, a 1000 milliliter (ml) plastic bottle labeled, "[MEDICATION NAME] 1.2" (a formula feeding used for people with feeding tubes inserted into the stomach) hung on a pole and was attached to a pump to deliver the formula at a specific rate. The feeding pump was set to deliver the formula at 30 ml per hour. The pump had delivered the formula for feeding into Resident 1's gastrostomy tube ([DEVICE], a tube inserted into the stomach). Resident 1 was observed lying in bed with eyes open, appeared thin and had not responded to questions. Review of Resident 1's clinical record indicated the resident was [AGE] years old with [DIAGNOSES REDACTED]. Resident 1 had been receiving hospice care for "Terminal [MEDICAL CONDITION]" beginning 6/13/13. Review of Resident 1's "monthly weight report" indicated Resident 1's weight as follows: 1/2/14 114.2 pounds (lbs.), 2/3/14 113.6 lbs., 3/4/14 106.2 lbs., 4/1/14 104.2 lbs., 5/1/14 104.0 lbs., 6/1/14 99.2 lbs. (15 lb weight loss in 4 months). Review of Resident 1's physician orders [REDACTED]." Review of Resident 1's physician orders [REDACTED]." Review of Resident 1's physician orders [REDACTED]. Review of Resident 1's physican orders for 6/1/14 through 6/30/14 indicated Resident 1 had no orders for food by mouth and had received nutrition through the [DEVICE] only. On 7/1/14 at 2:10 p.m., during an interview, the facility consultant Registered Dietician (RD) stated he did not know why the amount of the formula given in the tube feeding had been decreased for Resident 1. The RD stated Resident 1 had lost 12.8 percent of her body weight in the past six months. The RD stated 30 ml/hr for 20 hours of [MEDICATION NAME] 1.2 would only provide Resident 1 with 720 calories per day and that was not enough calories to maintain a normal weight for Resident 1. The RD stated, "It is starvation really." She (Resident 1) will continue to decline just from inadequate calories." The RD stated Resident 1 was 50 inches tall and should have weighed between 104 and 114 pounds for ideal body weight. The RD stated Resident 1 needed 25 calories per kilogram (1 kilogram equals 2.2 pounds) of ideal body weight daily to prevent weight loss. The RD stated Resident 1 needed a minimum of 1181 calories daily based on a minimum ideal body weight of 104 pounds (47.2 kilograms). Review of professional reference, "Weight Loss in the Elderly: What's Normal and What's Not", Michael Lewko, M.D. P&T, November 2003, Vol. 28, No.11, indicated, "A weight loss greater than 5% over six months should be investigated...The first steps in managing patients with weight loss are to identify and treat any specific causative or contributing conditions and to provide nutritional support when indicated...Some of the consequences of IWL (involuntary weight loss) include: [MEDICAL CONDITIONS] sores." Review of professional reference, "Older Adult Health Facts" http://www.health.gov.dietary guidelines/dga2005/toolkit/olderadults/OAnutrition.htm, "Estimated Calories Needed by Gender, Age, and Activity Level" indicated the daily caloric needs for a sedentary female age 51 or older was 1,600 calories daily. On 7/1/14 at 3 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 had tolerated the amount of formula given in the tube feedings without difficulty. The DON stated the weight variance committee reviewed Resident 1's weights but had not sent reports to the Quality Assessment and Assurance committee (QAA), (a group that reviews problems and seeks solutions for the facility). The DON stated Resident 1's weight loss had not been reviewed in QAA because the resident was on hospice care and weight loss was not unusual for hospice residents. The DON stated Resident 1's tube feeding orders for 720 calories per day had not been reviewed by the QAA committee. The DON stated hospice was responsible for the resident's orders. "They write the orders and we carry them out." On 7/1/14 at 3:15 p.m., during an interview, the hospice medical director (MD) 1 stated he was not sure why the tube feeding had been decreased to 720 calories per day. MD 1 stated feedings were sometimes decreased if the Resident was unable to tolerate the feeding. MD 1 stated the feeding had been decreased on the recommendation of the hospice nurse. On 7/2/14 at 2:15 p.m., during an interview, Hospice Nurse (HN) 1 stated Resident 1 had tolerated the tube feeding without difficulty. HN 1 stated Resident 1's feeding was decreased to 720 calories per day because the family was having conflicting feelings regarding continuing treatment. HN 1 stated Resident 1's care plan did not address interventions for the weight loss because it was not unusual for hospice patients to lose weight. HN 1 stated Resident 1 would continue to decline on the low calorie feeding. HN 1 stated, "She will decline overall. I expect all my clients to decline." HN 1 stated she had not reviewed the facility RD's progress note dated 6/8/14. On 7/3/14 at 10:15 a.m. during a phone interview, Hospice Nurse (HN) 2 stated there was no policy or procedure that indicated a low calorie feeding of 720 calories per day was beneficial for Resident 1. HN 2 stated having received only the low calorie amount could place Resident 1 at risk for skin breakdown and pressure ulcers. On 7/7/14 at 9:40 a.m., during a phone interview, the facility Medical Director (MD) 2 stated she could not determine how lowering the tube feeding to 720 calories per day could have any benefit for Resident 1. MD 2 stated it would be acceptable to lower the tube feeding if the resident had not tolerated the feeding as shown by a residual amount. MD 2 stated family conflict would not be a medical reason to decrease the amount of the feeding. MD 2 stated she would of expected the facility to have communicated with her regarding Resident 1's significant weight loss and it should have been reviewed in the QAA committee meeting. Review of Resident 1's clinical record, "Progress Notes," written by the RD dated 6/8/14 indicated, "Wt. 99.2# (pounds) on 6/3/14; -4.8# in one month and -14.6# (12.8%) over 6 mos (months) noted as she continues to decline on Hospice low Calorie feeding regimen. Tolerates feeding well....Skin is at risk. Nutrional status is gradually declining due to low level feeding...Recommend feeding rate increase to 50 ml/hr..." Review of facility policy "Nutrition Care" dated 2011, indicated, "Residents/patients experiencing significant weight changes will be identified and assessed in a timely manner in order to minimize further unplanned significant weight changes by identifying the underlying causes and contributing factors, and intervening as appropriate to resolve the problem unless the resident's/patient's medical conditions demonstrate that this is not possible." Review of Resident 1's "Physician order [REDACTED]. party for health care (RP) indicated, "C- Artificially Administered Nutrition: Long-term artificial nutrition, including feeding tubes." On 7/1/14 at 4:05 p.m. during a phone interview, Resident 1's RP stated, "They (hospice) told me it was comfort care and I just want her comfortable. I don't want to stop treatment. I just want her comfortable. I never told them to stop care. They (hospice) told me she has lost weight because her stomach doesn't work anymore." 2. On 7/1/14 at 2:10 p.m., during an interview, the facility consultant Registered Dietician (RD) stated he did not know why the tube feeding had been decreased to 720 calories per day for Resident 1. The RD stated the hospice nurse had not communicated with him regarding the feeding. The RD stated he had not received any verbal communication from hospice and there was no written record which would have explained the change to the plan of care. The RD stated on 6/8/14 he had written a recommendation in the progress notes which recommended an increase to Resident 1's amount of formula given by the tube feeding due to her weight loss. The RD stated, "They (hospice) did not notify me (of the decreased tube feeding rate) or consult me or take my recommendations. She (Resident 1) will continue to decline just from inadequate calories." Review of Resident 1's clinical record "Progress Notes" written by the RD dated 6/8/14 indicated, "Wt. 99.2# (pounds) on 6/3/14; -4.8# in one month and -14.6# (12.8%) over 6 mos noted as she continues to decline on Hospice low Calorie feeding regimen. Tolerates feeding well....Skin is at risk. Nurtrional status is gradually declining due to low level feeding...Recommend feeding rate increase to 50 ml/hr..." On 7/1/14 at 3 p.m., during an interview, the Director of Nursing (DON) stated the hospice nurses communicated verbally with facility staff. The DON stated the hospice staff did not have access to the facility computer system; hospice staff would need to request a print out of any report they needed to review. The DON stated the hospice staff did their charting on a computer tablet but the facility staff did not have access to those notes. On 7/2/14 at 2:15 p.m., during an interview, Hospice Nurse (HN) 1 stated she had not reviewed the facility RD's progress note dated 6/8/14. HN 1 stated she did not have the ability to log onto the facility's computer system to access records. HN 1 stated she did her charting regarding her visits on a tablet computer and had them printed in the hospice office. HN 1 stated the record of the visit could be faxed to the facility but each visit created a record of nearly 20 pages and the facility did not want to receive that volume of paper. HN 1 stated she had communicated verbally with the nursing staff after visiting a resident. On 7/3/14 at 10:05 a.m., during a phone interview, HN 2 stated the hospice nurses did not have computer access to facility records. HN 2 stated hospice nurses communicated with the facility staff verbally and there had been no written communication tool utilized for reporting resident condition. HN 2 stated hospice could print a record of the visit and send it to the facility but the report was many pages long and the facility did not want the paper. On 7/3/14 at 2:30 p.m., during an interview at the nurse's station, Licensed Nurse (LN) 4 stated the hospice nurse brought a computer tablet to record her notes during a visit. LN 4 stated she did not have access to the Hospice nurses notes. LN 4 stated the hospice nurse did not have access to the facility computer system but could request to view a record in the resident's chart. LN 4 stated she had received verbal reports from the hospice nurse and that was the usual method of communication. On 7/3/14 at 2:30 p.m., during an interview at the nurse's station, LN 1 stated she had received verbal reports from the hospice nurses. LN 1 stated she was not aware of any written communication method from the hospice nurse. Review of "Hospice Care Services Agreement" dated December 3, 2008 indicated, Page A-4: "documentation of communication between hospice and SNF (skilled nursing facility) to ensure that patient needs are addressed 24 hours a day is the responsibility of both the SNF and hospice. The care services agreement includes the SNF is responsible for "immediate communication to the hospice by the SNF if significant change in a patient's physical, mental, or social or emotional status, clinical complications that suggest a need to alter the plan of care..." Page A-5 "The Hospice RN shall be responsible for (i) assessment/management and symptom control...(iii) collaboration with Facility Personnel in delivery and updating Plan of Care."

Based on observation, staff and family interview, and clinical record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one of 15 sampled residents (Resident 1), when calories provided in the diet were not adequate to maintain normal body weight or sustain life. This failure resulted in a significant weight loss for Resident 1 and put Resident 1 at risk for skin breakdown, further decline and death. Findings: On 6/30/14 at 1:10 p.m., during an observation in Resident 1's room, a 1000 milliliter (ml) plastic bottle labeled, "[MEDICATION NAME] 1.2" (a formula feeding used for people with feeding tubes inserted into the stomach) hung on a pole and was attached to a pump to deliver the feeding at a specific rate. The feeding pump was set to deliver 30 ml per hour. The pump had been delivering the feeding into Resident 1's gastrostomy tube ([DEVICE], a tube inserted into the stomach). Resident 1 was lying in bed with eyes open, was thin and did not respond to questions. Review of Resident 1's clinical record indicated the resident was [AGE] years old with [DIAGNOSES REDACTED]. Resident 1 had been receiving hospice care for terminal [MEDICAL CONDITION] beginning 6/13/2013. Review of Resident 1's "monthly weight report" indicated Resident 1's weight as follows: 1/2/14 114.2 pounds (lbs.) 2/3/14 113.6 lbs. 3/4/14 106.2 lbs. 4/1/14 104.2 lbs. 5/1/14 104.0 lbs. 6/1/14 99.2 lbs. Review of Resident 1's physician orders [REDACTED]." Review of Resident 1's physician orders [REDACTED]." Review of Resident 1's physician orders [REDACTED]." Review of Resident 1's physican orders for 6/1/14 through 6/30/14 indicated Resident 1 had no orders for food by mouth and had received nutrition through the [DEVICE] only. On 7/1/14 at 2:10 p.m., during an interview, the facility consultant Registered Dietician (RD) stated he did not know why the tube feeding had been decreased for Resident 1. The RD stated the hospice nurse had not communicated with him regarding the feeding. The RD stated 30 ml/hr for 20 hours of [MEDICATION NAME] 1.2 would only provide Resident 1 with 720 calories per day and that it was not enough calories to maintain a normal weight for Resident 1. The RD stated, "It is starvation really." The RD stated Resident 1 had a significant weight loss of 12.8% of body weight over the past six months due to the low calorie feeding regimen The RD stated "I made a recommendation to increase calories on 6/8/14 when I saw her weight loss. Even 960 calories was not adequate. Today I found out hospice decreased the feeding even more, down to 30 ml/hr. They did not notify me or consult me or take my recommendations. She (Resident 1) will continue to decline just from inadequate calories."The RD stated Resident 1 was 50 inches tall and should have weighed between 104 and 114 pounds for ideal body weight. The RD stated Resident 1 needed 25 calories per kilogram (1 kilogram equals 2.2 pounds) of ideal body weight daily to prevent weight loss. The RD stated Resident 1 needed a minimum of 1181 calories daily based on a minimum ideal body weight of 104 pounds (47.2 kilograms). Review of professional reference, "Weight Loss in the Elderly: What's Normal and What's Not", Michael Lewko, M.D. P&T, November 2003, Vol. 28, No.11, indicated, "A weight loss greater than 5% over six months should be investigated...The first steps in managing patients with weight loss are to identify and treat any specific causative or contributing conditions and to provide nutritional support when indicated...Some of the consequences of IWL (involuntary weight loss) include: [MEDICAL CONDITIONS] sores." Review of professional reference, "Older Adult Health Facts" http://www.health.gov.dietary guidelines/dga2005/toolkit/olderadults/OAnutrition.htm, "Estimated Calories Needed by Gender, Age, and Activity Level" indicated the daily caloric needs for a sedentary female age 51 or older was 1,600 calories daily. On 7/1/14 at 3:15 p.m., during an interview, the hospice medical director (MD) 1 stated he was not sure why the tube feeding had been decreased to 720 calories per day. MD 1 stated tube feedings are sometimes decreased if a resident is unable to tolerate the amount of the feeding. MD 1 stated it would have been done on the recommendation of the hospice nurse. On 7/1/14 at 3 p.m. during an interview, the Director of Nursing ( DON) stated review of Resident's 1's nursing notes over the past 6 months indicated the resident had tolerated tube feedings without difficulty. The DON stated resident weight loss was usually reviewed by the facility's Quality Assessment and Assurance committee (QAA), (a committee to identify problems and create solutions) but Resident 1 had not been reviewed because she was on hospice care. The DON stated, "Hospice writes the orders and we carry them out. They are responsible for writing orders." On 7/2/14 at 12:15 p.m., during an interview in the DON's office, Hospice Nurse (HN) 1 stated Resident 1 did not have trouble tolerating the tube feeding. HN 1 stated the tube feeding was decreased to 720 calories per day without consulting the facility RD or the hospice staff RD who was available to advise regarding nutritional requirements. HN 1 stated there was no hospice policy regarding reducing tube feedings to a low level and had no knowledge of any research that would indicate it was beneficial to the resident. HN 1 stated the reason for decreasing the feeding was Resident 1's family was having difficulty deciding to discontinue feedings completely so the decision was made by hospice and the facility to decrease the amount of the feeding. HN 1 stated the effect of the low calorie feeding would be that the resident would decline. "She will decline overall. I expect all my clients to decline." HN 1 stated she did not review the facility consultant RD's progress note of 6/8/14. On 7/3/14 at 10:15 a.m. during a phone interview, hospice nurse (HN) 2 stated there was no policy or procedure that indicated a low calorie feeding of 720 calories per day was beneficial for Resident 1. HN 2 stated the low calories could place Resident 1 at risk for skin breakdown and pressure ulcers. On 7/7/14 at 9:40 a.m., during a phone interview, the facility Medical Director (MD) 2 stated family conflict was not a medical reason to lower a tube feeding to a level inconsistent with maintaining normal weight. MD 2 stated she did not see how lowering the tube feeding to 720 calories per day would have had any benefit for the resident. MD 2 stated she expected the Registered Dietician and the resident's personal physician to be consulted before the feeding was lowered. MD 2 stated the facility should have notified her of Resident 1's significant weight loss and it should have been reviewed in the QAA committee. Review of Resident 1's clinical record "Progress Note" written by the RD dated 6/8/14 indicated, "Wt. 99.2# (pounds) on 6/3/14; -4.8# in one month and -14.6# (12.8%) over 6 mos noted as she continues to decline on Hospice low Calorie feeding regimen. Tolerates feeding well....Skin is at risk. Nutritional status is gradually declining due to low level feeding...Recommend feeding rate increase to 50 ml/hr..." Review of Resident 1's "Physician order [REDACTED]. indicated, "C- Artificially Administered Nutrition: Long-term artificial nutrition, including feeding tubes." On 7/1/14 at 4:05 p.m. during a phone interview, Resident 1's RP stated, "They (hospice) told me it was comfort care and I just want her comfortable. I don't want to stop treatment. I just want her comfortable. I never told them to stop care. They told me she has lost weight because her stomach doesn't work anymore."