Every finding on record at Merced Behavioral Center

Based on observation, interview, and record review, the facility failed to post daily nurse staffing information that reflected the actual hours worked by nursing staff for a facility census of 94 residents.This failure resulted in the facility posting projected nursing hours instead of the actual nursing hours worked for residents and visitors to view. Findings:During an observation on 8/19/26 at 3:08 p.m., two Census and Direct care Service Hours Per Patient Day (DHPPD) forms were posted at the facility. One form, dated 8/19/26, identified a beginning patient census of 94 and listed estimated direct care services hours by shift for Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants/Restorative Nursing Assistants (CNAs/RNAs). The Actual Hours field for each shift and for the total direct care service hours per day were blank. A second form, also dated 8/19/26, identified a beginning census of 94 and listed scheduled total direct care service hours and scheduled CNA direct care service hours. The section titled, Actual Direct Care Service Hours and DHPPD, indicated, This section must be completed at the end of each 24-hour patient day. The fields for actual total direct service hours, actual CNA direct care service hours, actual DHPPD, and actual CNA DHPPD were blank. During a concurrent interview and record review on 8/21/26 at 8:03 a.m. with the Staffing Coordinator (SC), the Appendix PP, dated 2/3/23 was reviewed. The SC stated the facility posted the nursing staffing schedule each morning with the projected staffing hours. The ST stated the previous days posting was removed and replaced with the new posting. The ST stated the actual hours worked were calculated after receiving the previous days staffing total from the front office. The ST stated the actual hours were entered onto the form, signed by management, and then filed away. The ST stated and confirmed the actual hours worked were not posted and only the projected hours were visible on the posting board. The SC stated the Appendix PP indicated the actual hours worked were required to be posted rather than the projected hours. The SC stated posting the actual hours worked showed who actually worked and provided accurate information regarding the facilities staffing. During a concurrent interview and record review on 8/21/26 at 10:02 a.m. with the Director of Nursing (DON), the Appendix PP, dated 2/3/23 was reviewed. The DON stated the SC was responsible for posting the daily nurse staffing information and stated the facility posted the projected staffing hours and resident census. The DON stated and confirmed the actual hours worked were not posted for residents and visitors to view. The DON stated once the form containing the actual hours worked was completed, it was filed away and was not reposted for viewing. The DON stated he believed the projected hours were required to be posted and would need to review the facility policy. The DON stated the posting requirements had been addressed during previous surveys, he believed the facility was in compliance and acknowledged the process needed to be revisited. After review of Appendix PP, the DON stated posting the actual hours worked provided residents and visitors reassurance regarding facility staffing and stated the facility should comply with the requirement. During a review of facilities policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised 8/2022, the P&P indicated, 2. The information recorded on the form shall include the following: g. the actual time worked during that shift for each category and type of nursing staff.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were stored in accordance with currently accepted professional standards of practice when the facility failed to ensure the medication refrigerator containing drugs was set at the proper temperature for the storage of medications for two of 20 days.This failure had the potential to result in medications becoming ineffective (not producing any significant or desired effect) and placed residents at risk of medication adverse (resulting in negative or harmful effect) reactions.Findings:During a concurrent observation and interview on 8/20/2026 at 10:17 a.m. with Licensed Vocational Nurse (LVN) 1, the medication refrigerator was observed with a temperature reading of 30 degrees Fahrenheit (F - a unit of temperature measurement). LVN 1 stated the refrigerator temperature was 30 degrees F. LVN 1 stated the refrigerator temperature was not in the appropriate range for storing valbenazine tosylate (a medication used to treat tardive dyskinesia [uncontrollable movement of the face, tongue, or other body parts]), which had a label that indicated, .store at 15 degrees Celsius (C - a metric unit of temperature measurement) to 30 degrees C [59 degrees F to 86 degrees F]. and semaglutide injection (a medication injected into the tissue used to treat type 2 diabetes [a condition where the blood sugar levels in the body are too high], which had a label that indicated, .REFRIGERATE - DO NOT FREEZE. LVN 1 stated if the refrigerator temperature was not in the appropriate range, the medication would not be good anymore. LVN 1 stated the refrigerator should be kept in the appropriate range to store resident medications.During a concurrent interview and record review on 8/20/26 at 10:19 a.m. with LVN 1, the Refrigerator Temperature Log (RTL), dated August 2026 was reviewed. The RTL indicated, the refrigerator must be maintained between the temperatures 36 degrees F-40 degrees F. and the medication refrigerator temperature dated 8/14/26 was documented to be 35 degrees F. LVN 1 stated the night shift nurse checked the temperature of the refrigerator and wrote it in the log. LVN 1 stated one documentation on the temperature log dated 8/14/26 indicated the refrigerator temperature was too low. LVN 1 stated if the refrigerator temperature was out of range, the Maintenance Director (MTD) was notified.During an interview on 8/20/2026 at 10:46 a.m. with the MTD, the MTD stated he checked the refrigerator every morning and if the temperature was too low, he changed the temperature setting and re-checked the temperature an hour later. The MTD stated the temperature of the refrigerator should be in the range specified on the temperature log. The MTD stated he did not know what could happen to the medications if the temperature of the refrigerator was out of range.During an interview on 8/20/2026 at 1:44 p.m. with the Unit Manager (UM), the UM stated the MTD was notified and changed the dial setting. The UM stated the pharmacy was informed and the medications that were in the medication refrigerator needed to be pulled and replaced. The UM stated if the medications were not kept in the appropriate temperature range, the medications could lose their efficacy. During an interview on 8/20/2026 at 2:42 p.m. with the Infection Preventionist (IP), the IP stated if the medication refrigerator was out of range, the nurse needed to reset the temperature to bring it back in range and recheck the temperature in one-half hour. The IP stated if re-setting the temperature gauge did not work, the MTD needed to switch out the gauges. The IP stated if in another one-half hour the temperature did not get in the appropriate temperature range, the staff should move the medications to another refrigerator until the current refrigerator was repaired. The IP stated staff should have documented and rechecked the refrigerator temperature if it was out of range. The IP stated it was important to keep the refrigerator within the appropriate range as it could affect the effectiveness of the medications. The IP stated if the refrigerator temperature was not within the appropriate temperature range, the medications were not being stored appropriately. The IP stated if the temperature was out of range, the nurse should have changed the temperature setting and rechecked the refrigerator temperature one-half hour later. The IP stated the documented temperature on 8/14/26 should have reflected the corrected temperature, not the temperature that was out of range with no documented action taken to correct it.During an interview on 8/21/2026 at 9:57 a.m. with the Director of Nursing (DON), the DON stated his expectation was for the medication refrigerator to be within the appropriate temperature range. The DON stated the nurse should have followed the medication manufacturer directions on the label for the appropriate temperature it should have been stored under. The DON stated if staff did not follow the manufacturer's guidelines on storing the medication at the appropriate temperature, the medication could lose its efficacy, or the desired effect of the medication would not be achieved if the medication was used. The DON stated the temperature of 30 degrees F was not an acceptable temperature to store medications. The DON stated his expectation was for staff to notify the supervisor if the refrigerator temperature was out of range, remove the medications, call the pharmacy and follow the Pharmacist's recommendations for the medication stored in the refrigerator. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 1/2025, the P&P indicated, .medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.medications requiring storage at [room temperature] are kept at temperatures ranging from 15 degrees C [59 degrees F] to 30 degrees C [86 degrees F].medications requiring [refrigeration]or [temperatures between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F)] are kept in a refrigerator with a thermometer to allow temperature monitoring.medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified.During a review of the facility's job description document titled, Charge Nurse, (undated), the document indicated, .ensure that an adequate stock level of medications, medical supplies, equipment, etc., is maintained on your unit/shift at all times to meet the needs of the residents.During a review of the facility's job description document titled, Maintenance Supervisor, (undated), the document indicated, .the purpose of your job position is to assist in supervising the day-to-day activities [installing, repairing and upkeep] of the facility in accordance with current applicable federal, state, and local standards and regulations to ensure the safety of all residents and personnel as directed by the Administrator.providing or scheduling facility repairs as needed.During a review of the medication package insert titled, [brand name] semaglutide injection, dated 5/2026, retrieved from, https://www.novonordiskmedical.com/product-information/storage-and-stability/glp-1-ras.html. The medication package insert indicated, .store your new, unused [brand name] pens in the refrigerator between 36 degrees F to 46 degrees F.store your pen in use for 56 days at room temperature between 59 degrees F to 86 degrees F.or in a refrigerator between 36 degrees F to 46 degrees F.do not freeze [brand name]. Do not use [brand name] if it has been frozen.During a review of the medication package insert titled, [brand name] sprinkle valbenazine capsules, for oral use, dated 4/2026, retrieved from, https://pi.neurocrine.com/ingrezza/INGREZZA-Full-Prescribing-Information.pdf, the package insert indicated, .store at.68 degrees F to 77 degrees F.protect from moisture.

Based on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 69), on a prescribed chopped diet received the correct meal when Resident 69 had a diet order for chopped meat and was served bacon which was not chopped. This failure resulted in Resident 69 not receiving his prescribed diet which could lead to choking or decreased ability to eat.Findings:During a dining observation on 8/18/26 at 7:08 a.m. in the dining room, breakfast was served to residents. Resident 69 was observed seated at a table. Resident 69 was observed with a meal ticket with his name and prescribed diet. Resident 69's meal ticket indicated he had a prescribed order for chopped meat. Resident 69's meal ticket indicated chop bacon. Resident 69's bacon was observed in one piece, not chopped. Resident 69 ate his breakfast.During a concurrent observation and interview on 8/20/26 at 9:45 a.m. with the Certified Dietary Manager (CDM), a picture of Resident 69's breakfast, dated 8/18/26 was reviewed. The CDM stated Resident 69 had a prescribed diet order for chopped meat. The CDM stated Resident 69's bacon was not chopped, per the meal ticket or prescribed diet. The CDM stated Resident 69 received a chopped diet because he had missing teeth. The CDM stated Resident 69 was served the wrong diet on 8/18/26. The CDM stated Resident 69 had an order for chopped meat and it was reflected on his meal ticket. The CDM stated all meal tickets and prescribed diet orders were expected to be followed. The CDM stated Resident 69 was at risk for not being able to eat his meal or choking when his bacon was not chopped, as ordered on 8/18/26. The CDM stated during tray line the cook was responsible for plating meals per meal tickets and diet orders. The CDM stated kitchen staff assisting the cook during tray line were responsible for confirming accuracy. The CDM stated licensed nursing staff were responsible for reviewing the meal ticket and diet orders to plated meals before serving to residents.During a concurrent observation and record review on 8/20/26 at 9:53 a.m. with the Registered Dietician (RD), Resident 69's diet order, and a picture of Resident 69's breakfast, dated 8/18/26 were reviewed. The RD stated Resident 69 had a prescribed chopped meat diet. The RD stated Resident 69's bacon was not chopped on 8/18/26, per the meal ticket or prescribed diet. The RD stated resident diet orders were expected to be followed, per provider orders. The RD stated if diet orders were not followed, residents were at risk of not being able to chew or swallow their food which could result in choking.During a concurrent observation and interview on 8/21/26 at 9:41 a.m. with the Director of Nursing (DON), a picture of Resident 69's breakfast, dated 8/18/26 was reviewed. The DON stated provider orders were expected to be followed, including diet orders. The DON stated kitchen staff were expected to prepare and serve food as per the meal ticket and provider order. The DON stated licensed nursing staff were expected to verify diet orders and meal tickets before serving meals to residents. The DON stated facility policy and procedures were not followed when Resident 69 was served breakfast on 8/18/26 and his bacon was not chopped, per provider orders. The DON stated Resident 69 was placed at risk for choking when he ate bacon that was not chopped. During a record review of Resident 69's document titled, Order Summary (OSR), dated 10/21/25, the OSR indicated Resident 69 had an active diet order for chopped meat.During a record review of Resident 69's document titled, Care Plan (CP), dated 7/7/26, the CP indicated, .has oral/dental health problems [related to history] of poor oral hygiene and no teeth on his upper row.on a regular diet, [regular consistency] [chopped] meat texture, and thin consistency.risk includes.difficulty chewing.During a record review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, dated 10/2017, the P&P indicated, . therapeutic diets are prescribed by the attending physician to support the residents treatment and plan of care.a 'therapeutic diet' is considered a diet ordered by the physician.as part of treatment.During a record review of the facility's P&P titled, Tray Identification, dated 4/2007, the P&P indicated, .the food services manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas.nursing staff shall check each food tray for the correct diet before serving the residents.During a record review of the facility's job duty document titled, Cook, undated, the document indicated, . essential duties and responsibilities.inspecting special diet trays to confirm the correct diet is served to the resident.

Based on observation, interview, and record review the facility failed to ensure food was stored, distributed, and served safely when:One package of expired sweet bread was in the freezer.A vendor was allowed to enter the kitchen, during tray line, without a hair net or performing hand hygiene.These failures had the potential to result in foodborne illness for 91 out of 91 residents receiving food from the kitchen. Findings:1.During a concurrent observation and interview on 8/18/26 at 6:04 a.m. with the Certified Dietary Manager (CDM), one package of sweet bread was observed in the freezer. The sweet bread had a use by date of 8/17/26. The use by date indicated the sweet bread was expired. The CDM stated the sweet bread was expired and should not be in the freezer. The CDM stated all expired food items were expected to be removed before the expiration date. 2. During a concurrent observation and interview on 8/19/26 at 12:03 p.m. with Dietary Aide (DA) 1, in the kitchen during lunch tray line, a vendor delivering milk was observed entering the kitchen. The vendor entered the kitchen and did not put on a hair net or perform hand hygiene. The vendor walked between the stove and tray line where [NAME] (CK) 1 was plating lunch meals for residents. The vendor stocked milk cartons into the fridge and left. DA 1 stated anyone entering the kitchen was expected to put on a hair net and perform hand hygiene. DA 1 stated kitchen staff were responsible for ensuring vendors put on a hair net and performed hand hygiene before entering the kitchen. DA 1 stated she saw the vendor enter the kitchen without a hair net or without performing hand hygiene and she should have stopped him. DA 1 stated when the vendor entered the kitchen without a hair net or performing hand hygiene there was a risk for contamination of resident food during lunch tray line. During an interview on 8/20/26 at 9:45 a.m. with the CDM, the CDM stated vendors were not allowed to enter the kitchen and stock products during tray line, when food was actively being plated. The CDM stated kitchen staff were responsible for ensuring all staff and vendors who entered the kitchen upheld food safety standards of practice. The CDM stated resident food was at risk for contamination during tray line when the vendor was not instructed to wear a hair net or perform hand hygiene when he entered the kitchen to stock products. During an interview on 8/20/26 at 9:53 a.m. with the Registered Dietician (RD), the RD stated expired food should not be retained in the kitchen. The RD stated when expired sweet bread was retained in the kitchen there was a risk for accidental serving of an expired food item which could result in food borne illness or poor food quality. The RD stated vendors were expected to wear a hair net and perform hand hygiene before entering the kitchen, and kitchen staff were expected to enforce and uphold food safety standards of practice for anyone entering the kitchen. During an interview on 8/21/26 at 9:41 a.m. with the Director of Nursing (DON), the DON stated food items were expected to be removed from the kitchen before their expiration date. The DON stated retaining expired food items increased the risk of accidental serving of expired food to residents which could result in food borne illness. The DON stated facility policy and procedure was not followed when expired sweet bread was in the kitchen. The DON stated anyone entering the kitchen was expected to wear a hair net and perform hand hygiene, per facility policy and procedure, and kitchen staff were responsible for ensuring vendors followed policy. The DON stated facility policy and procedure was not followed when a vendor was allowed to enter the kitchen to stock products without a hair net or performing hand hygiene during tray line. The DON stated residents were at risk for food contamination from loose hair or soiled hands which could result in foodborne illness. During a review of the facility's document titled, Diet Type Report, dated 8/20/26, the document indicated 91 residents received food from the kitchen. During a review of the facility's document titled, Inservice Training Food Dating and Labeling Regulations, dated 8/18/26, the document indicated, .labeling and dating will ensure spoiled food is discarded and not accidentally served. During a review of the facility's policy and procedure (P&) titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 11/2022, the P&P indicated, .must wash their hands.whenever entering or re-entering the kitchen.hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. During a review of the facility's P&P titled, Food Preparation and Services, 11/2022, the P&P indicated, .food and nutrition service staff wear hair restraints .so that hair does not contact food.

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for 92 of 92 residents in the facility when one of one sampled washing machines had a hard white substance built up on the hoses behind the washer and was leaking water from the front door of the washer and the back of the washer, causing a pool of dirty water to build up in the front and back of the washer.This failure placed residents at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease).Findings:During a concurrent observation and interview on 8/20/2026 at 10:52 a.m. with the Laundry (LND) personnel, in the laundry room, a pool of dirty water was observed behind the washer, and a wet dirty bucket was observed sitting in front of the washer, under the washer door. The LND stated the washer was leaking water from behind the washer and leaking from the front door of the washer. The LND stated the washer should not have been leaking. The LND stated she was not sure of the chance of cross-contamination from the leaking water. The LND stated she had notified the Maintenance Director (MTD) of the leaking washer verbally by calling him on the phone. The LND did not remember how long the washing machine had been leaking or when she notified the MTD.During a concurrent observation and interview on 8/20/2026 at 11:01 a.m. with the Housekeeping Supervisor (HKS) in the laundry room, a pool of water behind the washer, a white crusted substance on the hoses coming out of the washer and on the back of the washer was observed, and a wet dirty bucket in front of the washer was observed. The HKS stated water had been leaking from the back of the washer and the front door of the washer for approximately six months. The HKS stated the facility was in the process of ordering a new washer, but it took a while to get approved. The HKS stated the LND vacuumed the water, so the room did not overflow with water and the bucket in front of the washer was dumped every day. The HKS stated the bucket, and washer were sanitized every day. The HKS stated there was a risk of cross-contamination of the clothes with the dirty water and dirty bucket. The HKS stated the washer should not have been leaking. The HKS stated the maintenance department should have cleaned the white build up substance on the back of the washer and on the hoses. During a concurrent observation and interview on 8/20/2026 at 11:06 a.m. with the MTD, the white substance in back of the washer, the pool of water behind the washer and the wet dirty bucket in front of the washer was observed. The MTD stated the washer was leaking due to issues with the level of water filling too high in the washer. The MTD stated when the washer filled too much with water, the water dripped out the back of the washer. The MTD stated he did not have an answer to why there was a puddle of water behind the washer. The MTD stated there should not have been water in the area around the washer. The MTD stated the floor and bucket were not clean and there was the possibility of contamination of clean clothes with dirty water and the dirty bucket.During an interview on 8/21/2026 9:34 a.m. with the Infection Preventionist (IP), the IP stated she was not aware of a leaking washer but was just made aware of it. The IP stated she did not usually discuss infection control with the laundry staff as the Maintenance Director went over in-services on infection control with his staff. The IP stated the MTD communicated with her if there were any questions regarding infection control. The IP stated there was a dirty area and a clean area in the laundry room to prevent cross-contamination. The IP stated she was not sure if there could be cross-contamination between the dirty water and clean clothes. The IP stated the washer should not have been leaking and had leaking problems for a while.During an interview on 8/21/2026 at 9:52 a.m. with the Director of Nursing (DON), the DON stated his expectation was for a clearly delineated clean and dirty area in the laundry room to prevent the possible cross-contamination of clean clothes to dirty substances. The DON stated there was a risk of infection to the residents if their clothing touched something unclean, and the resident received dirty clothes back. The DON stated residents' clean clothes should not be in contact with the dirty area in the laundry room. The DON stated the leaking washing machine should have been brought up to the IP and during standup so it could have been addressed immediately.During a review of the facility's policy and procedure (P&P) titled, Policies and Practices - Infection Control, dated 4/2025, 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.this facility's infection control policies and practices apply equally to all personnel.During a review of the facility's document titled, Environmental Services [EVS] Policy Booklet, dated 2/3/2025, the document indicated, .the workflow of laundry processes should be designed in a way that prevents cross-contamination.the lip of the washer door should be disinfected prior to closing and starting the cycle. This reduces the risk of clean linens contacting soil or microorganisms.do not operate damaged or broken equipment.damaged or broken equipment should be marked or communicated as [Out of Order] or [Do Not Operate] in a manner that ensures others will not accidentally utilize the equipment while awaiting repairs.the laundry area must be kept neat, clean, and sanitary.During a review of the facility's job description document titled, Infection Preventionist, (undated), the document indicated, .the Infection Preventionist is accountable for decreasing the incidence and transmission of infectious diseases between patients, staff, visitors, and the community.partners with department directors in providing in-service trainings, facility hygiene to recognize and mitigate workplace conditions related to infection control and relevant safety programs.During a review of the facility's job description document titled, Maintenance Supervisor, (undated), the document indicated, .the purpose of your job position is to assist in supervising the day-to-day activities [installing, repairing and upkeep] of the facility in accordance with current applicable federal, state, and local standards and regulations to ensure the safety of all residents and personnel as directed by the Administrator.

Based on observation, interview, and record review, the facility failed to follow the policy and procedure (P&P) titled, Weight Assessment and Intervention, to ensure residents with significant unplanned weight changes had updated care plan interventions and that those interventions were carried out and monitored for their effectiveness to avoid further weight changes for one of five sampled residents (Resident 73). This failure resulted in significant, unplanned weight changes for Resident 73 and had the potential to result in malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). Findings: During a review of Resident 73's medical record, undated, the medical record indicated, Resident 73 was admitted on [DATE] with diagnoses of schizophrenia (mental disorder that affects a person's ability to think, feel, and behave clearly) and anxiety (mental disorder that causes worry and fear about everyday situations). Resident 73 was prescribed a regular diet. Resident 73 had a 4-ounce health shake that was ordered on 4/6/23 to be given one time a day per resident request. There was no intake recorded for the health shakes. From 11/2023 to 5/2023, Resident 73 had a weight loss of 11.9%. Weight loss of 10% of a resident's usual body weight in 6 months was considered severe. During a review of Resident 73's Nutrition Assessment, dated 11/17/22, the Nutrition Assessment indicated, Resident 73 had .inadequate oral intake r/t [related to] loss of appetite AEB [as evidenced by] po [oral] intake 47-64%. Recommendation Provide (sic) cold cereal for breakfast Add (sic) 4 oz [ounce] health shake BID [two times a day] with breakfast and dinner . During a review of Resident 73's Order Summary Report (OSR), dated 4/6/23, the OSR indicated, Health Shake as needed per resident request, may have one time a day. During a review of Resident 73's Weights and Vitals Summary (WVS), undated, the WVS indicated, Resident 73 was admitted on [DATE] with a weight of 179 pounds (lbs). Resident 73 was weighed monthly and has had the following weight changes: 11/8/22 176 lbs 11/29/22 175 lbs 12/09/22 175 lbs 1/6/23 171 lbs 2/3/23 167 lbs 3/3/23 163 lbs 4/3/23 159 lbs 5/3/23 155 lbs 11.9% weight loss in 6 months. During a review of Resident 73's Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 5/11/23, the MDS indicated, Resident 73 had a BIMS (Brief Interview for Mental Status) score of 15 which indicates cognitively (thought process) intact. The MDS indicated Resident 73 had a greater than 10% significant, unplanned weight loss in six months, and was not on a physician prescribed weight loss regimen. During a review of Resident 73's Documentation Survey Report (DSR), dated May 2023, the DSR indicated, Resident 73 refused breakfast 16 out of 31 days in the month of May. During a review of Resident 73's Documentation Survey Report (DSR), dated April 2023, the DSR indicated, Resident 73 refused breakfast 28 out of 30 days in the month of April. During a review of Resident 73's Documentation Survey Report (DSR), dated March 2023, the DSR indicated, Resident 73 refused breakfast 30 out of 31 days in the month of March. During a review of Resident 73's Medication Administration Record (MAR), dated April 2023, the MAR indicated, Resident 73 did not receive a health shake in April 2023 During a review of Resident 73's Medication Administration Record (MAR), dated May 2023, the MAR indicated, Resident 73 did not receive a health shake in May 2023 During a concurrent observation and interview on 6/1/23, at 12:10 p.m., with Resident 73, in the dining room, Resident 73 was sitting at the table eating. Residents clothing appears loose and does not fit well. Resident 73 did not finish his meal tray. Resident 73 stated, he did not like the food. Resident 73 was hard to hear, did not make eye contact, appeared timid. Resident 73 stated, he did not want anything else to eat. Resident 73 stated, he has never had the health shake. He did not like vanilla but likes chocolate or strawberry and would be willing try it in those flavors. During an interview on 6/1/23, at 12:18 p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated, Resident 73 refused breakfast today. Resident 73 did not get a health shake with meals according to resident diet list that CNA 4 had printed. During an interview on 6/1/23, at 12:23 p.m., Resident 73 stated, I'm having trouble waking up in the morning. Resident 73 stated, he did not want to bother the staff and that was why he did not ask for the health shake. Resident 73 stated, he preferred cereal and would eat if he could have it later in the morning. During an interview on 6/1/23, at 4:10 p.m., with Registered Dietician (RD), RD stated, she saw that Resident 73's weight was trending down. RD stated, she talked to him, but he did not want to engage in his meals. RD stated, I talked to staff, and they said that he don't want to get out of bed. RD stated, I don't think he will ask for the shake; it needs to be offered. Discussed Resident 73's weight. RD stated, weight was trending down, he was losing weight. That is pretty significant. RD stated, his intake was not good, it would be beneficial to closely monitor his weight every week. RD stated, he would benefit from weekly weights so we can continue to intervene as necessary. RD stated, sometimes it could be challenging with this population. A lot of the medications can cause drowsiness or fatigue. She did not discuss Resident 73 not wanting to get out of bed with the team in the recent weight variance meeting. RD stated, it was reasonable for the resident to request to have a later breakfast of cold cereal. RD stated, I should have put in an updated care plan for the cold cereal, later breakfast time and health shakes. RD stated, she did not think the health shake should have been changed from twice daily. RD stated, Not sure if it was even started. I'm sure there is some discrepancy. During a concurrent interview and record review, on 6/2/23, at 8:36 a.m., with Minimum Data Set Nurse (MDSN) 1, Resident 73's medical record (MR), dated 11/2/22 6/2/23 was reviewed. Resident 73's care plan for nutrition, updated 5/12/23, indicated, the care plan was not updated to include the BID health shakes, cold cereal for breakfast, or weekly weights. The Nutrition Assessment, dated 11/2/23 indicated, RD recommended health shake with breakfast and dinner. MDSN 1 stated, Resident 73 does not always have the capability to ask for the health shake. MDSN 1 could find no documentation that the RD recommendation made on 11/17/22 was carried out. MDSN 1 stated, without the documentation, there was no way to monitor if the intervention was effective. The Interdisciplinary (multiple disciplines working together) Team (IDT) should document root cause for the poor appetite. It was not documented. MDSN 1 stated facility did not follow the policy for monitoring and evaluating weight and did not individualize care plan for Resident 73. During a concurrent interview and record review on 6/2/23, at 8:45 a.m., with MDSN 2, Resident 73's MR, dated 11/2/22 6/2/23 was reviewed. The OSR indicated, no physician order for the health shake to be given BID with breakfast and dinner was ever written. MDSN 2 stated, he could not find order for the BID health shake or any documentation that Resident 73 ever received the health shake. The weight history from 11/2/22-5/31/23 for Resident 73 was reviewed with MDSN 2. The weight history indicated, Resident 73 had weight loss that was trending down since admission. MDSN 2 stated, it would benefit Resident 73 to be on weekly weights to monitor his weight loss more closely. MDSN 2 stated, Resident 73 was sleepy, withdrawn, and it can be difficult to get him up in the morning. Medications could be a cause, hard to assess if he is sleepy or depressed. MDSN 2 stated, facility had not addressed possible depression or medication issues in the weight interdisciplinary team meeting. MDSN 2 stated, weight loss could be a nursing issue. MDSN 2 stated, facility did not follow the policy to evaluate the root cause for Resident 73' weight loss. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated 1/12/18, the P&P indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents.The dietician will review monthly weights to follow individual weight trends. Negative trends will be evaluated by the treatment team whether or not the criteria for 'significant' weight change has been met.Individualized care plans shall address, to the extent possible: a. The identified cause of weight change. Interventions for undesirable weight change shall be based on careful consideration of the following. a. Resident choices and preferences. d. Environmental factors that may inhibit appetite or desire to participate in meals.

45580 Based on observation, interview, and record review, the facility failed to ensure care plans were created and/or revised for four of 37 sampled residents (Resident 49, 296, 58 and 73), when: 1. Resident 49 and Resident 296 had a change of condition (a change in a person's health or functioning), and their care plans did not reflect the care the residents were currently receiving. 2. Resident 73 lost 20 pounds in 6 months and his care plan for weight loss did not provide current interventions to help the resident maintain his weight. 3. Resident 58 gained unplanned 10 pounds for one month. Interdisciplinary Team (IDT-a group of health care professionals from different fields who work toward a common goal for the resident) did not develop an individualized care plan and implement effective interventions. These failures had the potential for residents to not receive the care required to meet their needs. Findings: 1. During a review of Resident 49's Admission Record (AR), dated 10/17/22, the AR indicated, Resident 49 was admitted to the facility on [DATE] with a primary diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally), anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and extrapyramidal movement disorder (side effects of medication causing movements one cannot control). During a review of Resident 296's AR, dated 6/5/23, the AR indicated, Resident 296 was admitted to the facility on [DATE], with a primary diagnosis of disorganized schizophrenia (a person who has symptoms to include showing little or no emotions in their facial expressions, voice tone, or mannerism). During an interview on 10/21/22, at 1 p.m., with the Director of Nursing (DON), the DON stated Resident 49 was placed on denial of rights (DOR) for sexual activity (not allowed to have sex in the facility) due to her impaired judgement on 10/12/22. During an interview on 10/21/22, at 1:58 p.m., with Resident 296, Resident 296 stated, staff told him to stay away from Resident 49, but Resident 49 came into his room anyways. Resident 296 stated, on 10/14/22, Resident 49 stated she wanted a baby, she pushed him onto his bed, pinned his arms down on the bed and tried to kiss him. Resident 296 stated, he was able to get Resident 49 off and informed Licensed Vocational Nurse (LVN) 5 about what happened. Resident 296 stated after he informed LVN 5, an officer came and spoke to him about the allegation between him and Resident 49. Resident 296 stated since the allegation, a staff member was always with Resident 49, so he felt safe in the facility and a staff member checked on him every fifteen minutes. During a concurrent observation and interview on 10/21/22, at 2:21 p.m., with Resident 49, in the Administrator's office, Resident 49 paced back and forth and responded to internal stimuli (behaving or interacting as if someone or something else was present). Resident 49 stated, on 10/14/22, she sat down next to Resident 296 in his room, hugged him, and tried to kiss him but he did not kiss her. Resident 49 stated she was with a man, and he snitched (to tell someone of authority that someone else has done something bad) on her. Resident 49 stated she was on one to one (ratio of one staff and one resident) since 10/14/22, which meant she always had a staff member with her. Resident 49 stated she felt safe in the facility. During an interview on 10/21/22, at 2:40 p.m., with LVN 5, LVN 5 stated, on 10/14/22, Resident 296 asked her and two male Certified Nurse Assistants (CNA) to go to his room and he told them Resident 49 seduced him, pinned him down and tried to kiss him. LVN 5 stated she notified her supervisor and Administrator (ADM) about Resident 296's allegations. LVN 5 stated she informed staff to watch Resident 49 until she received orders for one to one. LVN 5 stated she notified the local police department (LPD), conservators and physicians for both residents and she received orders to place Resident 49 on one to one with staff. LVN 5 stated Resident 296 was placed on every fifteen-minute checks (when a staff member visually sees and documents the resident's activity in the facility), and a new intervention implemented was counseling with a Program Counselor (PC) for the next three days. During an interview on 10/21/22, at 3 p.m., with Minimum Data Set LVN (MDSN) 2, the MDSN 2 stated he was aware of the allegation involving Resident 49 and Resident 296, but he did not know the details of the situation because he was not present when it happened. MDSN 2 stated he has not noticed any changes in behavior to Resident 49 or Resident 296 since the allegation. During an interview on 10/21/22, at 4 p.m., with the Activities Director (AD), the AD stated a new intervention implemented for Resident 296 was one to one counseling with her. The AD stated, Resident 296 has not had any behavior changes since the allegation and had improved with his group hours and learned about his diagnosis (the process of identifying a disease based on a person's symptom). During an interview on 10/21/22, at 4:11 p.m., with PC 2, PC 2 stated, Resident 49 had new interventions of one to one with a CNA or PC and her medications were adjusted. PC 2 stated Resident 49's behaviors had improved since the new interventions were implemented and Resident 49 had been re-directable (to change the course or direction). During an interview on 5/18/23, at 2:53 p.m., with the DON, the DON stated he was immediately notified by LVN 5 of the allegation that involved Resident 49 and Resident 296. The DON stated, Resident 296 had improved himself and did not have any issues or behavior changes after the allegation. During a concurrent interview and record review on 5/18/23, at 4 p.m., with the DON, Resident 49's Care Plan (CP-summarizes a person's health conditions, specific care needs, and current treatments) titled, Sexually Inappropriate, dated 9/28/22 was reviewed. The CP indicated, . Per preadmission assessment [Resident 49] was noted making sexually inappropriate comments . Interventions . After any incidents of sexually inappropriate behavior, [Resident 49] will be given follow-up counseling within 24 hours of incident . [Resident 49] will attend Behavior Modification group to help her learn sexually appropriate behavior, boundaries, and rules . Staff will provide [Resident 49] with clear and concise description of inappropriate behavior . The DON stated, the CP indicated there were no new interventions implemented for the allegation that occurred on 10/14/22. The DON stated the facility implemented interventions for Resident 49 which included one to one with a CNA or PC, medications reviewed, and redirection of behaviors but the CP was not revised to indicate the new interventions implemented for this allegation. During a concurrent interview and record review on 5/18/23, at 4:15 p.m., with the DON, Resident 296's CP, dated 2/24/21, was reviewed. The DON stated, the CP indicated Resident 296 did not have a CP associated with the allegation that occurred on 10/14/22. The DON stated a CP for Resident 296 could have been initiated, but he was not sure what to tell his licensed nurses as to why a CP should be created for this allegation. During a concurrent interview and record review on 5/18/23, at 4:30 p.m., with the DON, the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022 was reviewed. The DON stated, the P&P indicated, .The comprehensive, person-centered care plan .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The DON stated the interventions were the services the facility was providing to the residents and Resident 296 should have had a CP created for this allegation to include the interventions the facility provided to Resident 296. The DON stated, the interventions implemented for Resident 296 consisted of every fifteen-minute checks by a CNA, all staff were notified to keep Resident 49 and Resident 296 separated for safety and one to one counseling with a PC. The DON stated the interventions were implemented for Resident 296. The DON stated, the facility should have monitored Resident 296 for any acute changes and revised the interventions if required. The DON stated the importance of following the CP policy was to ensure the resident's plan of care was up to date and progressed as planned. During a concurrent interview and record review on 6/2/23, at 10:49 a.m., with LVN 1, Resident 49's CP, dated 9/26/22 and Resident 49's Order Summary Report (OSR), dated 6/5/23 were reviewed. The OSR indicated, Resident 49 had orders on 5/3/23 for . Spironolactone Oral Tablet (drug used to treat heart failure (occurs when the heart muscle does not pump blood as well as it should), Give 25 mg (unit of measure) by mouth two times a day for To Decrease Libido [a person's sexual desire] . LVN 1 stated Resident 49's response to Spironolactone was not monitored nor was a CP created. LVN 1 stated when a new medication was ordered, the license nurse should create a CP, notify the conservator, and start the medication. LVN 1 stated the importance of creating a CP was to monitor the new medication for any adverse effects (undesired effects of a medication) and monitoring of any changes in behavior of the resident. LVN 1 stated if a CP was not created when a new medication was ordered, the facility would not be able to monitor the effectiveness of the medication and if the resident had any side effects to the medication. During an interview on 6/5/23, at 2 p.m., with MDSN 2, MDSN 2 stated a CP should be created or revised within 72 hours of a new medication ordered. MDSN 2 stated Resident 49 was ordered a new medication called Spironolactone which was ordered to decrease her libido. MDSN 2 stated he forgot to create a care plan specific to this new medication for Resident 49. MDSN 2 stated if he created a CP for Spironolactone, the interventions could include: give prescribed medications, counseling of resident if behaviors occurred, monitor for 72 hours, and refer to a psychiatrist for medication evaluation. MDSN 2 stated when a new medication was ordered, it was his responsibility to create or revise the resident's CP. MDSN 2 stated it was important to create or revise a CP for continuity of care (an approach to ensure that the care team was cooperatively involved in ongoing healthcare management toward a shared goal of high-quality medical care). MDSN 2 stated if a CP was not created or revised when a resident had a change of condition, the resident's treatment plan would not be updated and accurate. During a record review of Resident 49's CP titled, Sexually Inappropriate, dated 9/28/22 and Resident 49's OSR, dated 5/3/23, the CP indicated, on 10/14/22 and 12/29/22, Resident 49 had two episodes of sexually inappropriate behavior towards two male residents in the facility. The CP indicated, on 10/14/22 and 12/29/22, there were no revisions to the interventions to further prevent Resident 49's sexually inappropriate behavior towards others. The CP indicated, on 6/5/23, the CP was revised to include, . Administer medications as ordered . Spironolactone 25 mg PO [by mouth] BID [two times a day] to decrease libido .Resident will be placed on Q [every]15 minute checks for behavior if sexually inappropriate behavior occurs .Will refer to (resident's physician) as needed . The OSR indicated, Spironolactone was ordered on 5/3/23 and the CP was not revised until 6/5/23. During an interview on 6/5/23, at 2:58 p.m., with the Administrator (ADM), the ADM stated he expected licensed nurses to create or revise care plans during an annual review, quarter review or when a resident had a change of condition. The ADM stated the IDT should do their part to update care plans and follow through with any new interventions or treatments. The ADM stated the importance of a created or revised CP was use the CP as a communication tool for staff to be updated on how to best treat and care for a resident who had identified problems and the interventions specific to the resident. The ADM stated if the CP was not created or revised, direct care staff would not be aware of the resident specific interventions and there would not be a continuity of care. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . includes measurable objectives and timeframes . describes the service that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions . interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers . Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . 2. During a review of Resident 73's Admission Record (AR-document that provides demographical information to include name, date of birth, date of admission, insurance, diagnosis), dated 6/1/23, and Brief Interview for Mental Status (BIMS-screening tool used in nursing facility to assess cognition) , dated 2/9/23, were reviewed. The AR indicated Resident 73 was admitted on [DATE] from a Psychiatric Hospital with the following diagnosis's schizophrenia and anxiety disorder. The BIMS indicated Resident 73 had a score of 15 meaning his cognition was intact (A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). During a concurrent observation and interview on 5/30/23, at 3:58 p.m., Resident 73 was seen lying in bed with a blanket that covered him. Resident 73 spoke softly and did not maintain eye contact. Resident 73 stated he did not know how long he had been here at the facility. Resident 73 stated he did not like the food, had not been in any altercations, and did not want to answer any more questions. During a concurrent interview and record review on 6/5/23, at 10:05 a.m., with the DON, Resident 73's care plans were reviewed. The DON stated Resident 73's oral intake was obviously a behavioral issue, ever since his sister told him she would not be bringing him [name of fast-food restaurant] this saddened and upset him. The DON reviewed the care plan for Resident 73's diet, dated 11/3/22, the care plan indicated, [Resident 73's name] on a regular diet regular texture thin consistency RD (registered dietician) wt. (weight) review 11/17/22 . 176# (pounds 11/15). 2/2/23 quarterly rev (review) CBW (Current body weight) 167# = 6.7% x 3 mo. (months). 4/6/23 PRN (as needed) health shakes per resident request 1-daily. 5/11/23: quarterly rev, CBW: 155# (5/3) significant wt. change x 3, 6 mo. PO (oral intake) 49% resident avoids eating food from facility, so family brings him fast-food. Dated Initiated: 11/03/2022 Revision on: 05/12/2023 Goal [Resident 73's name] will be encouraged to consume meals with 76-100% daily. Encourage stable weight. Maintain hydrated QD (every day). No significant wt. loss -5# (negative 5 pounds). Date Initiated: 11/30/2022 Revision on: 5/11/2023 . Interventions monitor weekly weights x 4 weeks then monthly weights notified MD/RD [medical doctor/registered dietician] of any significant weight change. Date Initiated: 11/03/2022. Position CNA (certified nursing assistant) NRCHG (charge nurse) DIETS (dietician) . The DON stated, I would bring it up to the weight management committee and the RD and put in the interventions that we are already doing to help with his dietary. There is no program. The care plan needs work. The DON stated Resident 73 had no program involvement related to his oral intake and this was something they planned to implement for him. During an interview on 6/1/23, at 12:23 p.m., with Resident 73, Resident 73 stated, I'm having trouble waking up in the morning. Resident 73 stated he did not want to bother staff, he would prefer cereal and would eat if he could do it later in the morning. During a concurrent interview and record review on 6/1/23, at 4:10 p.m., with the Registered Dietician (RD), Resident 73's weights, meal intake, and dietary care plan were reviewed. The RD stated after a review of his weights and meal intake since admit, That is pretty significant intake was not good. The RD stated it would be beneficial to closely monitor his weights and oral intake every week so we could continue to intervene as necessary. The RD stated it was reasonable for the resident to request to have a later breakfast of cold cereal. The RD stated she attempted to update the care plan every time she saw the resident. The RD stated she should have put in an updated care plan. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 3/22, indicated, .Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 10. When possible, interventions address the underlying source(s) of the problem area(s) not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the residence condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly in conduction with the required quarterly MDS (minimum data set- part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessments . 3. During a review of Resident 58's Admission Face Sheet, dated on 6/1/23, the Admission Face Sheet indicated, .Resident 58 was admitted to the facility on [DATE]. Resident 58's diagnoses included: Schizoaffective Disorder (mental disorder that affects a person's ability to think, feel, and behave clearly) Bipolar type (is a mental health condition defined by periods (or episodes) of extreme mood disturbances that affect mood, thoughts, and behavior), Hypothyroidism (medical condition which thyroid gland doesn't make enough of the thyroid hormone), Anxiety and Extrapyramidal and Movement disorder . During a review of Resident 58's Minimum Data Set (MDS- a standardized assessment and care-planning tool) dated 5/10/23, the MDS indicated Resident 58 was not on a physician-prescribed weight gain regimen in the last month. During a review of Resident 58's weights showed: 11/2/22: 224 pounds (lbs) 12/8/22: 221 lbs 1/5/23: 220 lbs 2/2/23: 220 lbs 3/2/23: 219 lbs 4/2/23: 220 lbs 5/2/23: 230 lbs During a review of Resident 58's IDT Weight Management Assessment note, dated 5/8/23, IDT Weight Management Assessment note indicated, .Weight Gain; Current weight (wt.): 230 Lbs.Wt. past 30 days: 220 Lbs.Recent wt. Gain: 10 Lbs. per 1 month 4.5 % . Expected Weight Gain . Resident was noted to ask for seconds during major meals.IDT Recommendations: 1) Encourage resident to diet and exercise. 2) MD will order labs and will relay the results in a timely manner. 3) Will review monthly weights. 4) Registered Dietitian (RD) will assess resident . During a review of Resident 58's Registered Dietician (RD) monthly wt. review progress note, dated 5/18/23, RD monthly wt. review progress note indicated, .Weights: 230 pounds (#) (5/2/23), 220 # (4/2/23), 219 # (3/2/23), 220 # (2/2/23), 220 # (1/5/23), 221 # (12/8/22), 224 # (11/2/22), 223 # (10/2/22), 222 # (9/2/22), 218 # ( 8/2/22), 222 # (7/5/22), 226 # ( 7/2/22), 213 # ( 6/2/22) . Weight change: + 10 #/ (4.5 %) for 1 and 3 month, +6 # (2.7 %) for 6 month. Resident weight has been between 220 -230 # x 8 months. BMI (Body Mass index) 35 reflects obesity class II status. Diet: Regular diet. PO intake (amount eating): 98 % x 21 meals Resident was not in room upon arrival. Resident has excellent PO intake .Will continue to monitor resident's PO intake, weights, follow up prn (as needed) per facility protocol. Goal is to avoid further significant weight gain . During a review of Resident 58's care plan, undated, the care plan indicated, .Focus: RD monthly weight review: Current body weight 230 # x 8 months, Revised on 5/18/23 .Goal weight: Maintain current weight 220 # +/- 5 #. Intervention: will monitor weekly weights x 4 weeks then monthly weights. Date initial: 11/5/2021 . The care plan did not address the causes for unplanned weight gain, there was no resident specific interventions and parameters for monitoring to prevent further unplanned weight gain. During a concurrent interview and record review, on 6/2/23, at 9:40 AM, with Minimum Data Set Registered Nurse 1 (MDSN 1) and MDSN 2, Resident 58's care plan was reviewed. MDSN 1 stated, MDS nurses and RD reviewed resident's nutrition care plan. MDSN 1 and MDSN 2 admitted Resident 58's care plan revised on 5/18/23 did not have any intervention and monitoring for unplanned weight gained. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, Revised 1/12/2018, the P&P indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents.Care Planning:1. Care planning for weight change or impaired will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address to the extent possible: .a.The identified causes of weight change . b. Goals and benchmarks for improvement; and .c. Time frames and parameters for monitoring and reassessment . 45977

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices for 93 of 93 residents who receive food from the kitchen when: 1. Ice machine was not kept in sanitary condition and put residents at risk for foodborne illness (stomach illness acquired from ingesting contaminated food). 2. The can opener in the kitchen was not kept in sanitary condition which could transfer to residents' foods. Dietary staff did not clean the can opener after use. This had the potential to cause foodborne illness and cross contamination. 3. The walk-in refrigerator had rusting storage shelves and had the potential to harbor bacterial growth. 4. Worn out green cutting board. 5. Hood filter above stove covered with grease and dust. 6. Dust: silver storage shelves stored clean kitchen ware in the dish washing area, light bulb grid in the walk-in refrigerator, steam table stainless storage shelves storage clean kitchen ware covered with dust. Vent above steam table, light above steam table. 7. Floor: walk in refrigerator under storage shelf had brown/black grime, 6 strawberries under food storage shelf. Reach in refrigerator and underneath the dish washing machine the floor was covered with trash, dust, and dirty cups. This had the potential to attract pest or rodents. 8. Worn out gasket in walk in refrigerator. 9. No cooling log for cooked beans. (Cross reference F802) 10. Green and white fuzzy substance found on the strawberries and cucumbers in walk in refrigerator. These failures had the potential to cause foodborne illness for all residents in the facility. Findings: 1. During an interview on 5/31/23, at 2:30 p.m., with Maintenance Supervisor (MS), MS stated, he cleaned the ice machine, but only the parts that are external. He stated the company that the facility rented the ice machine from does a thorough cleaning every three months. MS stated, he checked that the drain line was flowing good and works on the bottom of the hopper. MS stated, I do not work on the inside of the machine. MS stated, the facility just got it about 5 months ago. The company was out here about 2-3 weeks ago. they told us the ice machine was clean did not need to be serviced at that time. During a concurrent observation and interview on 5/31/23, at 3:12 p.m., with MS, ice machine noted to have pinkish orange slimy substance near the water releasing component of the ice machine. Black substance build-up noted behind the white cover. MS stated, (contracted company) was here two to three weeks ago and said the ice machine did not need to be cleaned. facility has had the ice machine about five or six months. MS stated, the ice machine has not been cleaned yet. The contracted company said they would be here every three months. During an interview on 3/31/23, at 3:25 p.m., with Dietary Supervisor (DSS), DSS stated, she prepped ice water cups this morning from this ice machine. During an interview on 5/31/23, at 3:51 p.m., with the Administrator (ADM), the ADM stated, facility was getting ice from this ice machine, ice machine had been shut down, and the facility was reaching out to the contracted company. During a concurrent observation and interview on 5/31/23, at 4 p.m., with Administrator, Infection Preventionist (IP- professionals who make sure healthcare workers and patients are doing all the things they should to prevent infections), Director of Nursing (DON), and MS, there was a black discoloration on the inside of the white plastic panel covering the inner component of the ice machine. Administrator stated, he will stand by ice machine until they bring an out of order sign. During an interview on 5/31/23, at 4:54 p.m., with ADM, the ADM stated, It was pretty bad. referring to the ice machine. During an interview on 6/1/23, at 3:17 p.m., with Registered Dietician (RD), RD stated, the facility got a new ice machine a couple months ago. She had MS open up the front cover, but he said he could not open it the rest of the way. MS told her that the contracted company would be the ones who do the routine cleaning. RD stated, she was not able to look inside. RD stated, it is a potential health hazard and can cause sickness. RD said her expectation was for it to be cleaned monthly and be free of mold and any build-up. During a review of the Service Activity Confirmation, dated 9/22/22, the Service Activity Confirmation indicated, the ice maker was installed on 9/22/22. Semi Annual Maintenance. During a review of the sanitation review (completed by RD), dated 3/24/23, the sanitation review indicated, .Ice machine is brand new, however no documentation of monthly maintence. [sic] working with maintenece [sic] to schedule cleaning and obtain records . During a review of the facility's policy and procedure (P&P) titled, Sanitization dated 11/22, the P&P indicated, .Ice machines and ice storage containers are drained, cleaned, and sanitized per manufacturer's instructions. 2. During a concurrent observation and interview on 5/30/23, at 11:37 a.m., with DSS, in the kitchen, there was a can opener in the stand at the end of the counter. The can opener blade had some type of red brown sauce dried on it. The same substance was also on the handle. DSS stated, This is dirty. The can opener should be cleaned after each use. During a concurrent observation and interview on 5/31/23, at 11:17 a.m., with Dietary Aide (DA) 3, DA 3 was using the can opener to open a can of peaches, did not clean after. DA 3 then used it to open a can of pineapple. DA 3 stated, she did not wash the can opener after she used it. During an interview on 5/31/23, at 11:42 a.m., with DSS, DSS stated, they clean the can opener at the end of the shift, not in between each use. DSS stated, Are we supposed to? During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, the can opener should be cleaned after each use to prevent any cross contamination. RD stated, it should be cleaned after each use. RD stated, she needed to review the policy and in-service dietary staff that can opener should be cleaned after each use. During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, dated 11/22, the P&P indicated, Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness. cleaning and sanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines. 3. During an observation on 5/30/23, at 10:28 a.m., in the walk-in refrigerator, there was some black grime in the corner of the top of the door. During a concurrent observation and interview on 5/30/23, at 3:01 p.m., in the walk-in refrigerator, with DSS, rust was seen on the food storage shelves. DSS stated, those need to be replaced, rust was not supposed to be there. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, shelves are supposed to be free of rust, it can cause foodborne illness. RD stated, the expectation was for the food storage shelves to be replaced and kept free of rust. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers dated 11/22, the P&P indicated, .Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary . 4. During an observation on 5/30/23, at 11:29 a.m., in the kitchen, the green cutting board was noted heavy use and very worn. During an interview on 5/31/23, at 9:46 a.m., with DSS, the DSS stated, green cutting board needs to be replaced. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, she felt like the cutting boards needed to be replaced. RD stated, she did not put it in her report or tell the DSS. RD stated, food and bacteria can get stuck in the grooves left by the knife and cause illness. 5. During an interview and observation on 5/30/23, at 3:34 p.m., with DSS, in the kitchen, vent and pipe in the ceiling covered in dust. DSS stated, dust could fall from pipe in ceiling onto containers of food. Oven hood filter had oil and dust mixed. DSS stated, it did not get clean enough in the dishwasher. DSS stated, they were supposed to be cleaning it one time per week, maybe it needs to be cleaned twice per week. DSS stated, steam table shelves have dust even though they are cleaned two times a week on Wednesday and Saturday. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, I cannot recall looking at the hood above the stove, mix of grease and dust on hood filter was a potential fire hazard and cross contamination. RD stated, the hood filter needs to be clean and free from dust and build up. During a review of the facility's policy and procedure (P&P) titled, Section F: Safety and Sanitation, dated 2/18/20, the P&P indicated, .Stove tops, ovens and hoods will be routinely cleaned to keep them free of grease build-up to prevent accidental grease fires. Wash grease filters in hoods over ranges at regular intervals to prevent grease build up that could result in a fire . 6. During an observation and interview on 5/30/23, at 3:25 p.m., with DSS, in the dishwashing area of the kitchen, DSS was showed the dust on the top shelf where the clean dishes were being stored. DSS stated, the dust should not be there because it could contaminate the clean kitchenware. During an interview and observation on 5/30/23, at 3:34 p.m., with DSS, in the kitchen, vent and pipe in the ceiling covered in dust. DSS stated, dust could fall from pipe in ceiling onto containers of food. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, light grate in the walk-in refrigerator, the steam table shelves, vent above and light above steam table were covered with dust. I expect the light grate in the walk-in refrigerator, steam table shelves and the vent and light above the steam table to be cleaned so that dust doesn't fall into the food. They should keep the kitchen clean and free from dust. 7. During an observation on 5/30/23, at 11:06 a.m., in the walk-in refrigerator, five of six packages of strawberries on the food storage shelf had a green and white, furry mold like substance. 6 old strawberries noted on the floor under the shelf. red stuff splattered on the wall behind the shelf. Rust on the wire shelves noted. Dirt and grim in the corners on the floor of the walk in refrigerator. Box of cucumbers on the food storage shelf were wilted and mushy to touch. Green and white fuzzy substance noted on some of the cucumbers in the box. During a concurrent observation and interview on 5/30/23, at 3:07 p.m., with DSS, in the walk-in refrigerator, DSS was shown the floor in the corners behind the storage shelves. DSS stated, looks like dirt. DSS stated, if dirt accumulates people will get sick. DSS saw the dirt on the light grate cover and saw the strawberries on floor. DSS stated, they are supposed to sweep and mop every day at end of shift. During a concurrent observation and interview on 5/30/23, at 3:17 p.m., with DSS in the kitchen, dust and trash seen under the reach in refrigerator. DSS stated, the dust and trash should not be there. DSS stated, it could attract mice, or pest. During a concurrent observation and interview on 5/30/23, at 3:24 p.m., with DSS, in the kitchen, dust, dirty cups, and trash seen under the dishwasher. DSS stated, it looks like it needs to be swept and mopped under dishwasher. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, the expectation was that the floors were cleaned at least looked at daily. Dirt and trash could get into food, cause contamination, and attract pest. During a review of the facility's policy and procedure (P&P) titled, Section F: Safety and Sanitation, dated 2/18/20, the P&P indicated, .Floors are to be kept clean, dry, uncluttered and free of broken tiles or defective boards . During a review of the facility's policy and procedure (P&P) titled, Sanitization dated 11/22, the P&P indicated, .All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris . 8. During an observation and interview on 5/30/23, at 2:58 p.m., with DSS, in the kitchen, gasket was loose and worn on the walk-in refrigerator door. DSS stated, maintenance was aware and was told the seal was loose three weeks ago. During a concurrent observation and interview on 5/30/23, at 4:03 p.m., with MS, in the kitchen, gasket on the walk-in refrigerator was examined. MS stated, nobody came and said it was the round gasket that need to be repaired. MS stated, he looked for one but could not find one when he replaced the other seal around the frame. MS stated, it was a miscommunication with DSS. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, she had put the gasket needed to be replaced in a previous sanitation review. RD stated, if the gasket does not get replaced, it could affect the temperature of the refrigerator and potentially cause illness. During a review of the sanitation review (completed by RD), dated 3/24/23, the sanitation review indicated, .door gaskets in walk-in fridge need to be replaced, unsticking from door . During a review of the sanitation review (completed by RD), dated 1/20/23, the sanitation review indicated, .door gaskets in walk-in fridge need to be replaced, unsticking from door . During a review of the sanitation review (completed by RD), dated 10/29/22, the sanitation review indicated, .Door gaskets in walk-in fridge need to be replaced, unsticking from door . During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers dated 11/22, the P&P indicated, .Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately . 9. During an observation on 5/31/23, at 9:44 AM, a pan of cooked bean labeled and dated 5/30/23, used by 6/3/23 was observed in the walk-in refrigerator. During a concurrent interview and record review, on 5/31/23, at 9:56 a.m., with DSS, the Safe ways to cool foods guideline, undated was reviewed. Safe ways to cool foods guideline indicated, cooked beans were one of the food items that needed to have the cool down process. DSS stated, Cook 1 made the cooked beans yesterday morning stored in the walk-in refrigerator yesterday morning. DSS stated, they never did cool down process for cooked beans. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, the cooked beans stored in the walk-in refrigerator needed to have cool down process. The RD stated, improper cooling of cooked beans could cause foodborne illness. The RD's expectation was Cooks followed the Safe ways to cool foods guideline. During a review of the facility's job description titled, DIETARY SUPERVISOR, undated, the job description indicated, .Monitoring staff to confirm they adhere to all .safety and procedural guidelines within the department . During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, dated 11/22, the P&P indicated, .Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness. Potentially hazardous foods are cooled rapidly. Large or dense foods are cooled using special interventions in order to meet the time and temperature requirements for cooling. For example. beans or legumes may be cooled in shallow pans or food containers may be placed in ice baths to expedite cooling . 10. During an observation on 5/30/23, at 11:06 a.m., in the walk-in refrigerator, five of six packages of strawberries on the food storage shelf had a green and white, furry mold like substance. 6 old strawberries noted on the floor under the shelf. red stuff splattered on the wall behind the shelf. Rust on the wire shelves noted. Dirt and grim in the corners on the floor. Box of cucumbers on the food storage shelf were wilted and mushy to touch. Green and white fuzzy substance noted on some of the cucumbers in the box. During a concurrent observation and interview on 5/30/23, at 3:07 p.m., with DSS, in the walk-in refrigerator, DSS was shown the floor in the corners behind the storage shelves. DSS saw the strawberries on floor. DSS stated, they are supposed to sweep and mop every day at end of shift. During a concurrent observation and interview with on 5/30/23, at 3:23 p.m., with Cook 2, in the kitchen, Cook 2 was noted cutting cucumbers for cucumber, tomato, and onion salad. Cook 2 stated, she used cucumbers for the salad from the same box that the moldy ones were in. Cook 2 stated, she just used the ones that were ok During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, she did look at the produce in the walk in on Monday 5/29/23 during the sanitation review but did not see any issues. RD stated, expectation is the facility not use the moldy food. RD stated, facility should toss them out and buy new ones because moldy food can cause illness.

Based on observations, interviews, and record reviews the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services for 93 out of 93 sampled residents when: 1. Cook 1, Cook 2 and Dietary Supervisor (DSS) did not know they need to do cool down process (is an essential process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 135 F to 41 F, also referred to as the temperature danger zone. Cooked Foods not served immediately must be cooled quickly to minimize bacterial growth. If cooked foods left for improper cool down process, cooked foods can become unsafe to eat in a matter of hours) for cooked bean. (Cross referred 812) 2. Dietary Aide 1 did not follow manufacturer guideline time length to submerse kitchen ware into [NAME] (sanitizer) in the sanitizing sink. 3. Cook 1 did not follow manufacturer instructions time length to test the concentration of the [NAME] in the sanitizing sink. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) for all residents who received foods from the kitchen. Findings: 1. During an observation on 5/31/23, at 9:44 a.m., a pan of cooked bean labeled dated 5/30/23 with the used date of 6/3/23 was observed in the walk-in refrigerator. During a concurrent interview and record review, on 5/31/23, at 9:56 a.m., with DSS and Cook 2, Safe Ways to Cool Foods guideline posted next to Cool down Log, undated was reviewed. DSS stated, the cooked bean found in walk in refrigerator was made by Cook 1 yesterday morning. DSS stated, they never did cool down process for cooked bean so there was no cool down process done for yesterday cooked bean. Cook 2 stated, she and other cooks never did cool down process for the cooked bean. DSS reviewed the guideline and stated cooked bean was one of the food items needed to have cool down process. During a phone interview, on 6/1/23, at 3:17 p.m., with the Registered Dietician (RD), the RD stated, the cooked bean stored in the walk-in refrigerator needed to have cool down process. The RD stated, improper cooling of cooked bean could cause foodborne illness. The RD expectation was Cooks to follow the Safe Ways to Cool Foods guideline. During a review of the facility's job description titled, COOK, undated, the job description indicated, . Adhering to . food safety guidelines during meal preparation . During a review of the facility's job description titled, DIETARY SUPERVISOR, undated, the job description indicated, . Monitoring staff to confirm they adhere to all . safety and procedural guidelines within the department . 2. During a concurrent observation, interview, and record review on 5/31/23, at 11:15 a.m., with Dietary Aide (DA) 2, in front of 3 compartment sinks (sinks used for manual washing kitchen ware. 1st sink is for wash, 2nd sink is for rinse and 3rd sink is for sanitizer), Three Sink Washing and Sanitizing procedure provided by [NAME] vendor posted above 3 compartment sinks was reviewed. DA 2 was observed dipping a serving bowl for 1 second into [NAME] solution in the sanitizing sink and then placed the serving bowl onto drain board. DA 2 dipped 2 serving pans into [NAME] solution in the sanitizing sink for 3 second and then placed the 2 serving pans onto the drain board. DA 2 stated, she was not sure how long she needed to submerge the serving bowl and serving pans into [NAME] solution in the sanitizing sink. DA 2 stated, she never read the Three Sink Washing and Sanitizing procedure posted above 3 compartment sink. Reviewed Three Sink Washing and Sanitizing procedure with DA 2, DA 2 read the Three Sink Washing and Sanitizing procedure and stated , she needed to submerge kitchen ware into [NAME] sanitizing sink for at least 1 minute. During a phone interview, on 6/1/23, at 3:17 p.m., with the RD, the RD stated, dietary staff did not follow manufacturer guideline for time length to submerse kitchen ware into [NAME] in the sanitizing sink which could cause cross contamination. The RD expectation was for dietary staff to know the policy and procedure (P&P), to follow the P&P, and to follow manufacturer guideline and procedure. During a review of the facility's job description titled, DIETARY AIDE, undated, the job description indicated, . Adhering to sanitation and food safety guideline . During a review of the facility's P&P titled, Manual Washing: Three Compartment Sink Method, revised 2/18/20, the P&P indicated, . 5. Submerse in the sanitizing sink according to the chemical vendor's time requirements. 3. During a concurrent observation and interview, on 5/30/23, at 10:59 a.m., with Cook 1, Cook 1 was observed using the [NAME] test strip to test the concentration of the [NAME] solution in the sanitizing sink. Cook 1 dipped the [NAME] test strip into [NAME] solution for approximate 3 seconds and took the [NAME] test strip out. Cook 1 stated, it only needed 3 seconds to dip [NAME] test strip to test the concentration of the [NAME]. During an interview, on 5/30/23, at 3:47 p.m., with the DSS, the DSS stated, the [NAME] test strip needed to dip into [NAME] in the sanitizing sink for 10 seconds to test the concentration of the [NAME] in the sanitizing sink. During a phone interview, on 6/1/23, at 3:17 p.m., with the RD, the RD stated, the [NAME] test strip needed to dip into [NAME] in the sanitizing sink for 10 seconds to test the concentration of the [NAME] in the sanitizing sink. The RD's expectation was dietary staff followed the [NAME] test strip container instructions. During a review of the [NAME] test strip container instructions, undated, the instructions indicated, Dip for 10 seconds. During a review of the facility's job description titled, COOK, undated, the job description indicated, . Adhering to sanitation and food safety guidelines .

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Pest Control, when the facility did not maintain an environment free of pests. This failure had the potential to result in illness related to cross contamination of food. Findings: During an observation on 5/30/23, at 3:16 p.m., a fly was noted flying above the steam table. During an observation on 5/30/23, at 3:17 p.m., a fly was noted flying near the two-compartment sink. Dietary Supervisor (DSS) saw the fly, attempted to swat it with her hand. During an observation on 5/30/23, at 3:23 p.m., there was a fruit fly inside a box of moldy cucumbers on the counter near the two-compartment sink. During a concurrent observation and interview on 5/31/23, at 9:40 a.m., a house fly landed on the prepared cups of ice water. DSS stated, she killed the fly from yesterday. During an observation on 5/31/23, at 10:28 a.m., a house fly landed on the steam table (table that uses steam to provide consistent heat that surrounds food pans, used to hold prepared foods at safe temperatures for extended amounts of time). During an interview on 5/31/23, at 11:54 a.m., with the Maintenance Supervisor (MS), MS stated, the company we use for pest control was just here yesterday. MS stated, they come once per month. No one notified MS there was any problems with flies. During a concurrent observation and interview on 5/31/23, at 2:45 p.m., with Dietary Aide (DA) 1, in hallway outside of kitchen, 2 flies were noted. DA 1 validated, there were two flies. During a concurrent observation and interview on 5/31/23, at 2:56 p.m., with DSS, in front of the ice machine, black ants noted crawling across the floor. DSS stated, those are ants, and [pest control company] was just here yesterday. During a concurrent observation and interview on 5/31/23, at 3:01 p.m., with MS, in front of the ice machine, black ants noted. MS stated, Those are ants, they shouldn't be here. MS stated, the pest control company usually sprays in here, but they didn't spray inside yesterday. During a concurrent observation and interview on 5/31/23, at 4 p.m., with the Administrator (ADM), ants were noted crawling in front of the ice machine. The ADM stated, they will get some ant spray. During an interview on 6/1/23, at 3:17 p.m., with the Registered Dietician (RD), RD stated, they should not have any pest or rodents in the facility at all because it can cause residents or staff to get sick. During a review of the facility's P&P titled, Pest Control, the P&P indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview and record review, the facility failed to honor a food request for one of one sampled residents (Resident 59), when a Licensed Vocational Nurse (LVN) denied his verbal request for a biscuit and did not offer him an alternative item. This failure resulted in Resident 59's individual preference or choice being devalued (reduce or underestimate the worth of importance of) and not being treated with honor or respect. Findings: During an observation on 5/30/23, at 12:10 p.m., in the resident dining room, Resident 59 asked licensed vocational nurse (LVN) 2 if he could have a biscuit instead of two pieces of toast on his plate. Three other residents at his table had biscuits. Resident 59 went and sat back down and five minutes later got up to ask again. Resident 59 was not given the biscuit and did not receive an alternative. During an interview on 5/30/23, at 12:16 p.m., with LVN 2, LVN 2 stated, if Resident 59 would like an alternative then he needed to finish his current meal first and then Resident 59 could have a biscuit. LVN 2 stated, Resident 59 was a diabetic, but Can't deny him if that's what he wants. During a review of Resident 59's Order Summary Report- Dietary (OSRD), dated 6/1/23, the OSRD indicated, .Diet- Reduced Concentrated Sweets (RCS- a diet avoiding foods with a lot of sugar or high calorie sweeteners) diet, regular texture, thin consistency, related to Type 2 Diabetes Mellitus (a disease of inadequate control of blood levels of glucose) without complications . During a review of Resident 59's Meal Ticket (MT), dated 5/30/23, the MT indicated, Noon Meal .Diet Order: RCS .Diet Cons: Regular .Bread* 1-each .Apple Crisp* . During an interview on 6/1/23, at 11:38 p.m., with the Registered Dietician (RD), the RD stated, the RCS diet should be getting smaller portions of the concentrated sweets, such as, a smaller dessert or no whip cream on top of dessert. The RD stated, the RCS diet was not a diet for carbohydrate (essential nutrients which include sugars, fibers and starches) control, it was for sweets only. The RD stated, Resident 59's request for a biscuit should have been honored and it was his right to receive one if he wishes. The RD stated, it was not proper to have Resident 59 finish his meal first and get the biscuit as a second serving. During an interview on 6/1/23, at 2:20 p.m., with the Dietary Supervisor (DSS), the DSS stated, she never received a request for Resident 59 to have a biscuit from staff, if she did, she would have honored the request. During an interview on 6/1/23, at 2:41 p.m., with Resident 59, Resident 59 stated, he looked on the menu board before lunch, read the menu and saw they were having biscuits for the day. Resident 59 stated, he did not know why he received bread instead of a biscuit like other residents at his table. Resident 59 stated, he was upset and bothered that he did not receive a biscuit. During a review of Resident 59's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 59's MDS assessment indicated, Resident 59's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 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 59 was cognitively intact. During an interview on 6/2/23, at 10:17 a.m., with the Director of Nursing (DON), the DON stated, he was unsure of what the RCS diet consisted of and he would defer to the RD or DSS. The DON stated, LVN 2 should have notified the DSS of Resident 59's biscuit request. The DON stated, it appears Resident 59's rights were not honored. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2/2021, the P&P indicated, . b. be treated with respect, kindness and dignity . f. communication with and access to people and services, both inside and outside the facility . h. be supported by the facility in exercising his or her rights . The facility's definition of an RCS diet was requested, but not provided. The facility provided a document titled, Controlled-Carbohydrate Diet (CCD), dated January 2022, CCD indicated, .The American Diabetes Association states the terms reduced concentrated sweets (RCS), no sugar added and ADA diets are inappropriate because these terms do not reflect current nutrition recommendations . The controlled-carbohydrate diet meets the RDA of the National Academies for persons 51 and over .

Based on observation, interview and record review, the facility failed to inventory personal property for one of one sampled residents (Resident 14) when Resident 14's hand-held radio was not inventoried (item entered in to a list). This failure resulted in Resident 14's property being lost or stolen and the facility not replacing it. Findings: During a concurrent observation and interview on 5/30/23, at 9:46 a.m., with Resident 14, in Resident 14's room, a small black hand-held radio was seen on his nightstand next to his bed. Resident 14 stated, he had a box sized radio missing a year or so ago and was not replaced. Resident 14 stated, it was a boom box. Resident 14 stated, the small radio on the nightstand was a different radio and his other boom box size radio was never replaced. During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 14's MDS assessment indicated Resident 14'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 14 was cognitively intact. During an interview on 5/31/23, at 3:52 p.m., with the Social Services Director (SSD), the SSD stated, Resident 14 has had the black radio that is bedside since she has been here. The SSD stated, she had been working at the facility for about a year. The SSD stated, I know he [Resident 14] said the black radio was stolen, but he already has a radio. I discussed it with the conservator about replacing it, but it wasn't on his inventory sheet. The SSD stated, it was the program counselor's responsibility to update the inventory sheets. During a concurrent interview and record review on 5/31/23, at 3:54 p.m., with the SSD, Resident 14's Inventory List (IL), dated 1/5/12 was reviewed. The IL indicated, no record of the current black radio that was on Resident 14's nightstand. The SSD stated, there were no other inventory lists made for Resident 14 and the current black radio he had was not on the IL in the chart. The SSD stated, program counselors could not find His current black radio on an inventory sheet either. The SSD stated, The inventory sheet is there as evidence to show if things go missing. The SSD stated, the facility can not replace items if they are not on the inventory sheet. During a concurrent interview and record review on 6/1/23, at 10:55 a.m., with the Director of Nursing (DON), Resident 14's IL, dated 1/5/12 was reviewed. The IL indicated, no record of the current black radio that was on Resident 14's nightstand. The DON stated, The inventory list is not updated when it should have been. DON stated, Everything in the room that is a personal item, should be on the inventory list. DON stated, IL should be updated at admission and as needed by staff. During a concurrent interview and record review on 6/1/23, at 10:55 a.m., with the DON, the facility's policy and procedure (P&P) titled, Personal Property, dated August 2022, was reviewed. The P&P indicated, .10. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary . The DON stated, The policy was not followed for [Resident 14]. He should have had the radio on his inventory list.

Based on observation, interview and record review, the facility failed to allow residents to submit grievances (complaints) anonymously (not being named or identified) for one of four sampled residents (Resident 60) when the grievance box was inaccessible (not able to be accessed) for residents to submit grievances anonymously. This failure resulted in Resident 60 not being able to voice concerns without discrimination, or fear of reprisal (retaliation). Findings: During an interview on 5/31/23, at 11:38 p.m., with Resident 60, the Resident 60 stated, handing the grievance form to a staff member to place in the grievance box would no longer make him anonymous. Resident 60 stated, I want to stay anonymous, so that I feel safe. Resident 60 stated, if staff knew it was him making the complaint, he would be embarrassed and get upset. During a review of Resident 60's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 60's MDS assessment indicated Resident 60'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 60 was cognitively intact. During a concurrent observation and interview on 5/31/23, at 1:54 p.m., with the Activities Director (AD), in the locked nursing station (NS), grievance box 1 was observed to be located on the door of the schedule coordinator's office inside the nursing station, inaccessible to residents. The AD stated, the resident would have to give their grievance to staff and staff would have to put it in the grievance box for them. The AD stated, the resident would not be anonymous anymore by giving their form to a staff member. During a concurrent observation and interview on 5/31/23, at 1:54 p.m., with the AD, in the south wing hallway, grievance box 2 was observed to be located behind two locked double doors, outside of the unit, inaccessible to residents. The AD stated, the resident would have to give their grievance to staff and staff would have to put it in the grievance box for them. The AD stated, the resident would not be anonymous anymore due to having to give their form to a staff member. The AD stated, there were only two grievance boxes in the facility. During a concurrent interview and record review on 5/31/23, at 2:39 p.m., with the Social Services Director (SSD), the facility's policy and procedure (P&P) titled, Grievances/Complaints, Filing, dated April 2017, was reviewed. The P&P indicated, .2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal .5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously . The SSD stated, After reviewing the P&P, we are to have it anonymous, but I can see now how it currently isn't anonymous. The SSD stated, she was the facilities grievance officer and was responsible for checking the grievance boxes. The SSD stated residents must give their grievances to staff members to place in the boxes for them because the grievance boxes were located behind locked doors. The SSD stated, Those resident grievances are no longer anonymous because staff will know it is from the resident. During an interview on 5/31/23, at 3:03 p.m., with the Director of Nursing (DON), the DON stated, residents did not have direct access to the two grievance boxes and must give their grievance form to a staff member to put in the grievance box for them. The DON stated, The grievance is no longer anonymous at the point of giving it to the staff member.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment accurately reflected the resident's status for one of five sampled residents (Resident 3) when Resident 3 had an open skin wound and was coded with intact skin in the MDS assessment. This failure resulted in an inaccurate assessment of Resident 3's skin condition and had the potential for Resident 3's needs to go unmet. Findings: During a review of Resident 3's face sheet titled Admission Record, undated, the face sheet indicated, resident 3 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a serious mental disorder in which people interpret reality abnormally) and anxiety disorder (a mental disorder in which people have persistent and excessive worry that interferes with daily activities). During a review of Resident 3's MDS assessment, dated 5/15/23, the MDS assessment indicated Resident 3's Brief Interview for Mental Status (BIMS-screening tool used in nursing facility to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 3 has no cognitive deficit. During a concurrent observation and interview on 5/30/23, at 10:00 a.m., Resident 3 was observed walking in the hall in clean clothes in no apparent distress. Resident 3 had an open wound to his face on his left cheek. Resident 3 did not respond to questions about care but did say hi. During a concurrent interview and record review on 5/31/23, at 4:25 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 3's Care plan, dated 1/6/2023 and Program Counselor note, dated 5/24/2023 at 11:47 a.m., were reviewed. Resident 3's Care plan, dated 1/6/2023 indicated, .Alteration in skin integrity related to left facial pustule dt [due to] non compliance with good hygiene and non compliance with not picking at his skin . Left Facial Tumor (Assessed by NP [Nurse practitioner]) .1/6/2023. Date initiated 9/25/2020 . Assess progress of skin weekly . observe/report any skin irritation, eruption, rashes, redness, itchiness to MD [doctor] promptly . observe/report s/s [signs/symptoms] of skin infection such as local fever, redness, drainage, tenderness, pain, swelling from affected site(s) to MD promptly . Program Counselor note, dated 5/24/2023 at 11:47 a.m., indicated, DISCHAGE PLAN REVIEW: Resident was seen in staffing today with [MD 2] [calm] an [and] pleasant during the visit. IDT (Interdisciplinary team-multiple disciplines working together)reminded and educated resident regarding his refusal to have growth/lesion on his left cheek be checked out by a specialist . LVN 1 stated Resident 3 said Resident 3 scratched at the lesion and we would see blood on his pillow. LVN 1 stated if the wound was draining the nurses will try to clean it but he was non compliant and will refuse. During a concurrent interview and record review on 6/1/23, at 10:39 p.m., with LVN 1, Resident 3's Nursing Weekly Summaries, dated 5/13/2023, 5/20/2023 and 5/27/2023, were reviewed. LVN 1 stated the no skin problems was documented on 5/13/2023, 5/20/2023 and 5/27/2023 but are not accurate as he has the wound on his cheek for some time. LVN 1 stated only 5/13/2023 documented that Resident 3 refused skin assessment times three. During an interview on 6/2/2023, at 9:41 a.m., with the Director of Nursing (DON), the DON stated his expectation was nursing weekly summaries to be accurate and the nurses should document if the resident refuses to be assessed. The DON stated his expectation was the MDS assessment to be performed accurately and MDS should match the assessment of the resident when it was reported to Centers for Medicare and Medcaid Services (a government agency which provides health coverage). During a concurrent interview and record review on 6/2/23, at 10:31 a.m., with the Minimum Data Set Registered Nurse) MDSN 1, the MDSN 1 reviewed Resident 3's MDS admission assessment Section M dated 5/15/23, Section M indicated, .Skin Conditions . D. Other lesions other than ulcers, rashes, cuts (e.g. cancer lesion) . [coded as No] . The MDSN 1 reviewed Section M and stated she had entered a No for other skin conditions. The MDSN 1 stated the skin conditions, other lesions in Section M was inaccurate and should have been coded as Yes.

Based on observation, interview, and record review, the facility failed to ensure it was free of accident hazards when they did not use a wet floor sign to identify a hallway floor that was wet from mopping. This failure had the potential to result in residents, staff, and visitors slipping on the wet floor and sustaining a fall or injury. Findings: During a concurrent observation and interview on 6/1/23, at 3:10 p.m., with the Infection Preventionist (IP), in the Program Building hallway, wet floor was noted with no sign to indicate that the floor was wet. IP stated, there was no sign to indicate that the floor was wet. IP stated, housekeeping would come to mop after the residents have had their snacks. IP stated, She [housekeeper] knows better than to leave it [floor] wet like that without putting up a wet floor sign. During an interview on 6/2/23, at 2:09 p.m., with the Housekeeping Manager (HKM), HKM stated, housekeepers are supposed to have the wet floor sign up before they start mopping. They were only supposed to mop half of the hallway at a time because residents and staff come in and out of the program building we don't want them to slip. During a review of the facility's policy and procedure (P&P) titled, DAMP MOPPING, undated, the P&P indicated, .HALLWAYS AND COMMON AREAS: Use 'Wet Floor' signs to mark the wet side of floor (mop 1/2 hallway at a time) . During a review of the facility's P&P titled, Section F: Safety and Sanitation, dated 2/18/20, the P&P indicated, .Wet floor signs will always be used when floors are wet .

Based on interview and record review, the facility failed to complete a performance evaluation of a nurse aide at least every 12 months for one of two sampled Certified Nurse Assistant (CNA 7), when CNA 7 did not have a performance evaluation review. This failure had the potential to result in residents to not receive the appropriate care and services performed by CNA 7. Findings: During a concurrent interview and record review on 6/5/23, at 10:42 a.m., with the Director of Staff Development (DSD), CNA 7's Employee File (EF), dated 4/24/22 was reviewed. The DSD stated, the EF indicated, CNA 7 was hired on 4/24/22. The DSD stated, the EF indicated CNA 7's annual Performance Evaluation (PE) was not in the file and should have been completed in April 2023. The DSD stated, CNA 7's PE form could be with the Director of Nursing (DON), who was responsible for the completion of direct care staff evaluations. During an interview on 6/5/23, at 3:15 p.m., with the DON, the DON stated his expectations of staff annual PEs were that they should be completed within the month the staff was hired and the PE should be filed in the EF. The DON stated CNA 7 worked the night shift and he was not able to complete CNA 7's PE. The DON stated the importance of staff PEs was to allow the facility to inform the staff if they were meeting the facility's expectations and if there were any areas requiring improvements. The DON stated it was his responsibility to complete CNA 7's PE and he did not have an excuse for not completing it timely. The DON stated since CNA 7's PE was not completed, CNA 7 was not provided with an opportunity for a pay raise, was not made aware of her job performance and any improvements if required were not addressed. The DON stated PEs should be completed annually to meet regulatory requirements. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated September 2020, the P&P indicated, . The job performance of each employee shall be reviewed and evaluated at least annually . Performance evaluations may be used in determining employee promotions, shift/position transfers, demotions, terminations, wage increases . to improve the quality of the employee's work performance . The written performance evaluations will contain the director's and/or supervisor's remarks and suggestions, any action that should be taken (e.g., further training, etc.), and goals . The completed performance evaluation will be sent by the director or supervisor to the director of human resources to be placed in the employee's personnel file. A copy will be provided to the employee .

Based on observation, interview and record review, the facility failed to destroy controlled (drugs that are tightly controlled because of their abuse potential or risk) medications per facility policy for one of two sampled medication storage rooms, when controlled substances were discarded in an unlocked medication destroy bin accessible to all staff members. This failure had the potential to result in the potential diversion (transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illegal use) of controlled medications. Findings: During an observation on 6/2/23, at 1:35 p.m., in the Nursing Station (NS), the nursing station was accessed by key via two different doors. The nursing station had a connected hallway around 10-feet long and the medication storage room was at the end of the hallway. The nursing station, connected hallway and medication storage area were all in the same room. The medication room was accessible to any employee with a key to the nurse's station. Observed in the nursing station area, were two certified nursing assistants, one person who was the scheduler and two Licensed Vocational Nurses (LVN) at their computers, with their backs to the other staff in the room. During a concurrent observation and interview on 6/2/23, at 1:50 p.m., with LVN 1, in the medication storage room, a white medication destroy bin (WMDB) with a blue unlockable lid was observed on the floor next to the medication cart. The opening to the WMDB was an estimated nine-inches in diameter and two-feet deep. Inside the WMDB were an estimated 50 medications of various tabs, pills, vials (small container made of glass, used especially for holding liquid medications) and clear packages with white residue. LVN 1 stated, the WMDB was not locked and a person could stick their arm in and access the disposed medications. LVN 1 stated, there were more than 50 pills . random pills, unsure of what they are inside of the WMDB. LVN 1 stated, any staff with a key to the nurse station could access the WMDB. LVN 1 stated, all staff have a key to the nursing station that work on the unit, including administration who also have keys. LVN 1 stated, the WMDB was where controlled medications are disposed of. LVN 1 stated, the controlled medications were disposed by crushing with a pill-crusher in a clear package and then dumping the medication and the clear package into the WMDB. LVN 1 stated, there were clear packages with white residue on them in the WMDB. LVN 1 stated, the residue inside the packages could be a narcotic (medication with numbing or paralyzing [causing a person or part of the body to become partly or wholly incapable or movement] properties). LVN 1 stated, she was unsure if there was a policy regarding medication disposal and if there was, she had never read it. During a concurrent observation and interview on 6/2/23, at 2:32 p.m., with the Assistant Director of Nursing (ADON), in the medication storage room, the WMDB was observed. The ADON stated, every medication that needs to be disposed went into the WMDB, but only controlled medications were crushed. The ADON stated, any staff member with keys can access the WMDB because there wasn't a door to the medication storage room. The ADON stated, there were roughly 100 or more pills inside of the WMDB. During a concurrent observation and interview on 6/2/23, at 2:32 p.m., with the Director of Nursing (DON), in the medication storage room, the WMDB was observed. The DON stated, there was not a door to the medication storage room and it was possible for anyone to go in and open the WMDB because it was not locked. The DON stated, a person could stick their arm in the WMDB and take out anything they wanted. During an interview on 6/5/23, at 10:15 a.m., with the Pharmacy Consultant (PC), the PC stated, there was a chance someone could come in the room and access the WMDB because there was not a locked door to the medication storage room. The PC stated, there was a possibility of getting a controlled medication from the WMDB because the facility was not disposing the medication in a drug buster solution (DBS- solution that makes the controlled medication ineffective or harmless). The PC stated, the DBS, makes the controlled medication unretrievable and adds an extra layer of protection. The PC stated, he thought the facility was already using the DBS for controlled substances and did not know they were not. During an interview on 6/5/23, at 2 p.m., with the DON, the DON stated, the facility had some holes that needed to be fixed and stated there should be improvements to their medication disposal process. During a concurrent interview and record review on 6/5/23, at 2 p.m., with the DON, the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated November 2022 was reviewed. The P&P indicated, .Medications that cannot be returned to the dispensing pharmacy (e.g., non-unit dose medications, medications refused by the resident, and/or medications left by residents upon discharge) are disposed of in accordance with federal, state and local regulations governing management of non-hazardous waste and controlled substances . 7. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the Environmental Protection Agency recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. B. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage . The DON stated, the facility was not following this P&P.

Based on observation, interview, and record review the facility failed to provide dental services to meet the needs of each resident and follow its policy titled, Dental Services, for one of eight sampled residents (Resident 34), when Resident 34 broke his dentures in November 2022, informed staff and no dental appointment was made. This caused Resident 34 to miss out on foods that he enjoyed due to not having his dentures to use. Findings: During a review of Resident 34's Face Sheet (document that provides demographic information on the resident i.e. name, date of birth, insurance, contact information and diagnosis), dated 6/2/23 and Brief Interview for Mental Status (BIMS- a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility), dated 3/21/23, the Face Sheet indicated Resident 34 was admitted to this facility on 6/15/2018 with diagnosis of Schizoaffective Disorder Bipolar Type (a mental illness that can affect your thoughts, mood and behavior), Diabetes type 2 (A chronic condition that affects the way the body processes blood sugar.), and essential hypertension (abnormally high blood pressure that's not the result of a medical condition). The BIMS indicated Resident 34 had a score of 15 meaning his cognition was intact (0-15 scale-a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). During a concurrent observation and interview on 5/30/23, at 3:49 p.m., with Resident 34, Resident 34 was seen sitting on his bed, looked clean and smelled like he just took a shower. Resident 34 stated his dentures had been broken since November 2022 and he informed staff, but they had not done anything to repair or get them replaced. Resident 34 stated he only ate softer food but would like to go back to eating everything. Resident 34 walked to the bathroom and opened a pink container that was sitting on the sink, inside were a pair of dentures and one piece was seen broken in half. During a review of Resident 34's Care Plan titled, Dental Care Plan, under the section Focus on the Care plan indicated, [name of resident 34] has oral/dental health problems r/t him being edentulous (lacking teeth). [name of resident 34] has upper and lower dentures that he uses most of the time. [name of resident 34] lower denture is loose due to the loss of bone due to years of not having teeth or dentures prior to allowing facility to help him get dentures. [name of resident 34] was educated on risk vs. (versus) benefits of using dentures to help him chew his food. Risk includes possible dental infections, pain, weight loss, and difficulty chewing food. Benefits include better oral health, decreased possibly of dental infections, pain and difficulty chewing food. Facility will refer [name of resident 34] to ancillary services as needed. 7/26/21: [name of resident 34] received his full set of dentures today. Fitting and adjustment provided. Reviewed and restated on 3/21/23 by [initials of Social Services Director (SSD)] SSD Date initiated: 9/25/2019 Revised on: 3/21/23 . Interventions . Coordinate arrangements for dental care, transportation as needed/as ordered. Date Initiated: 9/25/2019 Revision on: 9/28/2022 Monitor/document/report to MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) of oral/dental problems needing attention: pain . Teeth missing, loose, broken, eroded, decayed . Date Initiated: 9/25/2019 Revision on: 9/28/2022 . During an interview on 6/2/23, at 10:33 a. m., with the SSD, the SSD stated she started working here 7 months ago and at that time Resident 34 mentioned his dentures did not fit but she was not aware that Resident 34's dentures were broken. The SSD stated the dentist came to the facility every 2 months and she was informed that Resident 34 could not get new dentures until it had been a year since he got his new ones. The SSD stated Resident 34 was on the list to get to be seen by [company name of dental mobile services] to get x-rays, then will be seen by [dentist name]. The SSD stated Resident 34 reminded her daily he needed work on his dentures. The SSD stated, Yes, ill-fitting, and broken dentures are considered an emergency, but he has not verbalized having issues eating so it is not an emergency for this patient. Weights are being monitored. The SSD stated she would call [company name of mobile dental services] to see when Resident 34 had his appointment. During an interview on 6/2/23, at 10:33 a.m., with Schedule Coordinator (SC) 1 of [company name of mobile dental services], SC 1 stated Resident 34's last dental appointment was on 4/28/22, she stated he had missed his annual exam on 7/22. SC 1 stated Resident 34's next scheduled appointment was made today for 6/7/23. During a concurrent interview and record review on 6/2/23, at 10:33 a.m., with the SSD, Resident 34's Social Services notes were reviewed. The SSD stated there were no notes to indicate why the resident missed his appointment in July of 2022. The SSD stated she had a list that the residents go on who are to be seen next for dental. The SSD showed the list she kept at her desk and confirmed Resident 34's name was not on it. During a concurrent interview and record review on 6/2/23, at 2:40 p.m., with the SSD, Resident 34's Quarterly Review Assessment (QRA) dated 12/21/22 and 3/21/23 were reviewed. The QRA for 12/21/22 indicated, . Res [resident] recently broke his dentures and would like to get them replaced . The SSD stated she wrote the QRA dated 3/21/23 and it indicated, . Res recently broke his dentures and would like to get them replaced . The SSD stated she copied the previous QRA note dated 12/21/22 but did not know Resident 34's dentures were broken. During an interview on 6/2/23, at 3:04 p.m., with the Administrator (ADM), the ADM stated his expectation when a resident had broken dentures was for the Social Services Department to get that resident an appointment as soon as possible. The ADM stated broken dentures could affect a resident's ability to eat and thus affect their weight. During an interview on 6/5/23, at 9:48 a.m., with SC 2, SC 2 stated Resident 34 had Medi-cal insurance and this insurance covered Resident 34's dentures to be fixed and/or replaced once a year. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 12/16, the Dental Services P&P indicated, . 10. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services and the reason for the delay .

Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment for two of three sampled pill crushers (device for crushing medications) when the pill crushers were not free of medication residue (white substance). This failure had the potential to result in cross-contamination (process by which bacteria is transferred from one substance or object to another, with harmful effect) of medications and possibly cause serious harm, or death. Findings: During a concurrent observation and interview on 6/2/23, at 1:50 p.m., with Licensed Vocational Nurse (LVN) 1 in the medication room, two of the pill crushers were observed to have residue on them. LVN 1 stated, residue is from medications probably. LVN 1 stated, she was unsure of what medications the residue was from. LVN 1 stated, the same residue was on both pill crushers and it shouldn't be dirty like that. LVN 1 stated, don't want to cross-contaminate and if not cleaned properly, could put residents in harm's way. LVN 1 stated, she was unsure when the pill crushers were last cleaned. LVN 1 stated, the two pill crushers were used for crushing narcotics when needed. During an interview on 6/5/23, at 11:40 a.m., with the Infection Preventionist (IP-professionals who make sure healthcare workers and patients are doing all the things they should to prevent infections), the IP stated, she saw the white residue on both of the [pill crushers]. The IP stated, potential hazards for sure. IP stated, that cross-contamination could occur, a nurse could get the medication residue on their finger and not realize it and potentially pass on the unknown medication residue to a resident. The IP stated, she was not sure how staff were cleaning the pill crushers. The IP stated, Licensed Nurses should clean the pill crusher after every medication pass. During a review of manufacturer guideline titled, [Brand Name] Crusher In-Service, the manufacturer guideline indicated, .may be cleaned regularly with a damp cloth. A facility approved disinfectant wipe may also be used when indicated .The frequency in which the pill crusher is cleaned is dependent on a facility's cleaning and disinfection protocol . The facility cleaning and disinfection protocol was requested, but not provided.

Based on interview and record review the facility failed to implement its policy and procedure that prohibit and prevent abuse titled, Abuse Investigation and Reporting for one of five sampled residents (Resident 1) when the interviews were not done with Licensed Vocational Nurse (LVN) 1 and LVN 2 that were on duty during the time of the reported event. This failure had the potential for resident 1's abuse to not be investigated thoroughly and place other residents at risk of being abused by the suspected abuser. Findings: During a concurrent interview and record review on 4/19/23, at 9:20 a.m. with the Administrator (ADM), the staffing sheets for 4/13/23 were reviewed. The ADM stated Resident 1 reported having visions of Resident 2 raping (unlawful sexual activity and usually sexual intercourse carried out forcibly or under threat of injury against a person's will) her in the middle of the night. ADM stated as part of their investigation into this abuse, the facility interviewed the evening shift nurses who worked on 4/13/23 from 2:45 p.m. to 11:15 p.m. The ADM stated he did not interview the night shift nurses (LVN 1 nor LVN 2) who worked on 4/13/23 from 10:45 p.m. to 7:15 a.m. During a review of Resident 1's Admission Record indicated the facility admitted the resident on 1/5/23 with diagnosis of schizoaffective disorder (mental illness that can affect thoughts, mood and behavior), bipolar type (causing extreme mood swings that include emotional highs and lows). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 4/12/23 indicated Resident 1's Brief Interview for Mental Status (BIMS- a mandatory tool used to screen and identify the cognition of residents upon admission, scoring is from 0-15) was a 15 meaning she has intact cognitive skills for daily decision making. During an interview on 4/19/23, at 10:15 a.m., with Resident 1, Resident 1 stated she has been having night terrors (feelings of great fear experienced on suddenly waking in the night) of Resident 2 raping her and that she woke up the other night on 4/13/23 around midnight and saw him leaving her room. During an interview on 4/19/23, at 3:40 p.m., with LVN 1, LVN 1 stated she worked night shift from 10:45 p.m. to 7:15 a.m. on 4/13/23 and had not been interviewed about the abuse reported by Resident 1. During an interview on 4/19/23, at 3:52 p.m., with LVN 2, LVN 2 stated he worked the night shift from 10:45 p.m. to 7:15 a.m. on 4/13/23 and the last time he worked was on 4/16/23 and he has not been interviewed by the facility about the abuse reported by Resident 1. During a review of the facility's policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, the policy indicated, Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be .thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation Role of the Administrator . Role of the Investigator: 1. The individual conducting the investigation, will, at a minimum: a. Review the completed documentation forms; . g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the residence roommate, family members and visitors .

Based on observation, interview, and record review, the facility failed to ensure the safety and protect residents from sexual abuse for one of four sampled residents (Resident 2) when Resident 2 experienced unwanted oral copulation (any contact, no matter how slight, between the mouth of one person and the sexual organ or anus of another person) and finger penetration (the act of inserting an object of body part into another) by Resident 1 on 10/6/2020. Nursing staff failed to develop and implement effective interventions to address Resident 1's sexual behaviors toward Resident 2 on 9/24/2020 to ensure Resident 2's safety. The nursing staff failed to recognize, intervene, and report the alleged sexual abuse on 10/6/2020 within two hours of alleged sexual abuse. The Interdisciplinary team (IDT) (a facility group composed of a physician, a registered nurse, a social worker and additional appointed facility staff) did not evaluate and revise Resident 2's consensual sexual consent (an agreement to participate in a sexual activity, both people must agree to sex every single time) to protect the resident from sexual abuse. These failures resulted in sexual assault by Resident 1 on Resident 2. Resident 2 required transportation to Sexual Assault Response Team (SART) (a medical-legal examination given to a survivor after a sexual assault has taken place) examination on 10/7/2020. Resident 2 experienced fear, increased episodes of hallucinations, vaginal pain, and flash backs (sudden involuntary recurrent memory) of sexual assault. Resident 2 required additional anxiolytic (medications used to prevent and treat anxiety disorders) medications by prescribing psychiatrist on 10/12/2020 and an increased in dosage of anxiolytic medication on 11/9/2020 for suicidal ideation (wanting to take your own life) with episodes of panic attacks. Findings: During a concurrent interview and record review on 10/8/2020, at 1:26 p.m., with Director of Nursing Service (DNS) and Director of Staff Development (DSD), the DNS reviewed Resident 1's consent titled, Sexually Active within the Facility - Resident Contract dated 10/18/2018 which indicated, .The facility will make any and all attempts to protect residents from sexual abuse and nonconsensual sex. If sexual abuse were to be suspected, facility abuse reporting policy will be followed. The document indicated Resident 1's consent signature dated 10/18/2018. The DNS reviewed Resident 2's consent titled, Sexually Active within the Facility - Resident Contract dated 10/18/2018 and reflected Resident 2's consent signature dated 10/18/2018. The DNS stated Resident 1 and Resident 2 consented for sexual activity on admission and the consents were not reviewed after admission. Resident 1 and Resident 2's IDT were reviewed and reevaluated by the attending psychiatrist on a monthly basis. The DSD stated Resident 2 was alert and coherent, active, independent, and stayed in a private room in the women's hallway (West wing) due to gender orientation (biologically female and self-identified as male). The DSD stated Resident 2 did not have a history of sexual relationships with other male or female residents in the facility. The DSD stated Resident 1 and Resident 2 were sexual partners since 2018. During an interview on 10/8/2020, at 1:36 p.m., with the Administrator (ADM), the ADM stated he conducted the investigation regarding the alleged sexual incident between Resident 1 and Resident 2 on 10/7/2020. The ADM stated the Program Counselor (PC) 2 reported to the Nursing Department the alleged sexual incident occurred on 10/6/2020 at approximately 1 p.m. to 1:30 p.m. when Resident 1 went into Resident 2's room where Resident 2 laid on the bed for a nap. The ADM stated Resident 2 instructed Resident 1 to go away and Resident 1 did not listen. Resident 1 began kissing Resident 2. Resident 1 removed Resident 2's pants and proceeded to perform oral copulation and inserted Resident 1's finger into Resident 2's vagina and when done Resident 1 left Resident 2's room. The ADM stated Resident 2 did not notify staff immediately about the incident; and at approximately 4 p.m. on the same day (10/6/2020) PC 1 noticed Resident 2 in the hallway and commented that Resident 2 did not look well. Resident 2 told PC 1 that Resident 1 was bothering him (Resident 2). PC 1 assured Resident 2 that she would make the nursing staff aware and redirect Resident 1 from Resident 2. The ADM stated Resident 2 informed Certified Nursing Assistant (CNA) 2 on 10/6/20 that Resident 2 did not want Resident 1 in the room and CNA 2 reported to Licensed Vocational Nurse (LVN) 2. The ADM stated LVN 2 spoke to Resident 2 about the request of not wanting Resident 1 into the room and Resident 2 stated Resident 1 had been in the room and had a sexual encounter with Resident 2. The ADM stated LVN 2 did not think or describe the incident as an assault. The ADM stated LVN 2 described Resident 2 as calm and did not appear in distress. The ADM stated LVN 2 spoke with Resident 1 and Resident 1 stated he only kissed Resident 2. The ADM stated Resident 2 spoke to PC 2 on 10/7/2020 (the following day of the sexual incident) about the alleged rape by Resident 1 and PC 2 reported the incident to ADM and Nursing Department. The ADM stated following PC 2's report, the ADM conducted the formal investigation of the alleged sexual incident and reported the incident to local authorities and (local county) police department. The ADM stated the (local county) Police Officer (PO) came to the facility on [DATE] at 8:20 p.m. and conducted investigative interviews with Resident 1, Resident 2 and nursing staff. The ADM stated the PO spoke to his supervisor and requested Resident 2's transport to (local county) SART for medical-legal examination. Resident 2 left the facility with two accompanying Certified Nursing Assistant (CNA) to (local county) hospital for examination. The ADM stated the PO arrested Resident 1 and transported to (local county) jail on 10/7/2020 at 11 p.m. The ADM stated Resident 2 returned to the facility following the exam and remained in the facility. During an interview on 10/8/2020, at 3 p.m., with the ADM, the ADM stated Resident 2 was interviewed on 10/7/2020 and made the ADM aware of the previous encounter on 9/24/2020 with Resident 1 which prompted the facility to interview LVN 1 about the incident. LVN 1 wrote an incident report for Resident 1 and Resident 2 dated 10/8/2020. The ADM stated Resident 2 had flat affect, appeared calm, articulate and highly functioning and Resident 1 had slow functioning level. During a review of Resident 2's social service note dated 10/7/2020, indicated Resident 2 was interviewed by Social Service Director (SSD) and ADM. The document reflected, . Has there been past issues between the two of you (Resident 1 and Resident 2)? Res (Resident 2) yes this has happened before about two weeks ago .and started rugging (rubbing) my feet and legs and then kissing me, when nursing staff came in I redirected him (Resident 1) away from me . Res (Resident 2) stated, No, he (Resident 1) never threatened me .but I (Resident 2) was afraid he (Resident 1) would get violent with me . During an interview on 10/8/2020, at 3:07 p.m., with the DNS and DSD, the DNS stated Resident 1 and Resident 2 had a previous incident (two weeks prior to 10/6/2020) when Resident 1 entered Resident 2's room and kissed Resident 2. DNS stated LVN 1 witnessed Resident 1 was in Resident 2's room and LVN 1 redirected Resident 1 back to his room. LVN 1 advised Resident 2 to notify the nursing staff immediately if Resident 1 returned to the room anytime. The DNS stated LVN 1 did not document the incident in progress notes and did not update Resident 1 and Resident 2's care plan. The DNS stated the incident on 9/24/2020 could have been investigated and placed Resident 1 in behavior close monitoring check and could have placed Resident 1 in facility's denial of rights (a professional person in charge has reason to believe specific rights would cause injury to person or others, serious infringement (action of breaking an agreement) on the rights of others and a serious damage to the facility) to protect Resident 2. The DNS stated the incident on 10/6/2020 should have been prevented if the previous incident on 9/24/2020 was addressed and should have alerted nursing staff to monitor Resident 1 and Resident 2. The DSD stated all nursing staff were trained to report suspected abuse and incidents investigated. The DSD stated, .When report of abuse was escalated, we (nursing staff) put resident on one on one close watch monitoring to protect other residents. During a review of Resident 2's face sheet dated 10/7/2020, the record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. During a review of Resident 2's Minimum Data Set ((MDS) dated [DATE], indicated Resident 2 had BIMS of 15. The MDS BIMS document indicated Resident 2 was cognitively intact and independent in decision-making during activities of daily living. During a concurrent observation and interview on 10/8/2020, at 3:27 p.m., with Resident 2, in the ADM's office with the DSD, Resident 2 sat on a chair with a cuddled teddy bear. Resident 2 appeared calm and displayed constant eye contact. Resident 2 consented the DSD to be present in the room during the interview. Resident 2 stated, I had been in the facility for two years and from (previous county) I stayed in a single room and transgender. Resident 2 stated, . On Tuesday (10/6/2020) at around 1 p.m. to 1:30 p.m. I was laying down in my room to get a nap when (Resident 1) came to my room. I asked him (Resident 1) to leave . I (Resident 2) need to go to sleep but (Resident 1) was persistent in kissing me in face, chin, lips, and went down to remove my pants and underwear. (Resident 1) rubbed my feet and legs. Resident 2 stated, .I (Resident 2) wanted to stand up but (Resident 1) pushed me back and started licking my vagina and when (Resident 1) was done (Resident 1) stood up and left the room . walked away. I (Resident 2) froze. Resident 2 stated, .I felt depressed and not the first time .this happened two weeks ago and I (Resident 2) don't remember the date but (Resident 1) went to my room .kissing, rubbing my feet and legs is the big thing . licking and kissing my vagina. I (Resident 2) did not report to CNA, licensed nurses because I'm scared a lot and staff would react. CNA 1 was aware of the incident. She (CNA 1) should have done something about it (incident on 9/24/2020). During an interview on 10/8/2020, at 3:32 p.m., with Resident 2, in the ADM's office, Resident 2 stated, .I (Resident 2) did not press the call light last Tuesday (10/6/2020) because (Resident 1) grabbed and pushed me and I am afraid of him (Resident 1). Resident 2 stated, I met him (Resident 1) in 2017 and we did not argue .we kissed before but no penetration of penis to vagina. Resident 2 stated, On Tuesday (10/6/2020) at around 4 p.m. PC 1 asked me if I am not feeling well. I explained to her (PC 1) that something happened to us with (Resident 1) and she (PC 1) said we (nursing staff) will keep an eye out to (Resident 1) CNA 2 told LVN 2 (assigned to Resident 2 on shift) and instructed me (Resident 2) not to tell anybody what had happened between me (Resident 1) and (Resident 2). Resident 2 stated, I felt angry and frustrated and . yes, I felt violated my right. Resident 2 stated, I did not tell anyone until the next day, I told (PC 2) about the incident on Tuesday (10/6/2020). During an interview on 10/8/2020, at 3:40 p.m., with Resident 2, in administrator's office, Resident 2 stated, Rape is type of penetration and this is not normal .I felt uncertainty and fear people .noise .I am shaking and escalated my feelings . I Have [MEDICAL CONDITION] (post-traumatic stress disorder). During a phone interview on 10/9/2020, at 2:56 p.m., with LVN 1, LVN 1 stated she was aware of previous incident on 9/24/2020 between Resident 1 and Resident 2 when she covered lunch time of another staff (unrecalled date) around 5 p.m. on the East hallway (opposite hallway of Resident 2). LVN 1 stated she saw when Resident 1 knocked and entered Resident 2's room. LVN 1 stated Resident 1 did not wait to get permission from Resident 2 to enter the room. LVN 1 stated she instructed CNA 1 to check and follow Resident 1 in Resident 2's room and she (LVN 1) was not sure if Resident 2 was in the room. LVN 1 followed CNA 1 in the room and saw Resident 1 in Resident 2's room and asked him (Resident 1), What are you doing here? Resident 1 answered back and stated, I am talking to my friend. LVN 1 stated she saw Resident 2 covered in sheets with a cuddled teddy bear laid on bed while Resident 1 was standing at the foot of Resident 2's bed. LVN 1 asked Resident 2, Are you ok with (Resident 1) here? LVN 1 stated Resident 2 replied, No and LVN 1 instructed Resident 1 to leave Resident 2's room because Resident 2 does not want you (Resident 1) here (Resident 2's room). During a phone interview on 10/8/2020, at 3:08 p.m., with LVN 1, LVN 1 stated she did not document the incident on 9/24/2020 in the progress notes. LVN 1 stated, I was not aware Resident 1 and Resident 2 had consensual (existing mutual consent) sexual relationship, if I could have known I would investigate further. LVN 1 stated she did not consider the incident alarming on 9/24/2020. LVN 1 stated, Resident 2's demeanor did not change . more than normal and seems okay with flat affect. If I see him (Resident 2) worried and nervous, I could have reported it. LVN 1 stated she did not see Resident 2 act nervous or affected about the incident on 9/24/2020. During a concurrent phone interview and record review on 10/12/2020, at 3:45 p.m., with LVN 2, LVN 2 stated he was assigned to Resident 2 on the evening of 10/6/2020. LVN 2 reviewed Resident 2's progress note dated 10/6/2020 at 5:44 p.m. which indicated, . Approximately at 1700 (5 pm), this resident (Resident 2) reported that him (Resident 2) and Male peer (Resident 1) were kissing today at 1300 (1 p.m.) in his (Resident 2) room, and according to him (Resident 2), the male peer also put his (Resident 1) fingers in his (Resident 2) private part, which male peer (Resident 1) denied No other problems to note . (LVN 2) was informed by (CNA 2) that (Resident 2) doesn't want (Resident 1) in his (Resident 2) room anymore. (LVN 2) interviewed (Resident 2) and said that (Resident 2) had a bad experience with the male peer, stated, he (Resident 1) kissed me and put his fingers in my private part, I just don't want him (Resident 1) in my room anymore. (LVN 2) observed resident was in no distress during the interview, noted calm and did not state he (Resident 2) was violated or mistreated by male peer. LVN 2 stated he observed Resident 2 with no distress, appeared calm with no signs of anxiety at the time of interview. LVN 2 stated, I did not report and consider the incident as an alleged abuse. They (Resident 1 and Resident 2) had history of consensual sexual relationship. Resident 2 did not want Resident 1 in the room but Resident 2 did not appear distressed and anxious. During a phone interview on 10/12/2020, at 4:48 p.m., with CNA 2, CNA 2 stated she was assigned to Resident 2 on the evening of 10/6/2020. CNA 2 recalled Resident 2 approached her in the West Hallway on 10/6/2020 at 4:50 p.m. and CNA 2 stated Resident 2 had bad experience with Resident 1 and Resident 2 did not want Resident 1 back in the room. CNA 2 stated she notified LVN 2 and CNA 3 about Resident 2's statement of bad experience. CNA 2 stated she did not report the incident to facility ADM, ombudsman, law enforcement (police department) and did not document the incident. CNA 2 stated, I could have asked more questions to Resident 2 of what specifically happened and document the incident. Yes, it was reportable because it was a sexual act. I should have reported to DNS, ADM, ombudsman. We are mandated reporters. During a concurrent phone interview and record review on 10/13/2020, at 9:41 a.m., with PC 1, PC 1 stated she observed Resident 2 appeared upset on 10/6/2020 at approximately 4 p.m. outside the dining room. PC 2 reviewed Resident 2's progress note which indicated, . PC 1 note . late entry for 10/6/2020: (Resident 2) was standing outside the dining room door at approximately 1600 (4 pm). (PC 1) observed that (Resident 2) appeared upset. When asked if everything was ok, (Resident 2) shook his head no. When asked what was wrong, (Resident 2) stated, Somebody is bothering me. When asked who, (Resident 2) stated, (Resident 1). (PC 1) stated that she (PC 1) would keep an eye out and inform male PC working the late shift to do the same, to ensure (Resident 1) did not come up to (Resident 1). (Resident 2) gave a thumbs up, and (PC 1) proceeded to go facilitate 1600 group. (Resident 1) was not observed going near (Resident 2) during the shift (until 1930 (7:30 pm)). PCs will continue to monitor. PC 1 stated she did not attempt to talk to Resident 1 on the evening of 10/6/2020 after Resident 2 made her aware of the incident with Resident 1. PC 1 stated she could have talked to Resident 1 the next day (10/7/2020) about the incident and she did not. PC 1 stated, I did not see anything to be concerned of . I did not document the incident at that time (10/6/2020) and I should have. PC 1 stated she should have informed Resident 2's assigned licensed nurse on the evening of 10/6/2020 and could have investigated Resident 2's word of bothering. During a concurrent phone interview and record review on 10/13/2020, at 11:51 a.m., with PC 2, PC 2 stated she was not aware of alleged abuse between Resident 1 and Resident 2 on 10/6/2020. PC 2 reviewed Resident 2's progress note dated 10/7/2020, indicated, Counseling (Safety) After attending the 0915 (9:15 am) group (Resident 2) approached (PC 2) and asked to speak with (PC 2). (Resident 2) appeared calm and stated, So (Resident 1) raped me last night and that wasn't the first time. (Resident 1) came into my room and sat down next to me on my bed. (Resident 2) asked him to leave a few time (Resident 1) didn't. (Resident 1) didn't use his penis, (Resident 1) used his finger and tongue. (Resident 1) put his finger in my vagina, then (Resident 1) licked and kissed my vagina with his tongue. (Resident 2) was told by someone before if I'm ever in a situation like this to stay quiet and calm so you don't upset them, so I (Resident 2) did. After he (Resident 1) was done he (Resident 1) left, I (Resident 2) went and stood outside my door. Staff noticed I was upset and asked what's wrong that's when I told them (PC 1) . (PC 2) then notified nursing. PC 2 stated the incident on 10/6/2020 should have been reported immediately to the facility ADM, local law enforcement, ombudsman and local state agencies for the incident to be assessed and investigated in a timely manner. PC 2 stated Resident 2 appeared depressed and withdrawn on the morning of 10/7/2020 (the following day of the incident) and PC 2 encouraged Resident 2 to go outside the room and engage in activities. During a review of Resident 2's progress note dated 10/7/2020, at 11:41 a.m. to 11:55 a.m., indicated, . On 10/6/2020, (Resident 2) came up to PC and stated he was having a rough day because the hallucinations were getting worse. (Resident 2) was encouraged to speak to the doctor about this and he appeared receptive . at approximately 1200 she (LVN 4) went to assess with two CNA's this resident. Asked permission to assess and resident agreed. (Resident 2) stated she had vaginal pain but denies any other pain . (Resident 2) stated its internal pain . Offered (brand name) for pain but denied it. During a review of Resident 2's progress note dated 10/7/2020, at 2:05 p.m., indicated, Per female PC (Program Counselor) it was reported to her by (Resident 2) this morning after the morning meeting that (Resident 1) raped him (Resident 2) yesterday by putting his (Resident 1) finger and tongue in his vagina. Per female PC (Resident 2) stated, So (Resident 1) raped me yesterday and it wasn't the first time, he (Resident 1) came into my room and sat next to me on my bed, I (Resident 2) asked him (Resident 1) to leave a few times and he (Resident 1) didn't. He (Resident 1) didn't use his penis he used his finger and tongue. He (Resident 1) put his finger in my vagina and he (Resident 1) licked and kissed it. I (Resident 1) was told by someone before if I'm in situation like that I should remain calm and quiet so I did. When he (Resident 1) was done, he left. The investigation then started . During a review of Resident 2's program counselor note dated 10/8/2020, at 8:38 a.m., indicated, . (Safety): (PC 3) approached (Resident 2) in the main hallway. (Resident 2) stated, I'm afraid, angry, anxious. I (Resident 2) don't want to see him. And I'm tired. (Resident 2) discussed coping skills and asked to be excused from group to sleep . During a review of Resident 2,'s program counselor note dated 10/12/2020, at 10:42 a.m., indicated, . (Resident 2) also stated he has been experiencing flashbacks of a prior sexual assault (incident on 10/6/2020) . has been going to groups and walking out on grounds to cope with being sexually assaulted by peer at this facility. (Resident 2) asked for an increase in his (quetiapine) (a medication to treat [MEDICAL CONDITION] and depression). Add ([MEDICATION NAME]) (a medication to treat anxiety). During a review of Resident 2's physician's orders [REDACTED].with new orders . ([MEDICATION NAME]) 10 mg (milligram, unit of measure) PO (by mouth) BID (twice a day) for anxiety. During a review of Resident 2's psychiatrist progress note dated 11/9/2020, indicated, . ([MEDICATION NAME]) has helped a little with anxiety. Had five panic attacks. Has suicidal ideation with panic attacks . ([MEDICATION NAME]) 20 mg BID . During a review of Resident 2's physician's orders [REDACTED]. Give 20 mg by mouth two times a day for Anxiety . being restless. Resident was seen by MD 1 with the above order . During a phone interview on 10/13/2020, at 2:06 p.m., with CNA 1, CNA 1 stated she was assigned to Resident 2 on the evening of 9/24/2020 in West hallway when LVN 1 instructed her to check and follow Resident 1 who walked towards Resident 2's room. CNA 1 stated she saw Resident 1 in Resident 2's room and hid standing behind the bedroom curtain. CNA 1 stated LVN 1 asked Resident 1 what he was doing in the room and Resident 1 replied he was visiting a friend. LVN 1 asked Resident 2 if ok with Resident 1 to be in the room and Resident 2 replied no and did not want Resident 1 in the room. CNA 2 stated, I felt that the incident needed to be reported. CNA 2 stated she did not suspect an alleged abuse at the time and did not document the incident when Resident 2 stated did not want Resident 1 in the room and did not notice negative behavior by Resident 2. During a phone interview on 10/13/2020, at 3 p.m., with Medical Doctor (MD) 1, MD 1 stated he was the attending psychiatrist of Resident 2 in the facility and the DNS notified him of the alleged sexual abuse between Resident 1 and Resident 2 on 10/7/2020. MD 1 stated he was aware of consensual sexual relationship between Resident 1 and Resident 2. MD 1 stated, I was not aware up to what degree of sexual acts (between Resident 1 and Resident 2). MD 1 stated he cannot recall of facility notification on sexual incident between Resident 1 and Resident 2 prior to 10/6/2020. During a phone interview on 10/13/2020, at 3:29 p.m., with MD 2, MD 2 stated he was the attending psychiatrist of Resident 1 in the facility and facility nursing staff notified him of the alleged abuse between Resident 1 and Resident 2 on 10/7/2020. MD 2 stated he was aware of consensual sexual relationship between Resident 1 and Resident 2. MD 2 stated Resident 2 had poor impulse control (failure to resist a temptation or urge) and did not understand social cues due to his diagnosed mental illness ([MEDICAL CONDITION]). MD 2 stated resident's sexual activity consents on admission should be reevaluated and updated on changes in resident's decision on sexual concerns. During a review of Resident 1's psychiatrist progress notes dated 9/30/2020, indicated, . summary of behavior problems: agitation .sexually inappropriate behavior . poor judgment .some impulsiveness .sexually inappropriate behaviors . During a concurrent phone interview and record review on 10/14/2020, at 5:12 p.m., with LVN 3, LVN 3 stated she was assigned to Resident 1 on evening of 10/6/2020 and she was aware of consensual relationship between Resident 1 and Resident 2. LVN 3 stated she observed Resident 1 wander into resident rooms and licensed nurses would counsel Resident 1. LVN 3 reviewed Resident 1's progress note dated 10/6/2020, indicated, At around 1700 (5 pm), (Resident 2) reported that her and resident (Resident 1) were kissing in her room and at around 1300 (1 pm). (Resident 1) was interviewed about what was reported by (Resident 2). (Resident 1) said, I (Resident 1) just kissed her on her face and feet. When asked if (Resident 2) told him to stop, (Resident 1) sated, No, she (Resident 2) was nice, and then I (Resident 1) left. LVN 3 stated, I did not consider the incident between Resident 1 and Resident 2 an alleged abuse at that time. LVN 3 stated Resident 2 complained Resident 1 touched Resident 2's private parts and did not want Resident 1 to be in the room. LVN 3 stated she did not see it (incident) as a concern and did not report the incident to external entities (local police department, state authorities, and ombudsman) because Resident 1 and Resident 2 had consensual sexual relationship in the facility. LVN 3 stated she was not aware of the expectation to reevaluate the consents on sexual activities of residents in the facility. During a concurrent phone interview and record review on 10/14/2020, at 8:37 p.m., with LVN 3, LVN 3 reviewed Resident 1's behavior monitoring dated 10/6/2020 which indicated CNA 3 did not document sexually inappropriate behavior in Resident 1's flowsheets. LVN 3 stated licensed nurses should have checked resident's flowsheets as documented by assigned CNA after every shift and she did not check Resident 1's flowsheets on 10/6/2020. During an interview on 10/17/2020, at 6:45 p.m., with CNA 3, CNA 3 stated he was assigned to Resident 1 on the evening of 10/6/2020 and he was aware of the kissing and touching of Resident 1 to Resident 2's private part. CNA 3 stated he considered it as a sexual abuse because Resident 2 did not approve of Resident 1's sexual behavior at the time on 10/6/2020. CNA 3 stated, I did not report the incident. I left that to the nurses (LVN 2 and LVN 3). CNA 3 stated he should have documented Resident 1's flowsheets as sexually inappropriate behavior and he did not document it on 10/6/2020. CNA 3 stated flowsheets behavior monitoring were documented by CNAs every shift to monitor the behavior pattern and progress of residents every shift and served as a communication report to licensed nurses and attending medical doctors. During a review of Resident 1's Social Service Note dated 10/7/2020, at 2:49 p.m., indicated, . (Resident 1) at 10:55 a.m. with SSD and ADM . (ADM) asked (Resident 1) if he could explain what happen between, he and (Resident 2) yesterday? (Resident 1) stated, Kissing & hugging, stuff like that. Did (Resident 1) ever pull (Resident 2) pants off? (Resident 1) stated, Yes, I take her pats (pants) off.Can you tell me what happened next? (Resident 1) stated, I (Resident 1) put my finger inside her (Resident 2). ADM .repeated that calling the police is part of the reporting process. During a review of Resident 1's progress note dated 10/7/2020, at 11:05 p.m., indicated, (local city) PD was here to investigate regarding the sexual assault reported by (Resident 2). ADM, was here to meet the officers. After the investigation, (Resident 1) was taken by (local city) PD (police department) out of the facility at around 2255. (Conservator) was notified via fax. (Resident 2) was driven to (location) crisis center for examination. Transported by staff via facility car. During a review of the document titled, (Local city) Police Department Compact dated 10/28/2020, indicated, . (Resident 1) . Date/Time: 10/07/2020 23:08 .Arrest Charges .ORAL COPULATION .ANAL OR GENITAL PENETRATION BY FOREIGN OBJECT BY FORCE, VIOLENCE . (Resident 1) was arrested and booked into the Merced County jail for a violation of California penal code 287(c)(2), oral copulation, and 289(a)(1) of the California penal code, sexual penetration sexual assault occurred between 1:00 and 1:30 on the evening of Tuesday 10/6/2020. It should be noted that ADM related to me that although the confidential victim is a female, she identifies herself as a male . noted that referred to he, however, the he is in fact the confidential victim . asked the confidential victim if (Resident 2) believes if the suspect should have known that (Resident 2) did not want to have any sexual contact with (Resident 1). (Resident 2) confirmed that (Resident 2) told (Resident 1) multiple times to leave prior to incident . asked the confidential victim if the incident yesterday (10/6/2020) was consensual, (Resident 2) confirmed that it was not . (Resident 2) confirmed that (Resident 1) had licked, kissed, and had used his right index finger an unknown amount of time to penetrate (Resident 2) . (Resident 1) then proceeded to tell . confidential victim didn't want to do it and that (Resident 1) in fact had forced the confidential victim . Based on the statement by the confidential victim along with the confession by the (Resident 1), (Resident 1) was then taken into custody . The confidential victim was then transported to the (acute care hospital) to have a SART examination done . (ADM) related to me that (Resident 1) has a lower IQ (Intelligent Quotient) (person's reasoning ability) . what his age . However, I (officer) was able to have a normal and concise conversation with him during my investigation . During a phone interview on 10/15/2020, at 10:53 a.m., with ADM, ADM stated the IDT should have reviewed and reevaluated Resident 1 and Resident 2's sexual activity every month and if denial of rights should be implemented for sexual activity or behavior. The ADM stated sexual behavior and sexual rights should have been reevaluated by IDT every month regardless of resident's sexual consents and resident's sexual activity and behavior status should be part of checklist in IDT form. During a phone interview on 10/15/2020, at 1:30 p.m., with the DNS, the DNS stated the nursing staff should be trained on abuse investigation process and would check their competencies. The DNS stated part of the training process will include a new form for the nursing staff with guided follow up questions to facilitate suspected abuse investigation. The DNS stated facility staff (licensed nurses, CNAs, program counselors) would be trained on the investigation process of suspected abuse. The DNS stated the facility missed in-service training for nursing staff in the capacity of recognizing the behavioral signs of sexual abuse and the facility would do retraining for all nursing staff in mandated reporting. During a phone interview on 10/19/2020, at 3:01 p.m., with the DNS, the DNS stated licensed nurses should have followed up and investigated Resident 2's behavioral signs that indicated risk of sexual abuse. The DNS stated CNA's should have documented accurately the behavioral symptoms in Resident 1's flowshe(TRUNCATED)

Based on observation, interview and record review, the facility failed to follow professional standards of practice and California Code of Regulations Title 22 requirements for safe medication administration and to ensure residents were free of significant medication errors when: 1. The facility had a system of medication administration whereby licensed nurses poured resident medications into cups and stored the cups for later administration. The medication cups were poured for multiple residents at the same time. The pre-poured medication cups were unlabeled for resident name, drug and dose. The pre-poured medication cups were stored in bins labeled with resident names. The licensed nurses who pre-poured the medication cups signed the medication as administered (on the Medication Administration Record - MAR) at the time medications were poured, not at the actual time medications were administered. This facility practice was observed to affect 19 of 19 sampled residents (Residents 20, 62, 26, 41, 90, 40, 67, 644, 87, 85, 42, 78, 80, 29, 35, 646, 27, 43 and 74). For two of 19 sampled residents (Resident 87 and 644), Registered Nurse (RN) 1 was observed administering the medications that were pre-poured and signed as given by another licensed nurse, the Assistant Director of Nursing/Director of Staff Development (DON/DSD) against the standard of practice for safe medication administration. 2. For 22 of 92 sampled residents (Residents 4, 7, 9, 11, 13, 22, 27, 29, 37, 38, 42, 46, 54, 58, 63, 71, 73, 75, 78, 80, 82, and 244), medications were administered late (between 73 minutes and 170 minutes) based on the scheduled 8 pm administration time for 11/1/18. These systemic failures resulted in a significant medication error rate of 75.25% and jeopardized the health, safety and psychosocial well being of the residents. Because of the serious potential harm to all residents related to administering the wrong medication to the wrong resident at the wrong time, an Immediate Jeopardy (IJ) situation was called on 11/2/18 at 11:53 a.m. in the presence of the Administrator (ADM) and the Director of Nursing (DON). The facility submitted an Action Plan that addressed the IJ situation and was acceptable on 11/4/18. The Action Plan was validated and implemented that addressed the timeliness of administering medications and the implementation of safe administration practice. The IJ situation was removed on 11/4/18 at 4:48 p.m. in the presence of the DON and Assistant Director of Nursing/Director of Staff Development (ADON/DSD). 3. Metered dose inhalers were not administered according to manufacturers specifications and the physician's orders [REDACTED]. This failure resulted in the potential harm due to ineffective medication administration. Findings: 1. On 10/31/18 at 8:10 a.m., during an observation, the ADON/DSD poured medications into unlabeled cups for Resident 20, Resident 62 and Resident 26. The medication cups were stored in bins with labeled resident names. The medications were not administered to Residents 20, 62 and 26 at the time the medications were poured. The MAR was signed by the ADON/DSD at the time the medications were poured. The MAR indicated the medications poured for Resident 20 were [MEDICATION NAME] ([MEDICATION NAME]) 100 milligrams (mg) by mouth two times a day related to Anxiety disorder and Norgestimate - [MEDICATION NAME] Estr (Ortho Tri Cyclen) tablet one tablet by mouth one time a day for Amenorrhea (an abnormal absence of menstruation). The MAR indicated the medications poured for Resident 62 were [MEDICATION NAME] tablet Delayed Release 500 mg by mouth two times a day for Mood Stabilizer related to [MEDICAL CONDITION] Disorder (characterized by hallucinations or delusions, and symptoms of a mood disorder, such [MEDICAL CONDITION] depression); DSS capsule 100 mg by mouth two times a day for constipation; [MEDICATION NAME] ER tablet (Extended Release 600 mg by mouth two times a day for Mood Stabilizer related to [MEDICAL CONDITION] Disorder; and [MEDICATION NAME] 100 mg by mouth two times a day for signs and symptoms (s/s) of [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) related to [MEDICAL CONDITION] Disorder. The MAR indicated the medication poured for Resident 26 were Actos (Pioglitazone) 45 mg by mouth one time a day related to Type 2 Diabetes Mellitus without complication; [MEDICATION NAME] XR (Quetiapine) Extended Release 24 hours 200 mg by mouth one time a day for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION] Disorder; [MEDICATION NAME] (Glimepiride) 4 mg tablet by mouth two times a day related to Type 2 Diabetes Mellitus without Complication; DSS 100 mg by mouth two times a day for constipation; and [MEDICATION NAME] HCL1000 mg by mouth two times a day related to Type 2 Diabetes Mellitus without Complication. On 10/31/18 from 8:43 a.m. to 8:50 a.m. during an observation, the ADON/DSD administered medication cups that were pre-poured and stored in the medication bin to Residents 41, 90, 40 and 67. The ADON/DSD did not pour the medications for Residents 41, 90, 40 and 67 at the same time the medications were administered. The ADON/DSD did not sign the MAR at the time medications were administered for Residents 41, 90, 40 and 67. The MAR was reviewed for the medications administered to Residents 41, 90, 40 and 67 later the afternoon of 10/31/18. The MAR indicated the medications administered to Resident 41 were [MEDICATION NAME] ER Tablet Extended Release 24 hours 1000 mg by mouth one time a day for Mood Stabilizer related to [MEDICAL CONDITION]; [MEDICATION NAME] tablet 5 mg by mouth one time a day related to Type 2 Diabetes Mellitus without Complication; [MEDICATION NAME] tablet Extended release 24 hours 6 mg by mouth one time a day s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION]; and DSS capsule 100 mg by mouth two times a day for constipation. The MAR indicated the medications administered to Resident 90 were [MEDICATION NAME] syrup ([MEDICATION NAME] Acid) 500 mg by mouth one time a day for Mood Stabilizer related to Disorganized [MEDICAL CONDITION]; Navana ([MEDICATION NAME]) 40 mg by mouth two times a day for s/s of [MEDICAL CONDITION] related to Disorganized [MEDICAL CONDITION]; [MEDICATION NAME] XR tablet Extended Release 24 hours 600 mg by mouth two times a day for s/s of [MEDICAL CONDITION] related to Disorganized [MEDICAL CONDITION]; [MEDICATION NAME] Syrup 500 mg by mouth one time a day for Mood Stabilizer related to Disorganized [MEDICAL CONDITION]; and [MEDICATION NAME] ([MEDICATION NAME]) 20 mg by mouth two times a day for s/s of [MEDICAL CONDITION] related to Disorganized [MEDICAL CONDITION]. The MAR indicated the medications administered to Resident 40 were [MEDICATION NAME] (Aripiprazole) 30 mg by mouth one time a day for s/s of [MEDICAL CONDITION] related to Paranoid [MEDICAL CONDITION] (a chronic mental disorder in which a person loses touch with reality ([MEDICAL CONDITION])). The MAR dated indicated the medications administered to Resident 67 were [MEDICATION NAME] 5 mg by mouth one time a day for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION] Disorder Current Episode Manic Severe with Psychotic Features; [MEDICATION NAME] Solution 30 mg by mouth two times a day for Mood Stabilizer related to [MEDICAL CONDITION] Disorder Current Episode Manic Severe with Psychotic Features; DSS capsule 100 mg by mouth two times a day for Constipation; [MEDICATION NAME] ([MEDICATION NAME]) 4 mg one tablet by mouth two times a day for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION] Disorder Current Episode Manic Severe with Psychotic Features; and [MEDICATION NAME] HCL ([MEDICATION NAME]) 5 mg by mouth two times a day related to Extrapyramidal (symptoms include [DIAGNOSES REDACTED] (continuous spasms and muscle contractions), akathisia (motor restlessness), parkinsonism (characteristic symptoms such as rigidity), bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements) and Movement Disorder. On 10/31/18 from 9:04 a.m. to 9:08 a.m. during an observation, registered nurse (RN) 1 administered pre-poured medications stored in the medication bin to Residents 644 and 87. RN 1 did not have the residents' MAR in front of her at the time of the medication administration to Residents 644 and 87. RN 1 was not observed to have poured the medications for Residents 644 and 87. RN 1 was not observed to have signed the MAR for Residents 644 and 87 at the time the medications were administered. The MAR's for Residents 644 and 87 were reviewed the afternoon of 10/31/18. The MAR indicated the medications administered to Resident 644 were [MEDICATION NAME] tablet 1 mg by mouth two a day related to Extrapyramidal and Movement Disorder; and Propanol 20 mg by mouth two times a day related to Essential (Primary) Hypertension (Abnormally high blood pressure). The MAR indicated the medications administered to Resident 87 were [MEDICATION NAME] tablet 1 mg by mouth two times a day related to Extrapyramidal and Movement Disorder; and DSS capsule 100 mg by mouth two times a day for constipation (refused). On 10/31/18 at 11 a.m. during an observation, licensed vocational nurse (LVN) 1 administered medication cups that were pre-poured and stored in the medication bin to Residents 85, 42, 78, 80, 29, 35, 646 and 27. LVN 1 did not have the residents' MAR in front of her at the time of the medication administration for these residents. LVN 1 did not sign the MAR at the time of medication administration for these residents. The MAR's for Residents 85, 42, 78, 80, 29, 35, 646 and 27 were reviewed the afternoon of 10/31/18. The MAR indicated the medications administered to Resident 85 were [MEDICATION NAME] tablet 10 mg by mouth one time a day for Seasonal allergies [REDACTED]. s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION], Unspecified. The MAR indicated the medications administered to Resident 42 were Aspirin EC ([MEDICATION NAME] coated) 81 mg by mouth one time a day for Cardiac prevention; [MEDICATION NAME] ([MEDICATION NAME]) tablet 10 mg by mouth one time a day related to Essential (Primary) Hypertension; [MEDICATION NAME] tablet 2 mg by mouth one time a day for s/s of [MEDICAL CONDITION] Disorder. [MEDICATION NAME] tablet Delayed Release 1000 mg by mouth two times a day for Mood Stabilizer related to [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION] Type; DSS capsule 100 mg bymouth two times a day for constipation; [MEDICATION NAME] (Klonopin) tablet 0.5 mg one tablet by mouth three times a day related to Anxiety Disorder, Unspecified; [MEDICATION NAME] HCL (Silenor) 25 mg by mouth three times a day related to Anxiety Disorder, Unspecified; and [MEDICATION NAME] capsule 300 mg by mouth three times a day for Mood Stabilizer related to [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION] Type. The MAR indicated the medications administered to Resident 78 was [MEDICATION NAME] ([MEDICATION NAME]) tablet 100 mg by mouth one time a day for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION], Unspecified. The MAR indicated the medications administered to Resident 80 were [MEDICATION NAME] Solution 500 mg by mouth one time a day Mood Stabilizer related to [MEDICAL CONDITION] Disorder, Unspecified; [MEDICATION NAME] tablet 300 mg by mouth one time day for , Unspecified; [MEDICATION NAME] Powder 17 gram by mouth one time a day for Constipation; [MEDICATION NAME] ([MEDICATION NAME] Hcl) Capsule 10 mg by mouth one time a day related to Major [MEDICAL CONDITION], Single Episode; Vitamin B12 1000 mcg (microgram) by mouth one time a day for Supplement; Vitamin C 1000 mg by mouth one time a day for Supplement; Vitamin D3 tablet 2000 unit one tablet by mouth one time a day for Supplement; Vitamin E 400 IU (International Unit) by mouth one time a day for Supplement; Latvian Tablet 2 mg one tablet by mouth two times a day related to Anxiety Disorder, Unspecified; DSS capsule 100 mg by mouth two times a day for Constipation; [MEDICATION NAME] (Aleve) tablet 500 mg one tablet by mouth two times a day for Pain; [MEDICATION NAME] ([MEDICATION NAME]) tablet Delayed Release 20 mg one tablet by mouth two times a day related to Gastro-[MEDICAL CONDITION] Reflux Disease (GERD- occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach)) With Esophagitis (inflammation or irritation of the esophagus (the gullet); [MEDICATION NAME] (Quetiapine [MEDICATION NAME]) tablet 200 mg by mouth two times a day for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION] Disorder, Unspecified; and [MEDICATION NAME] ([MEDICATION NAME]) 20 mg three times a day related to Anxiety disorder, Unspecified. The MAR indicated the medications administered to Resident 29 were [MEDICATION NAME] ([MEDICATION NAME]) tablet 10 mg by mouth one time a day related to Essential (Primary) Hypertention; [MEDICATION NAME] ([MEDICATION NAME]) tablet 50 mg one tablet by mouth one time a day related to Essential (Primary) Hypertension; [MEDICATION NAME] 8 mg by mouth one time a day for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION], Unspecified; [MEDICATION NAME] Sodium ([MEDICATION NAME]) Extended capsule 100 mg by mouth one time a day related to Other [MEDICAL CONDITION]; DSS capsule 100 mg by mouth two times a day for Constipation; Klonopin ([MEDICATION NAME] tablet 0.5 mg one tablet by mouth two times a day related to Anxiety Disorder, Unspecified; and [MEDICATION NAME] ([MEDICATION NAME]) tablet 10 mg by mouth two times a day for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION], Unspecified. The MAR indicated the medications administered to Resident 35 were [MEDICATION NAME] ([MEDICATION NAME]) tablet Dispersible 200 mg by mouth one time a day for s/s of [MEDICAL CONDITION] related to Paranoid [MEDICAL CONDITION]; and [MEDICATION NAME] ([MEDICATION NAME]) tablet 600 mg by mouth two times a day for Mood Stabilizer related to Paranoid [MEDICAL CONDITION]. The MAR indicated the medications administered to Resident 646 were [MEDICATION NAME] tablet 50 mg by mouth one time a day for allergies [REDACTED]. two times a day related to Anxiety Disorder, Unspecified.The MAR indicated the medications administered to Resident 27 was [MEDICATION NAME] HFA Aerosol Solution 108 (90 base) MCG/ACT 2 puff inhale orally four times a day related to [MEDICAL CONDITION], Unspecified. On 10/31/18 at 11:53 a.m. during an observation, LVN 4 poured medication into unlabeled medication cups and stored each medication cup in the residents' open medication bins for Resident 43 and Resident 74. LVN 4 signed the MAR at the time the medications were poured. The medications were not administered at this time. On 10/31/18 from 12 p.m. to 12:07 p.m., during an observation , LVN 4 administered the medication cups previously poured for Resident 43 and Resident 74. On 10/31/18 at 12:10 p.m., during an interview, LVN 4 stated he pre-poured medications into cups, stored the cups temporarily in the resident bin prior to administering the medications to Residents 43 and 74. LVN 4 stated he signed the MAR prior to the medications being administered. The MAR indicated the medications administered to Resident 43 was Strattera (Atomexetine) 25 mg by mouth one time a day related to Attention Deficit [MEDICAL CONDITION] Disorder, Combined Type.The MAR indicated the medications administered to Resident 74 were [MEDICATION NAME] ([MEDICATION NAME]) tablet 100 mg by mouth two times a day for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION], Unspecified; [MEDICATION NAME] tablet(625 (65 Fe) mg one tablet by mouth three times a day related to [MEDICAL CONDITION] (a decrease in the total amount of red blood cells (RBCs) or hemoglobin in the blood); Vitamin C tablet 500 mg by mouth three times a day for [MEDICAL CONDITION]. On 10/31/18 at 10:20 a.m., during an interview, the ADON/DSD described the facility's medication administration process. The ADON/DSD stated the facility did not use medication administration carts. The facilty had one usuable room equipped with a window where residents lined up in order to be given their medications. The medications were routinely pre-poured into medication cups that were unlabeled for resident name and stored in a medication bin. The medication cups were pre-poured for multiple residents at the same time. The bin was labeled with resident names. The ADON/DSD stated the cups were not labeled with the medications that were pre-poured and did not have the dose of the medications. The ADON/DSD stated the MAR was signed at the time of the pre-pouring, not at the time of the actual administration. The ADON/DSD stated the pre-pouring of the medications were done by licensed nurses soon after arriving at 6:45 a.m. each morning for the 8 a.m. medication administration. On 10/31/18 at 2:30 p.m., during an interview, RN 1 described the process for medication administration for the morning of 10/31/18. RN 1 stated the residents were assigned teams for the purpose of medication administration. LVN 1 was assigned to Teams 3 and 4 and another nurse was assigned to Teams 1 and 2. The nurse assigned to Teams 1 and 2 called in sick the morning of 10/31/18 and the ADON/DSD pre-poured medications for residents assigned to Team 1 and Team 2. RN 1 confirmed the practice of pre-pouring medications into unlabeled medication cups and temporarily storing the medication cups in resident labeled bins. RN 1 confirmed the practice of signing the MAR at the time the medications were poured into the cups and not at the time of administering the medications. RN 1 stated she administered medications to Residents 644 and 87 that were pre-poured and pre-signed by ADON/DSD. On 10/31/18 at 3:48 p.m., during a telephone interview, LVN 1 stated she had pre-poured medications and stored the medication cups in the resident bin for the morning medication administration on 10/31/18. LVN 1 stated she pre- poured all the medications scheduled for 8 a.m. and administered them herself to the residents assigned to her. LVN 1 stated she was assigned to residents who were on Team 3 and 4. LVN 1 stated she signed the MAR at the time of pre-pouring and not at the time of administering the medications. LVN 1 confirmed that the medication cups were unlabeled for resident name, dose and medication. The facility provided a document dated 10/30/18 indicating the residents on Team 1 included Residents 83, 77, 76, 5, 2, 24, 12, 30, 647, 72, 65, 644, 16, 21, 92, 32, 74, 87, 645, 14, 69, 79, 20 and 62; Team 2 included Residents 10, 47, 64, 67, 56, 33, 41, 90, 44, 68, 15, 84, 40, 55, 52, 70, 43, 17, 1, 39 and 26; Team 3 included Residents 58, 19, 13, 4, 57, 71, 38, 46, 35, 88, 34, 25, 78, 23, 66, 18, 28, 27, 3, 86, 61, 80, 81, and 82; Team 4 included Residents 85, 6, 37, 22, 8, 42, 646, 11, 54, 63, 59, 75, 93, 31, 244, 60, 45, 57, 49, 9, 7, 73, 36 and 29. On 10/31/18 at 4:04 p.m. during an interview, the ADON/DSD stated he pre-poured the medications for the residents assigned to Teams 1 and 2 for the morning medication administration on 10/31/18. ADON/DSD stated he signed the MAR prior to administering the medications for each of the residents assigned to Teams 1 and 2. On 11/6/18 at 2:39 p.m., during a telephone interview, the medical director (MD) stated, I was aware of staff pre pulling (meaning pre-pouring) medications. The MD stated he was not aware of the staff signing the MAR prior to medications being administered to the residents and was not aware of licensed nurses administering medications other nurses had pre-poured. The MD stated he would not approve of a process where medications were pre-poured by one nurse and administered by another nor being signed as given prior to the actual medication administration. On 10/31/18 at 4:40 p.m., during an interview, the DON stated the facility followed the Pharmacy Consultant Company policy and procedure because the policy and procedure followed state regulations. The DON stated he was not aware the the facility policy and procedure on pre-pouring medications was not in accordance with the Pharmacy Consultant policy and procedure. The DON stated the pharmacy was aware of the pre-pouring of medications. The DON stated the incident where one nurse administered the medication poured by another nurse was first time; it was an anomaly. The DON stated his expectation not to give medications unless they pour the medication. The DON stated, It has been our practice (meaning pre-pouring) for years. The DON stated all the possibilities for potential harm and diversion is a clear example of why the practice of pre-pouring and signing the medications prior to administration is not viable. The DON stated Absolutely we need to review our process. On 10/31/18 at 5:20 p.m., during a telephone interview, the facility consultant pharmacist (Pharm) stated he had oversight for anything in the facility related to medications. The Pharm stated he was aware of the facility practice to pre-pour medications. The Pharm stated he was aware of the practice of pre-pouring medications at another Psych facility as well. The Pharm stated he was not aware of the facility practice to initial the MAR after the medication was pre-poured and not after being administered. The Pharm stated the medication should be prepared and given immediately. On 11/2/18 at 4:36 p.m., during an interview, the ADM stated, the Continuous Quality Improvement (CQI) team reviews policies annually. The ADM stated policy revisions related to pharmacy and medication administration would be discussed at the CQI committee meetings. The ADM stated the facility has a contract with a consultant pharmacist and the consultant pharmacist would submit to the facility polices related to pharmacy and medication administration. The ADM stated those policies and procedures reflect skilled nursing facilities and they (the facility) are a Special Treatment Program (STP). The ADM confirmed the facility is a certified SNF. The ADM stated each facility under the corporation was responsible for approving their own policies and procedures. The ADM was unable to provide documentation of the approval for the pharmacy policy and procedure manual. The ADM stated the pharmacist did not attend the CQI/QAPI (Quality Assurance Process Improvement) meetings. The ADM stated the facility practice had always been to pre-pour medications and sign the MAR prior to the actual medication administration. On 11/5/18 at 2:15 p.m., during a concurrent interview and record review, the ADON/DSD stated he pre-poured the medications on the morning of 10/31/18 for residents assigned to Teams 1 and 2. The ADON/DSD stated he asked RN 1 to give the medication he had poured and she said okay. The ADON/DSD acknowledged the initials on the MAR for Resident 644 were his initials and the medications for Resident 644 were administered by RN 1. The ADON/DSD stated pre-pouring and pre-signing was the practice at the facility. The ADON/DSD validated his initials on the MAR for Resident 87 and the medications for Resident 87 were administered by RN 1. The ADON/DSD stated, It is my initial, I pre-poured and signed for Team 1 and 2 for (residents from) A-W on 10/31/18 (Residents 644 and 87 were on Team 1) .The ADON/DSD stated the five rights of medication administration are, The right patient, right dose, time, medication and documentation. On 11/5/18 at 3:03 p.m., during an interview, RN 1 stated the five rights for medication administration are the right person, dose, time, route and drug. RN 1 stated she administered medications that the ADON/DSD pre-poured and she administered those medications to Resident 644 and Resident 87. RN 1 validated the ADON/DSD's initials on the MAR for Resident 644's medications given at 8:00 a.m., on 10/31/18. RN 1 stated those were the ADON/DSD's initials. RN 1 stated she didn't initial anything because the ADON/DSD was the one who pre-poured all of Teams 1 and 2's medications. RN 1 stated, I said to myself that I should not pass another nurse's popped pills (pre-poured pills), but I did anyway. RN 1 stated she did not ensure the five rights for medication administration for Residents 87 and 644. Review of facility policy and procedure provided by the ADON on 10/31/18 at 11 a.m., titled Administering Medications dated (MONTH) 2012 indicated, Medications shall be administered in a safe and timely manner, and as prescribed . 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 7. The individual administering the medication must check the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 20. g. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: .The signature and title of the person administering the drug . The document made no reference to pre-pouring of medications. On 10/31/18 at 4:10 p.m., during a concurrent interview and record review, the DON provided a second titled Merced Behavioral-Administering Medications dated (MONTH) 2012 that indicated, Medications shall be administered in a safe and timely manner, and as prescribed . Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Medications may be prepoured for the Residents due to the facility having all ambulatory residents who walk to the nurses' station and line up during med pass times each day. 7. The individual administering the medication must check the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 19. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 20. g. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: The signature and title of the person administering the drug . The DON did not explain why the facility had two policies and procedures on medication administration. The DON did not provide a professional reference or standard that supported the section of the policy that allowed pre-pouring. The ADON/DSD submitted the following facility policy and procedure for review on 10/31/18 titled Procuring, Storing, administering and Disposing of Medications Section B B.5 indicated, Administration . k. Medication shall be administered at the time they are prepared. Medications shall not be pre-poured. l. The person who prepares the dose for administration shall be the person who administers the dose . y. The resident's MAR shall be initialed by the person administering the medication, in the space provided under the date , and on the line for that specific medication dose administration. Initial on each MAR shall be verified with a full signature in the space provided Professional reference at http://lippincottsolutions.com/promo-content/nursesweek2016/procedures/safemedicationadministrationpractices titled Lippincott Solutions: Procedures: Safe Medication Administration Practices, General . To promote a culture of safety and to prevent medication errors . adhere to the five rights of medication administration: identify right patient . right medication . administer the right dose .right time .right route . Review of professional reference titled, Fundamentals of Nursing-Potter-Perry dated 2005, pages 847, 853, 854 indicated, Recording Medication Administration. After administering a medication, the nurse records it immediately . The nurse never charts a medication before administering it. Recording it after administration prevents errors . 7. Prepare medications: d. Prepare medications one client at a time . 8. a. Administering medications: Take medications to client at correct time . c. Explain purpose of each medication and its action to client . A review of the California Code of Regulations (CCR), Title 22, Register 2013, indicated, § . Nursing Service-Administration of Medications and Treatments . (4) Preparation of doses for more than one scheduled administration time shall not be permitted . (6) Medications shall be administered as soon as possible, but no more than two hours after doses are prepared, and shall be administered by the same person who prepares the doses for administration. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. (7) Patients shall be identified prior to administration of a drug treatment. (8) . (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment . 2. On 11/1/18 at 7:45 p.m., during a concurrent observation and interview in the medication room, licensed vocational nurse (LVN) 4 entered the medication room to continue the 8 p.m. medication pass for the residents. Residents formed a line at the east hallway window and waited for their scheduled 8 p.m. medications to be administered. The west hallway window in the medication room was broken and could not be used for medication administration. LVN 4 stated the west hallway window was broken for several months and it was a challange to administer medications to the residents on time with one window for use. On 11/1/18 at 8:55 p.m., during a concurrent observation and interview in the hallway, LVN 4 continued with the scheduled 8 p.m. medication pass. Residents in line became restless and asked the certified nursing assistant (CNA) why medication administration took so long. Resident 80 paced in and out of the line and stated he was waiting for his scheduled medications and he felt tired. Resident 80 stated medications scheduled for 8 p.m. were usually administered late around 9 p.m. On 11/1/18 at 9:13 p.m., during a concurrent observation and record review in the medication room, LVN 4 administered antipsychotic (major tranquilizer), antianxiety (medicine to relax), anti-[MEDICAL CONDITION], acid reflux and stool softener medications to Resident 80 in a four ounce (unit of measure) cup of applesauce. The medications were scheduled for 8 p.m. but were administered by LVN 4 one hour and 13 minutes late. A review of Resident 80's admission record (a facility document containing resident personal information) indicated Resident 80 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 80's medication administration record (MAR) dated 11/1/18 to 11/30/18 indicated, . Aspirin Tablet 81 milligram (mg)(unit of measure) Give 1 tablet by mouth at bedtime for Cardiac [MEDICATION NAME] (prevent heart problems) . [MEDICATION NAME] Tablet (antipsychotic medication) Give 800 mg by mouth at bedtime for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION] DISORDER . [MEDICATION NAME] Tablet (antipsychotic medication) Give 20 mg by mouth at bedtime for s/s of [MEDICAL CONDITION] related to [MEDICAL CONDITION] DISORDER . [MEDICATION NAME] Tablet (antianxiety medication) Give 1 tablet by mouth two (TRUNCATED)