Every finding on record at Millbrae Care Center

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA 1) received necessary resident specific information when Licensed Vocational Nurse (LVN 1) did not communicate an allegation of financial abuse involving Resident 1. This failure did not ensure Resident 1's care needs and safety concerns were communicated to all care team members.Findings: During a review of Resident 1's medical record titled Progress Notes, dated 06/12/2026, it indicated an allegation of financial abuse involving Resident 1 and a family member. During an interview on 08/12/2026 at 3:01 PM with CNA 1, CNA 1 stated he had not been informed of any allegation of financial abuse involving Resident 1 and stated he did not receive any information regarding monitoring, safety concerns, or visitation expectations related to the allegation. During an interview on 08/12/2026 at 3:07 PM with LVN 1, LVN 1 stated she was aware of the allegation of financial abuse involving Resident 1 and was able to identify Family Member 2 as the alleged perpetrator. LVN 1 was asked if she provided this allegation of financial abuse to CNA 1. LVN 1 paused and finally stated she did not want to answer the question. During an interview on 08/13/2026 at 2:17 PM with the Administrator, the Administrator stated her expectation was that any important care information especially regarding any sort of abuse should be shared among all care team members. During a review of the facility's policy titled Nursing Communication and Resident Care Information, not dated, it indicated .Resident care information communicated to Certified Nursing Assistants (CNAs) may include, . Information related to investigations, allegations, grievances, mandated reports, personnel matters, legal matters, or other confidential administrative processes will be managed by the Administrator, Director of Nursing, or designee in accordance with applicable facility policies and regulatory requirements. Such information is communicated to direct-care personnel when necessary to implement resident-specific care, protection, supervision, or other assigned interventions.

Based on interview and record review, the facility failed to ensure Resident 1's care plan reflected current needs when the facility resolved Resident 1's financial abuse care plan while the allegation was still active. The facility also failed to implement visitation restrictions and/or supervised visitation for Resident 1 to protect her safety. These failures did not ensure Resident 1's care was planned and delivered according to her assessed needs. Findings: During a review of Resident 1's medical record titled Progress Notes, dated 06/12/2026, documentation indicated a Social Worker (SW 1) met with Family Member (FM 1) and Resident 1 at her bedside. The note indicated FM 1 reported that Family Member 2 (FM 2) allegedly withdrew over $90,000 from Resident 1's bank account. Resident 1 had a bank statement showing deposits and withdrawals of the funds and stated she wished to file a police report. During a review of Resident 1's medical record titled care plan, initiated on 06/12/2026, it indicated .Resident reported Alleged Financial Abuse on 6/12/26 . Review of the care plan found no intervention regarding visitation restrictions and/or supervised visitation for FM2. Further review indicated this alleged financial abuse care plan was resolved on 08/04/2026 by a Minimum Data Set Nurse (MDS Nurse: a nurse who does a standardized assessment using an assessment tool). During an interview on 08/13/2026 at 1:26 PM with the MDS Nurse, the MDS Nurse stated she resolved the care plan for allegation of financial abuse by mistake. During an interview on 08/13/2026 at 2:17 PM with the Administrator, the Administrator provided no evidence the facility had implemented visitation restrictions and/or supervised visits for Resident 1 following the allegation of financial abuse. The Administrator acknowledged the allegation of financial abuse was still active. The Administrator stated the facility re-activated Resident 1's financial abuse allegation care plan after learning the care plan was resolved by accident. During a review of the facility's policy titled Care Plans, Comprehensive Person-Centered, not date, the policy indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered aspart of the comprehensive assessment.

Based on interview and record review, the facility was aware of an allegation of financial abuse regarding Resident 1 and a family member. The facility failed to protect Resident 1 from the likelihood of further abuse when the facility did not implement any visitation restrictions for Resident 1. This failure did not ensure Resident 1's right to be free from abuse was upheld.Findings: During a review of Resident 1's medical record titled Progress Notes, dated 06/12/2026, it indicated a Social Worker (SW) met with Family Member (FM) 1 and Resident 1 at her bedside. The document indicated .(FM 2) allegedly withdrew over $90,000 from. (Resident 1's) bank account. (Resident 1 had a bank) statement showing deposit and withdraw of the fund.(Resident 1 stated she) wished to file a personal police report. During an interview on 08/12/2026 at 3:01 PM with Certified Nursing Assistant (CNA 1), CNA 1 stated he had not been informed of any concerns regarding suspected financial abuse involving Resident 1. CNA 1 stated he was not informed of any visitation restrictions for Resident 1. During an interview on 08/12/2026 at 3:07 PM with a Licensed Vocational Nurse (LVN 1), LVN 1 stated she was aware of alleged financial abuse involving Resident 1. LVN 1 was able to name FM 2 as the alleged perpetrator. LVN 1 was unable to provide a physical description regarding FM 2. LVN 1 was unable to provide information if there was visitation restrictions and/or supervision for FM 2. During an interview on 08/13/2026 at 2:17 PM with the Administrator, the Administrator provided no evidence the facility had implemented visitation restriction and/or supervision for Resident 1. Until this allegation is resolved, the Administrator agreed it would be reasonable to ask anyone visiting Resident 1 to present identification when visiting. During a review of the facility's policy titled Visitation, revised on November 2025, it indicated .Some visitation may be subject to reasonable clinical and safety restrictions to protect the health, safety, security, and/or rights of the facility's residents. Examples of such restrictions may include the following: .If an individual is suspected of abusing, exploiting, or coercing a resident, visitation may be denied or limited until an investigation into the allegation has been completed.

Based on interview and record review, the facility failed to ensure required face to face physician visits were conducted and that the corresponding documentation was completed and maintained in the residents' medical records, as required, for 5 of 12 sampled residents (Residents 1, 2, 3, 4, and 5). This failure has the potential to result in negative outcomes for residents, including delays in identifying changes in condition, missed opportunities for timely medical interventions, unmanaged or worsening chronic conditions, increased risk of avoidable hospitalizations or emergency department visits, inadequate medication management, and overall decline in residents' health status due to lack of timely clinical oversight.During a review of Resident 1's Electronic Medical Record (EHR), the Resident 1's EHR indicated Resident 1 was admitted on [DATE] and has a Brief Interview for Mental Status (BIMS) Summary Score of 14 as of 06/01/2026. The Brief Interview for Mental Status (BIMS) is a short assessment used in nursing facilities to evaluate a resident's memory and thinking abilities. A score of 13 to 15 indicates intact cognition, meaning the resident is thinking clearly, remembers well, and can make decisions without noticeable cognitive problems. A score of 8 to 12 reflects moderate cognitive impairment, meaning the resident may have some difficulty with memory, learning new information, or staying oriented, though they can usually still take part in simple decision making. A score of 0 to 7 indicates severe cognitive impairment, meaning the resident has significant problems with memory and thinking and may require substantial support with daily decision making.During a concurrent interview and record review on 06/25/2026 at 3:21 PM with the Medical Records Director (MRD), Resident 1's EHR was reviewed. The record showed that the last physician progress note was dated 03/16/2026, which was 101 days before the interview. The Medical Records Director confirmed that 03/16/2026 was the most recent physician progress note in Resident 1's EHR.During an interview on 06/25/2026 at 4:54 PM with Resident 1, Resident 1 stated that their most recent physician visit occurred on 06/10/2026 with a physician outside the facility, though they could not recall the physician's name. Resident 1 further explained that physicians do not come to see them at the facility and that the only time they were seen by a physician on-site was when they first arrived about five years ago.During a review of Long Term Care (LTC) Skilled Nursing Facility (SNF) Monthly Progress Note for Resident 1, dated 03/16/2026, the LTC SNF Monthly Progress Note indicated that this entry constituted a physician encounter for 03/16/2026, and the physician progress note was completed and signed on 03/23/2026 at 5:45 PM. The physician encounter is 209 days after the previous physician LTC SNF Monthly Progress Note dated 08/19/2025.During a review of LTC SNF Monthly Progress Note for Resident 1, dated 08/19/2025, the LTC SNF Monthly Progress Note indicated that this entry constituted a physician encounter for 08/19/2025, and the physician progress note was completed and signed on 08/20/2025 at 10:41 PM, which is 96 days after the previous physician encounter for an LTC SNF Annual History & Physical on 05/15/2025.During a review of Long Term Care (LTC) Skilled Nursing Facility (SNF) Monthly Progress Note for Resident 1, dated 04/15/2025, the LTC SNF Monthly Progress Note indicated that this entry constituted a physician encounter for 04/15/2025, and the physician progress note was completed and signed on 09/04/2025 at 11:32 PM. The physician encounter is 90 days after the previous physician LTC SNF Monthly Progress Note dated 01/15/2025.During a review of a History & Physical Note for Resident 1, dated 05/16/2023, the History & Physical Note indicated that the author's credentials could not be verified and the electronic signature could not be confirmed as valid. The History & Physical Note was completed 518 days after the previous physician LTC SNF Monthly Progress Note dated 10/15/2024. During a review of a History & Physical Note for Resident 1, dated 05/28/2022, the History & Physical Note indicated that the author's credentials could not be verified and the electronic signature could not be confirmed as valid. The History & Physical Note was completed 353 days after the previous physician LTC SNF Monthly Progress Note dated 05/16/2023. The facility failed to ensure that Resident 1 received physician visits at the required frequency and within the allowable timeframes. Several physician encounters occurred outside the 70 day window permitted for required visits (including the 10 day grace period). The facility also failed to ensure that physician visit notes were uploaded into Resident 1's electronic health record in a timely manner, limiting clinical staff's ability to review and respond to the resident's ongoing medical needs.During a review of Resident 2's Electronic Medical Record (EHR), the Resident 2's EHR indicated Resident 2 was admitted on [DATE] and has a BIMS Summary Score of 11 as of 12/02/2025. During a concurrent interview and record review on 06/25/2026 at 3:21 PM with the Medical Records Director (MRD), Resident 2's EHR was reviewed. The record showed that the last physician progress note was dated 01/19/2026, which was 157 days before the interview. The Medical Records Director confirmed that 01/19/2026 was the most recent physician progress note in Resident 2's EHR.During an interview on 06/25/2026 at 5:08 PM with Resident 2, Resident 2 stated that they had been seen by a physician and believed their most recent visit was about a month ago for shortness of breath. Resident 2 added that they do not see the facility's physician very often.During a review of LTC SNF Annual History & Physical Note for Resident 2, dated 11/21/2025, the LTC SNF Annual History & Physical Note indicated that this entry constituted a physician encounter for 11/21/2025; however, the completion date, time, and electronic signature could not be verified. This physician encounter occurred 78 days after the previous LTC SNF Monthly Progress Note dated 09/04/2025.During a review of LTC SNF Monthly Progress Note for Resident 2, dated 09/04/2025, the LTC SNF Monthly Progress Note indicated that this entry constituted a physician encounter for 09/04/2025, and the physician progress note was completed and signed on 09/04/2025 at 9:28 PM. The physician encounter is 142 days after the previous physician LTC SNF Monthly Progress Note dated 04/15/2025.During a review of LTC SNF Monthly Progress Note for Resident 2, dated 03/15/2025, the LTC SNF Monthly Progress Note indicated that this entry constituted a physician encounter for 03/15/2026; however, the completion date, time, and electronic signature could not be verified and the note was marked as a draft. The physician encounter is 90 days after the previous physician LTC SNF Monthly Progress Note dated 12/15/2024.The facility failed to ensure that Resident 2 received physician visits at the required frequency and within the allowable timeframes. Several physician encounters occurred outside the 70 day window permitted for required visits (including the 10 day grace period). The facility also failed to ensure that physician visit notes were uploaded into Resident 2's electronic health record in a timely manner, limiting clinical staff's ability to review and respond to the resident's ongoing medical needs.During a review of Resident 3's Electronic Medical Record (EHR), the Resident 3's EHR indicated Resident 3 was admitted on [DATE] and has a BIMS Summary Score of 06 as of 05/27/2026. During a concurrent interview and record review on 06/25/2026 at 3:21 PM with the Medical Records Director (MRD), Resident 3's EHR was reviewed. The record showed that the last physician progress note was dated 03/03/2026, which was 114 days before the interview. The Medical Records Director confirmed that 03/03/2026 was the most recent physician progress note in Resident 3's EHR.During an interview on 06/25/2026 at 5:05 PM with Resident 3, Resident 3 stated that they have not been seen by a physician at the facility since becoming a resident, but they have seen physicians outside the facility several times.During a review of SNF Custodial 30 Day Visit Note for Resident 3, dated 05/14/2026, the SNF Custodial 30 Day Visit Note indicated that this entry constituted a physician encounter with creation time of 05/14/2026 at 10:54 PM; however, the completion date, time, and electronic signature could not be verified. This physician encounter occurred 72 days after the previous SNF Progress Note dated 03/03/2026.The facility failed to ensure that Resident 3 received physician visits at the required frequency and within the allowable timeframes. Some physician encounters occurred outside the 70 day window permitted for required visits (including the 10 day grace period). The facility also failed to ensure that physician visit notes were uploaded into Resident 3's electronic health record in a timely manner, limiting clinical staff's ability to review and respond to the resident's ongoing medical needs.During a review of Resident 4's Electronic Medical Record (EHR), the Resident 4's EHR indicated Resident 4 was admitted on [DATE] and has a BIMS Summary Score of 99 as of 04/27/2026, which means Resident 4 was unable to complete the Brief Interview for Mental Status (BIMS).During a concurrent interview and record review on 06/25/2026 at 3:21 PM with the Medical Records Director, Resident 4's EHR was reviewed and found to contain no physician notes. The Medical Records Director confirmed that none were present. Following a subsequent records request, the facility provided six physician written notes for dates of service 04/18/2025, 10/08/2025, 12/10/2025, 02/11/2026, 04/08/2026, and 06/10/2026. During a review of SNF Custodial 60 Day Visit Note for Resident 4, dated 10/08/2025, the SNF Custodial 60 Day Visit Note indicated that this entry constituted a physician encounter with creation time of 10/08/2025 at 6:04 PM; however, the completion date, time, and electronic signature could not be verified. This physician encounter occurred 173 days after the previous Physician Progress Note dated 04/18/2025.The facility failed to ensure that Resident 4 received physician visits at the required frequency and within the allowable timeframes. At least one physician encounter occurred outside the 70 day window permitted for required visits (including the 10 day grace period). The facility also failed to ensure that physician visit notes were uploaded into Resident 4's electronic health record in a timely manner, limiting clinical staff's ability to review and respond to the resident's ongoing medical needs.During a review of Resident 5's Electronic Medical Record (EHR), the Resident 5's EHR indicated Resident 5 was admitted on [DATE] and has a BIMS Summary Score of 13 as of 05/25/2026. During a concurrent interview and record review on 06/25/2026 at 3:21 PM with the Medical Records Director (MRD), Resident 5's EHR was reviewed. The record showed that the last physician progress note was dated 03/16/2026, which was 101 days before the interview. The Medical Records Director confirmed that 03/16/2026 was the most recent physician progress note in Resident 5's EHR. Following a subsequent records request, the facility provided eight physician written notes for dates of service 02/04/2026, 02/10/2026, 02/13/2026, 02/19/2026, 03/11/2026, 03/16/2026, 05/15/2026, and 06/18/2026.The facility failed to ensure that physician visit notes were uploaded into Resident 5's electronic health record in a timely manner, limiting clinical staff's ability to review and respond to the resident's ongoing medical needs.During a review of the facility's policy and procedure titled Physician Services, dated June 2022, indicates that the policy requires residents to be seen by a physician at least once every 30 days for the first 90 days following admission, and at least once every 60 days thereafter. The policy also states that a physician visit is considered timely if it occurs no later than 10 days after the required due date. Additionally, all physician visits must be conducted personally by the physician.

Based on observation, interview, and record review, the facility failed to ensure the attending physician reviewed the resident's total program of care and failed to write, sign, and date progress notes as required for 3 out of 12 sampled residents (Residents 1, 2, and 3). This failure had the potential to result in the residents not receiving timely evaluation of their medical regimen and necessary adjustments to treatments, placing the residents at risk for unmet medical needs and a decline in physical, mental, or psychosocial well being.During a review of Resident 1's Electronic Medical Record (EHR), the Resident 1's EHR indicated Resident 1 was admitted on [DATE] and has a Brief Interview for Mental Status (BIMS) Summary Score of 14 as of 06/01/2026. The Brief Interview for Mental Status (BIMS) is a short assessment used in nursing facilities to evaluate a resident's memory and thinking abilities. A score of 13 to 15 indicates intact cognition, meaning the resident is thinking clearly, remembers well, and can make decisions without noticeable cognitive problems. A score of 8 to 12 reflects moderate cognitive impairment, meaning the resident may have some difficulty with memory, learning new information, or staying oriented, though they can usually still take part in simple decision making. A score of 0 to 7 indicates severe cognitive impairment, meaning the resident has significant problems with memory and thinking and may require substantial support with daily decision making.During a concurrent interview and record review on 06/25/2026 at 3:21 PM with the Medical Records Director (MRD), Resident 1's EHR was reviewed. The record showed that the last physician progress note was dated 03/16/2026, which was 101 days before the interview. The Medical Records Director confirmed that 03/16/2026 was the most recent physician progress note in Resident 1's EHR. A records request was submitted after the interview with the MRD.During a review of History and Physical Note for Resident 1, dated 05/28/2022, the History and Physical Note indicated that the author's credentials were not identified. This was the only physician note the facility provided for Resident 1 for the year 2022.During a review of History and Physical Note for Resident 1, dated 05/16/2023, the History and Physical Note indicated that the author's credentials were not identified. This was the only physician note the facility provided for Resident 1 for the year 2023.During a review of Long Term Care (LTC) Skilled Nursing Facility (SNF) Monthly Progress Note for Resident 1, dated 10/15/2024, the LTC SNF Monthly Progress Note indicated that this entry constituted a physician encounter for 10/15/2024. Most of the information documented in the 10/15/2024 LTC SNF Monthly Progress Note appeared to be cloned from the progress note completed on 11/15/2024. Cloned means the information was copied from one note to another, instead of being newly written. It suggests the content wasn't updated for the resident's current condition but was repeated from a previous entry.During a review of Acute Skilled Nursing Facility Visit Note for Resident 1, dated 04/16/2026, the Acute Skilled Nursing Facility Visit Note indicated that the note remained unsigned and its status was listed as open. The note did not reflect the resident's overall program of care, including the resident's current condition, progress, problems in maintaining or improving physical, mental, and psychosocial well-being, or clinical decisions regarding the continued appropriateness of the resident's medical regimen. The note was not available for review during the concurrent interview and record review on 06/25/2026 at 3:21 PM with the MRD and was only made available after a record request was submitted following the interview.During a review of Long Term Care (LTC) Skilled Nursing Facility (SNF) Monthly Progress Note for Resident 1, dated 06/08/2026, the LTC SNF Monthly Progress Note indicated that this entry constituted a physician encounter for 06/08/2026. Most of the information documented in the 06/08/2026 LTC SNF Monthly Progress Note appeared to be cloned from the progress note completed on 03/16/2026 and the LTC SNF Annual History and Physical Note completed on 05/14/2026.During a review of Resident 2's Electronic Medical Record (EHR), the Resident 2's EHR indicated Resident 2 was admitted on [DATE] and has a BIMS Summary Score of 11 as of 12/02/2025. During a concurrent interview and record review on 06/25/2026 at 3:21 PM with the Medical Records Director (MRD), Resident 2's EHR was reviewed. The record showed that the last physician progress note was dated 01/19/2026, which was 157 days before the interview. The Medical Records Director confirmed that 01/19/2026 was the most recent physician progress note in Resident 2's EHR. A records request was submitted after the interview with the MRD.During a review of LTC SNF Annual History and Physical Note for Resident 2, dated 11/15/2024, the LTC SNF Annual History and Physical Note indicated that the note remained unsigned and in draft status, bearing a draft timestamp of 08/26/2025 at 11:40 AM--284 days after the documented date of service.During a review of Physician Progress Note for Resident 2, dated 12/18/2024, the Physician Progress Note indicated that this entry constituted a late entry for a physician encounter for 12/18/2024. Most of the information documented in the 12/18/2024 Physician Progress Note appeared to have been cloned from the progress note completed on 11/15/2024.During a review of Physician Progress Note for Resident 2, dated 11/15/2024, the Physician Progress Note indicated that this entry constituted a late entry for a physician encounter for 11/15/2024. Most of the information documented in the 11/15/2024 Physician Progress Note appeared to have been cloned from the progress note completed on 10/18/2024.During a review of Physician Progress Note for Resident 2, dated 10/18/2024, the Physician Progress Note indicated that this entry constituted a late entry for a physician encounter for 10/18/2024. Most of the information documented in the 10/18/2024 Physician Progress Note appeared to have been cloned from the progress note completed on 09/23/2024.During a review of LTC SNF Monthly Note for Resident 2, dated 03/15/2025, the LTC SNF Monthly Note indicated that the note remained unsigned and in draft status, bearing a draft timestamp of 10/12/2025 at 1:23 AM--211 days after the documented date of service.During a review of LTC SNF Monthly Note for Resident 2, without a date of service, the LTC SNF Monthly Note indicated that the note remained unsigned and in draft status, bearing a draft timestamp of 08/20/2025 at 11:37 PM.During a review of Resident 3's Electronic Medical Record (EHR), the Resident 3's EHR indicated Resident 3 was admitted on [DATE] and has a BIMS Summary Score of 06 as of 05/27/2026. During a concurrent interview and record review on 06/25/2026 at 3:21 PM with the Medical Records Director (MRD), Resident 3's EHR was reviewed. The record showed that the last physician progress note was dated 03/03/2026, which was 114 days before the interview. The Medical Records Director confirmed that 03/03/2026 was the most recent physician progress note in Resident 3's EHR. A records request was submitted after the interview with the MRD.During an interview on 06/25/2026 at 5:05 PM with Resident 3, Resident 3 stated that they have not been seen by a physician at the facility since becoming a resident, but they have seen physicians outside the facility several times.During a review of SNF Progress Note for Resident 3, dated 02/28/2026, the Physician Progress Note indicated that this entry constituted a physician encounter for 02/28/2026. Most of the information documented in the 02/28/2026 SNF Progress Note appeared to have been cloned from the SNF Progress Note completed on 02/10/2026.During a review of SNF Progress Note for Resident 3, dated 03/03/2026, the Physician Progress Note indicated that this entry constituted a physician encounter for 03/03/2026. Most of the information documented in the 03/03/2026 SNF Progress Note appeared to have been cloned from the SNF Progress Note completed on 02/28/2026.During a review of the facility's policy and procedure titled Physician Services, dated June 2022, indicates that the policy requires the attending physician to:Review the resident's total program of care at each visit, including all medications and treatments.Evaluate the resident's current condition and determine whether the existing medical regimen remains appropriate.Write, sign, and date a progress note at every physician visit, documenting the evaluation and care review.Complete all documentation-whether in the paper chart or electronic record-in accordance with facility practices, and sign and date all medical orders associated with the visit.

Based on record review and interview, the facility failed to ensure accurate and timely encoding and transmission of resident assessments for 18 of 116 sampled residents. The facility did not encode the Minimum Data Set (MDS, It's a detailed check up form the nursing home fills out to understand what a resident needs and to plan the right care) assessments within the required timeframe and did not ensure successful transmission to the Centers for Medicare & Medicaid Services (CMS) database.This failure to complete and transmit required resident assessment data resulted in incomplete clinical information being available for care planning, increased risk of inaccurate care plans, and potential negative impact on each resident's ability to receive individualized, person centered care.During a concurrent interview and review on 5/6/26 at 2:56 PM with MDS nurse, Resident 71's quarterly MDS with an Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) of 2/12/26 was reviewed and indicated, the assessment was completed on 2/13/26. However, the assessment was transmitted on 5/5/26, 81 days after the MDS assessment was completed. The MDS nurse confirmed and stated that the assessment was transmitted late due to late completion in some sections of the MDS. Review of facility document titled Final Validation Report for Resident 71, dated 5/5/2026, indicated, Record Submitted Late: The submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment. During a concurrent interview and review on 5/7/26 at 1:51 PM with RN 4, Resident 16's quarterly MDS with an ARD21 of 1/31/26 was reviewed and indicated, the assessment was completed on 2/2/26. However, the assessment was transmitted on 4/23/26, 80 days after the MDS assessment was completed. RN 4 confirmed and stated it was late. Review of facility document titled Final Validation Report for Resident 16, dated 5/5/2026, indicated, Record Submitted Late: The submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment. During a concurrent interview and record review on 5/06/2026, at 3:54 PM, with MDS Nurse, Resident 28's MDS Quarterly Assessment Reference Date (ARD - It is a specific day that the facility staff looks back from to gather all the patient's medical information) dated 2/20/2026 is still In Progress. During a concurrent interview and record review on 5/06/2026, at 3:58 PM, with MDS Nurse, Resident 94's MDS Quarterly Assessment Reference Date (ARD) dated 2/25/2026 is still In Progress. During a concurrent interview and record review on 5/06/2026, at 4:06 PM, with MDS Nurse, MDS Nurse stated, Resident 151's admission date is 11/19/2022. The 11/19/2025 Annual Assessment for Resident 151 was completed on 1/25/2026. MDS Nurse's MDS Record review indicated 2/17/2026 Quarterly Assessment is still In Progress. During a review of MDS 3.0 NH Final Validation Report, for Resident 18 indicated, Assessment Completed Late: An OBRA assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. A prior record with an ARD (A2300) within 92 days of the submitted record could not be found. During a record review of Quarterly Minimum Data Set (MDS,) dated 12/8/25 for Resident 15, on 5/6/26 at 3:48 PM with MDS nurse, Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed. The MDS indicated, Quarterly due 11/24/25, was completed 12/8/25 and accepted 1/22/26. During an interview on 5/6/26 at 3:38 PM with MDS nurse, MDS nurse stated, Annual Assessment for Resident 15 is due 2/24/26 ARD 3/1/26, shows in progress. It is now May 2026. Resident 15's annual assessment is late and not completed and not submitted. Resident 15 is now due for another quarterly 5/22/26. Per MDS nurse, they have a new MDS nurse to work on these assessments. During a concurrent interview and record review on 05/06/2026 at 4:21 PM with MDS Nurse, and a facility document titled Final Validation Report, dated 4/29/2026 was reviewed, the Validation Report indicated Resident 6 Assessment completed late, MDS Nurse stated Resident 6 is in progress for submission. Quarterly Assessment Reference Date (ARD, a date the nursing home uses to record the resident's condition for the assessment) of Resident 6 was 2/18/2026 and last submission of ARD was on 11/20/2025, while Resident 110 indicated, Assessment Completed late, MDS Nurse further stated, quarterly submission is in progress, Resident 110 quarterly ARD was 2/25/2026 and last submission of Resident 110 quarterly was last 9/1/2025. During review of facility document titled Final Validation Report, dated 4/29/2026, the Validation Report indicated Resident 130 Assessment completed late. A prior record with an ARD within 366 days of the submitted record could not be found, and Resident 14 indicated, Assessment Completed late.A prior record with an ARD within 92 days of the submitted record could not be found. During review of facility document titled Final Validation Report, dated 5/5/2026, the Validation Report indicated, Resident 80 record submitted late: the submission date is more than 14 days.

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS, a resident assessment tool) quarterly assessment was completed at least every 92 days following the previous OBRA (Omnibus Budget Reconciliation Act of 1987) assessment for six of 19 sampled residents (Resident 71, Resident 73, Resident 94, Resident 111, Resident 121, and Resident 16).Failure to complete quarterly resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of the residents.1. Review of Resident 71's admission record indicated, was admitted to the facility on [DATE].Review of Resident 71's quarterly MDS with an Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) of 11/14/25 indicated, the assessment was signed by the RN assessment coordinator as complete on 12/17/25, 33 days after the ARD.During concurrent interview and record review on 5/6/26 at 2:56 PM, the MDS nurse reviewed Resident 71's quarterly MDS and stated, the MDS should have been completed and signed on 11/27/25. The MDS nurse also stated that the quarterly MDS assessment should be signed 14 days after the ARD.2. Review of Resident 73's admission record indicated, was readmitted to the facility on [DATE].Review of Resident 73's quarterly MDS with an ARD of 8/28/25 indicated, the assessment was signed by the RN assessment coordinator as complete on 10/30/25, 63 days after the ARD.During a concurrent interview and record review on 5/6/26 at 3:02 PM, the MDS nurse reviewed Resident 73's quarterly MDS and stated, the MDS should have been completed and signed on 9/11/25.3. Review of Resident 94's admission record indicated, was admitted to the facility on [DATE].Review of Resident 94's quarterly MDS with an ARD of 11/25/25 indicated, the assessment was signed by the RN assessment coordinator as complete on 12/15/25, 20 days after the ARD.During concurrent interview and record review on 5/6/26 at 3:07 AM, the MDS nurse reviewed Resident 3's quarterly MDS and stated, the MDS should have been completed and signed on 12/9/25.Review of Resident 94's quarterly MDS with an ARD of 2/25/25 indicated, the status of the assessment indicated in progress.During a concurrent interview on 5/6/26 at 3:08 PM, the MDS nurse stated that in progress means the assessment is not completed.4. Review of Resident 111's admission record indicated, was admitted to the facility on [DATE].Review of Resident 111's quarterly MDS with an ARD of 8/28/25 indicated, the assessment was signed by the RN assessment coordinator as complete on 10/30/25, 63 days after the ARD.During concurrent interview and record review on 5/6/26 at 3:10 AM, the MDS nurse reviewed Resident 111's quarterly MDS and stated, the MDS should have been completed and signed on 9/11/25.Review of Resident 111's quarterly MDS with an ARD of 2/19/26 indicated, the status of the assessment indicated in progress.During a concurrent interview on 5/6/26 at 3:12 PM, the MDS nurse stated that in progress means the assessment is not completed.5. Review of Resident 121's admission record indicated, was admitted to the facility on [DATE].Review of Resident 121's quarterly MDS with an ARD of 8/27/25 indicated, the assessment was signed by the RN assessment coordinator as complete on 10/29/25, 63 days after the ARD.During concurrent interview and record review on 5/6/26 at 3:17 AM, the MDS nurse reviewed Resident 121's quarterly MDS and stated, the MDS should have been completed and signed on 9/10/25.Review of Resident 121's quarterly MDS with an ARD of 2/23/26 indicated, the status of the assessment indicated in progress. During concurrent interview, the MDS nurse stated it should have been completed and submitted on 3/9/26. 6. Review of Resident 16's admission record indicated, was admitted to the facility on [DATE].Review of Resident 16's quarterly MDS with an Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) of 10/31/25 indicated, the assessment was signed by the RN assessment coordinator as complete on 1/12/26, 73 days after the ARD.Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored . The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type . The ARD must be within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA, SCPA, SCQA, or Annual assessment + 92 calendar days). The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) .

Based on observation, interview, and record review, the facility failed to develop and implement person centered care plans for two (2) of 28 sampled residents (Residents 12, 120, and 130) when:Resident 12 did not have a care plan for limited range of motion, despite being ordered Restorative Nursing services (person-centered programs designed to help patients maintain or improve their highest level of physical, mental, and psychosocial independence)Resident 130 received 5 L/min of oxygen instead of the prescribed 2 L/min, contrary to the care plan and physician orders.These deficient practices had the potential to result in unmet care needs, inadequate supervision, and failure to provide services in accordance with physician orders and individualized assessments.2. During initial pool observation on 5/4/2026 at 2:19PM, Resident 130 was noted to be receiving 5 L/min of oxygen. During an interview on 05/06/2026 at 11:41 AM with LVN 2, LVN 2 stated, Resident 130 is using 2 L of oxygen therapy, but sometimes, asked to increase the oxygen because resident 130 tells me it is not enough. When asked to check the current oxygen level, it was noted to be at 4 L. LVN 2 stated, Yes, I know that it should be supervised and checked frequently. Review of Resident 130's care plan indicated the resident oxygen therapy settings at 2 L/min via nasal cannula. Humidified Review with Physician order dated 1/28/2026, the Physician order, indicated, Oxygen inhalation via nasal cannula for COPD. During a review of Facility's Policy and procedure titled, Oxygen administration, delivery device dated August 2017, indicated, Guidelines: 1. The nasal cannula (low concentration) .the nasal cannula may deliver as much as 40% oxygen ( at 5lpm. Excessive flow rates are to be avoided as they will not significantly increase Fio2 (The amount of oxygen a person is breathing in) and may cause considerable pain in the frontal sinuses (The hollow spaces in the forehead). 1. Review of Resident 12's admission record indicated, was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI, a bacterial infection of the urinary system, including the bladder, urethra, or kidneys), gram-negative sepsis (a life-threatening medical emergency triggered when a Gram-negative bacterial infection enters the bloodstream and causes an extreme, body-wide inflammatory response), polyneuropathy (simultaneous damage to multiple peripheral nerves throughout the body), muscle weakness, pressure ulcer of right heel, and other abnormalities of gait and mobility. Review of Resident 12's Minimum Data Set (MDS, a resident assessment tool) dated 4/9/24 indicated moderate cognitive (thought process) impairment. Under the functional abilities section indicated, Resident 12 has impairment on bilateral upper extremities, dependent and required two or more helpers (persons) with walking and chair/bed-to-chair transfer. During an observation on 5/4/26 at 3:03 PM in resident's room, Resident 12 was in bed awake and having a conversation with the son at the bedside. During a concurrent interview, the son stated that Resident 12 was not receiving physical therapy and usually stays in bed. During a concurrent interview and record review on 5/8/26 at 10:44 AM with Registered Nurse (RN) 2, Resident 12's active orders for May 2026 was reviewed. The active orders indicated the following were ordered on 3/24/26: RNA (Restorative Nursing Assistant, an enhanced Certified Nursing Assistant (CNA) who specializes in helping patients maintain or regain their mobility, strength, and independence) for ambulation with front wheeled walker three times a week (3x/week) or as tolerated to maintain functional mobility. RNA for AROM (active range of motion) to left lower extremity (LLE) 3x/week or as tolerated to maintain function and strength, maintain ROM, to decrease risk of contractures. RNA for AROM to left upper extremity (LUE) 3x/week or as tolerated to maintain ROM, to decrease risk of contractures. RNA for AROM to right lower extremity (RLE) 3x/week or as tolerated to maintain ROM, to decrease risk of contractures. RNA for AROM to right upper extremity (RUE) 3x/week or as tolerated to maintain ROM, to decrease risk of contractures. RNA for bed mobility & transfers 3x/week or as tolerated to maintain functional mobility. Sit to stand 3x/week or as tolerated to maintain functional mobility. During a concurrent interview, RN 2 stated that Resident 12 had been discharged from therapy and placed on the Restorative Nursing Assistance (RNA) program on 3/25/26. RN 2 also reported that Resident 12 was consistently bedbound. During further record review and a concurrent interview with RN 2 on 5/8/26 at 10:48 PM, the care plan was reviewed and it was noted that the orders for the RNA program were not addressed. RN 2 confirmed the omission and stated there was no care plan outlining Resident 12's limited range of motion or the physician ordered RNA services. RN 2 acknowledged, there should be a care plan. Review of the facility's policy and procedure titled, Standards for Restorative Nursing Program, released September 2019, indicated, Restorative Nursing program is a service provided by the facility generally under nursing, to ensure maintenance of a patient's optimum level of function. The patients on this program are encouraged or assisted to achieve and maintain their highest level of self-care and independence . Documentation: .3. The specific treatment provided as outlined in the care plan will be initialed daily, or as specified by the plan, by the RNA.

Based on observation, interview, and record review, the facility failed to ensure prescription medications and biologicals were labeled and stored according to manufacturer's instructions and facility policy and procedures, as evidenced by the following:A bottle of Dabigatran etexilate (a prescription oral blood thinner) capsule and one vial of multi-dose Heparin Sodium 5,000 unit/mL (a fast-acting injectable anticoagulant used to prevent blood clots) were opened and undated.Residents and staff personal items such as pouch, jewelry, hearing aid, dentures, cellphones, cellphone charger, eyeglasses, and iPad were stored in the controlled medication compartment of Medication Carts #4 & #1.Two vials of Tubersol (Tuberculin Purified Protein Derivative-a sterile, standardized solution used primarily for Mantoux tuberculin skin testing) in the refrigerator in Station 1 medication storage room were opened and undated.These failures increased the risk of administering expired, contaminated, or improperly stored medications, which could lead to ineffective treatment or resident harm.During an inspection of Medication Cart #4 on [DATE] at 11:08 AM with Licensed Vocational Nurse (LVN) 1, a bottle of Dabigatran etexilate capsule and a vial of multi-dose Heparin sodium were found in the top drawer without open or use by dates.During a concurrent interview with LVN 1 on [DATE] at 11:08 AM, LVN 1 confirmed both medications were opened and undated, stating Heparin should be discarded after 28 days, while Dabigatran follows the manufacturer's expiration date.According to the manufacturer's package insert for Dabigatran etexilate, .Once opened, the product must be used within 4 months. Keep the bottle tightly closed. Store in the original package to protect from moisture.According to the manufacturer's package insert for Heparin sodium, .Multiple-dose vials: Once punctured, the vial should be dated and the unused portion discarded within 28 days.During further inspection of Medication Cart #4 with LVN 1on [DATE] at 11:15 AM, the following items were observed:Personal items including a black pouch, a necklace in a blue jewelry container, a hearing aid, and a cellphone were stored in the controlled medication compartment.A foreign currency (500 pesos) was kept on the top drawer alongside opened bottles of over the counter oral medications, injections, and suppositories.A printed red pouch was found in the bottom drawer alongside oral medications.During a concurrent interview on [DATE] at 11:15 AM, LVN 1 confirmed that the items in the controlled medication compartment were residents' valuables, and the printed red pouch had her own personal belongings. LVN 1 also stated that the foreign currency was kept in the medication drawer as good luck.During an inspection of Medication Cart #1 on [DATE] at 11:41 AM with Registered Nurse (RN) 3, it was observed that personal items including iPad, hearing aids, eyeglasses, dentures, batteries, and cellphone charger were stored in the controlled medication compartment. During a concurrent interview, RN 3 confirmed that the items in the controlled medication compartment were residents' valuables.During an inspection of the medication storage room in Station 1 on [DATE] at 11:58 AM with RN 3, two vials of Tubersol solution were stored in the refrigerator without an open or use by dates. During a concurrent interview, RN 3 stated that the solution should be discarded 28 days after opening.During an interview on [DATE] at 12:16 PM, the Director of Nursing (DON) stated that personal belongings should not be kept in the medication cart because of concerns about infection control and the risk of drug diversion.Review of the facility's policy and procedures titled, Storage of Medication, dated 09/2018, indicated, Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications .

Based on observation, interviews and record reviews, the facility did not collaborate with Hospice the plan of care for two out of five residents (Residents 27and 16)This failure could result to residents not receiving care as planned.During a review of Resident 27's admission Record, dated 5/6/26, the admission record indicated, admitted on [DATE] with diagnoses including: Alzheimer's Disease( a progressive, irreversible brain disorder that destroys memory and thinking), Osteoarthritis of Knees(a common form of arthritis). During an observation on 5/5/26 at 11 AM, observed resident up on wheelchair, smiling, not responding to questions. During an interview on 5/5/26 at 11 AM with Certified Nursing Assistant (CNA) 4, stated, she has been her permanent CNA for many years. Since after her fall, she is now in wheelchair, can still walk to the bathroom with assistance. She is now under Hospice Care since last month. She had no changes, eats with good appetite, 100 % of meals, no skin breaks. She has family but only came when she was signed up for Hospice. I see hospice nurse and CNA come here per CNA. During a review of Physician's order, dated May 2026, the Physician's order indicated Palliative Care ordered 4/22/26. Hospice under Sutter Health with diagnosis of Cerebral Atherosclerosis. During a concurrent interview and chart review on 5/7/26 at 2PM with Registered Nurse (RN)1, care plan for Resident 27 was reviewed. The care plan indicated, Sutter Hospice 5/6/26. RN1 stated, resident is admitted to Hospice on 4/22/26 as Physician ordered. RN 1stated, care plan should focus on pain management and comfort and should be in collaboration with Hospice agency. Hospice agency information not in the care plan, facility team member contact person not in the care plan. Per RN1, each Hospice agency has a binder for each Hospice patient that their staff document on when they visit. During a review of facility's policy and procedure (P&P) tilted, Hospice Care, dated 8/17, the P&P indicated, When a facility resident elects to provide hospice care, the facility staff communicates with the hospice agency to establish and agree upon a coordinated plan of care that is based on an assessment of the resident's needs and living situation in the facility. Guidelines: 2. Develop a plan of care that reflects the participation of the hospice agency, the facility, and the resident and family to the extent possible. 3. Ensure that the plan of car identifies the car and services which the facility and hospice agency will provide in order to be responsive to the unique needs of the resident and their expressed desire for hospice care. Review of Resident 16' admission record indicated, was admitted to hospice care on 3/29/26 with a diagnosis of cerebrovascular accident (CVA, commonly known as a stroke). During concurrent record review and interview with RN 3 on 5/7/26 at 1:51 PM, Resident 16's plan of care was reviewed and indicated there was no hospice care plan developed in collaboration with the Hospice agency. Additionally, there was no hospice information in Resident 16's electronic health record for facility staff to refer to. RN 3 stated, I don't see one.

Based on interview and record review, the facility failed to report allegations of abuse involving Resident 160 to the State Survey Agency, as required by facility policy and federal regulations.Failure to promptly report allegations of abuse had the potential to place residents at risk for unaddressed harm and compromise the facility's duty to protect residents' health, safety, and rights.Review of Resident 160's admission record indicated, was admitted to the facility on [DATE] with diagnoses that included a heart attack, a urinary tract infection, type 2 diabetes (high blood sugar), left lower leg closed fracture, and Alzheimer's disease (memory loss and confusion).Review of the Minimum Data Set (MDS) dated [DATE] indicated the Resident 160's cognition was moderately impaired.During a concurrent interview and record review on 5/8/26 at 1:29 PM, the Registered Nurse Supervisor (RNS) reviewed Resident 160's progress notes titled Nurses Notes. The entry dated 3/15/26 at 3:15 PM indicated the resident was discharged home with the daughter on 3/15/26 at 2:40 PM.During further review of the Nurses Notes dated 3/15/26 at 2:42 PM indicated, Upon discharge, daughter [Name] brought up a concern and asked the writer to asked her mom directly on what happened. Per resident, an incident happened between Monday 3/9 - Thursday 3/12 where two workers came to her room to clean her and one of the workers stuck his finger inside her rectum so hard that she screamed. Resident stated that it hurt very bad and she was in pain. When he pulled his finger out, he showed it to her and stated, you have a lot of poop, then resident told him not to touch her again. Per resident, this happened in the evening. The concern was brought up to the DSD (Directo of Staff Development) and daughter was assured that we will do a follow up on the incident.During the same interview on 5/8/26 at 1:29 PM, the RNS stated the Nurses Notes documented an allegation that required immediate reporting to the Ombudsman and the State Survey Agency. The RNS was unable to locate documentation that the allegation had been reported or investigated.During an interview on 5/8/26 at 1:50 PM, the Administrator stated they were not aware of the allegation and confirmed that the incident should have been reported, regardless of the resident's discharge.Review of the facility's policy and procedures titled, Abuse and Neglect Prohibition Policy, dated 06/2022, indicated, .F. Reporting of Incidents, investigations and facility's response to the investigation: 1.Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation the Administrator or designee will perform the following: i. All alleged violations-Immediately but not later than: 1. 2 hours - if the alleged violation involves abuse or results in serious bodily injury. 2. 24 hours-if the alleged violation does not involve abuse and does not result in serious bodily injury. ii. Report the incident to the local Ombudsman or the local law enforcement agency by telephone as soon as possible, and; iii. Submit written report to the local Ombudsman or the local law enforcement agency using the California Report of Suspected Dependent Adult/Elder Abuse Form (SOC 341) . iv. The Licensing and Certification Program Distric Office is required to receive these reports .

Based on observation, interview, and record review, the facility failed to ensure that respiratory care and services were provided as required for two of six sampled residents (Resident 130 and Resident 4). The facility did not provide appropriate supervision during the residents' nebulizer treatments (A nebulizer treatment is a process in which a machine turns liquid medication into a mist that the resident breathes in through a mask or mouthpiece to help improve breathing).This failure resulted in the residents not receiving respiratory treatment in accordance with the facility's policy, procedure, and individualized care plans, placing the residents at risk for unmet respiratory needs. During an observation on 5/4/2026 at 2:30 PM at Resident 130 room, Resident 130 was found sleeping with the nebulizer tubing on the resident's chest. The nebulizer machine was on the bed beside the resident, and the machine was still on. During a concurrent interview and observation on 5/4/2026 at 2:32PM in front of room [ROOM NUMBER], with License Vocational Nurse (LVN) 3, LVN3, stated, The Resident 130 wants to do it on his own. We don't wait until he finishes his nebulizer treatment. We just remind the resident to turn off the machine because he always forgets it. LVN 3, was observed giving the respiratory medication to Resident 130 and then leaving the resident unattended during the treatment. During an interview on 05/6/2026 at 11:41 AM with License Vocational Nurse, (LVN) 2, LVN2 stated, Its a routine that's why its always on the residents bedside, Resident 130 don't it want to removed. the resident does that all the time, turn it without the medication, the room mate comes to tell me that the machine is on. Review of resident 130's admission record, dated 5/7/2026, the admission record indicated, resident 130 was admitted [DATE], with active diagnosis of chronic respiratory failure with hypoxia (person's lungs are not able to get enough oxygen into their body over a long period of time), chronic obstructive pulmonary disease (COPD) (a person has long term lung damage that makes it hard to breathe). A review of Physicians order dated 1/26/2026, the physician order Resident 130, indicated, 1. Albuterol Sulfate 3ml inhale orally via nebulizer every 6 hours for SOB while awake 2. AR formoterol Tartrate Inhalation Nebulizer 2ml inhale orally via nebulizer two times a day for short of breath (SOB) 3. Budesonide inhalation Suspension 0.5mg/2ml. 1 application inhale orally two times a day for COPD via nebulizer. Rinse mouth with water and spit back into cup after use. During Record review of resident care plan on nebulizer dated 5/7/2026, the care plan indicated, Educated resident regarding safety hazards and infection control concerns associated with keeping nebulizer machine on bed. Encouraged resident to store nebulizer equipment in designated safe area after treatments. During a review of facility's Policy and Procedure titled Aerosolized Medication (Neb Med) dated August 2017, indicated, Procedure .8. assess the resident .b. check respiratory rate prior to treatment. 10 .Encourage and work with the resident throughout the treatment for use of the proper and most effective technique. 11. Continue to monitor resident throughout treatment .17. Rinse the nebulizer and mouthpiece. Shake to air dry and store in a plastic bag that is labeled with the resident's name and room number. During initial tour on 5/04/2026 at 2:15 PM, Resident 4 is awake, sitting on the left side of bed, nebulizer was on; the resident holding the breathing mask near the nose and mouth but elastic straps were not secured on the resident's ears. Resident 4 was nebulizing, no staff present in the room, turned off the nebulizer on his own. During a follow-up visit on 5/06/2026 at 12:12 PM, at Resident 4's room, resident was sleeping in bed, nebulizer machine was on the left side of bed. During an interview on 5/06/2026 at 12:20 PM at resident 4's room, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Resident 4 needs to nebulize for shortness of breath due to Chronic Obstructive Pulmonary Disease (COPD), (a progressive, long-term disease that makes it difficult to breathe by causing inflammation, damage, and obstruction in the airways). LVN 2 further stated, the resident needs supervision by assigned Licensed Nurse until nebulizing is done. The schedule to nebulize on morning shift is every 9:00 AM but not sure of the exact time on PM shift. During an interview on 5/06/2026 at 12:30 PM with Certified Nursing Assistant (CNA) 2, CNA 2 stated, LVN knows when resident needs to nebulize. CNA 2 further stated, Resident 4 becomes agitated when he needs medication and nebulizer treatment. During record review of Physician's Order dated 1/02/2026 indicated Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML-inhale orally via nebulizer every 4 hours as needed for shortness of breath (SOB)/wheezing.

Based on observation, interview, and record review, the facility failed to implement its infection control program when:Certified Nursing Assistant (CNA) 4 did not perform hand hygiene when handling soiled linens and entering resident rooms.Residents and staff personal items such as pouch, jewelry, hearing aid, dentures, cellphones, phone charger, eyeglasses, and iPad were stored in the controlled medication compartment of the medication cart.Foreign currency was kept in the top drawer of the Medication Cart #4, alongside opened bottles of over the counter oral medications, epinephrine injections (the primary emergency treatment for severe allergic reactions), and suppositories (medications administered through the rectum, vagina, or urethra).These failures had the potential for cross contamination of infection that can compromise the health and safety of residents and staff.1. During an observation on 5/4/26 at 2:54 PM in the hallway, CNA 4 was seen exiting a resident's room that had an Enhanced Barrier Precaution (are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) sign posted by the door. CNA 4 was wearing a surgical mask and gloves while carrying a transparent bag containing soiled linens. CNA 4 discarded the bag into a soiled linen hamper, removed gloves, and did not perform hand hygiene before re-entering the resident room.During a follow-up interview on 5/4/26 at 2:57 PM, CNA 4 acknowledged forgetting to perform hand hygiene after handling soiled linens. CNA 4 stated that hand hygiene is required before and after handling soiled linens, and when entering or exiting a resident's room.During an interview on 5/8/26 at 2:20 PM, the Infection Preventionist (IP) stated that staff are required to practice hand hygiene both before and after delivering care to residents, when handling soiled linens, and donning (putting on) and doffing (taking off) personal protective equipment (PPE- which refers to equipment used to reduce exposure to hazards that could lead to serious workplace injuries or illnesses).Review of the facility's policy and procedure titled, Hand Hygiene, released 08/2017, indicated, All staff having direct resident contact will use appropriate hand hygiene . 1. All employees having direct resident contact will sanitize their hands at least under the following situations: . c. Before and after any physical contact with resident equipment or personal articles that are likely to be contaminated with bodily secretions . i. After removing gloves. 2. During an inspection of Medication Cart #4 on 5/6/26 at 11:08 AM with Licensed Vocational Nurse (LVN) 1, it was observed that personal items including a black pouch, a necklace in a blue jewelry container, a hearing aid, and a cellphone were stored in the controlled medication compartment. Additionally, a printed red pouch was found in the bottom drawer alongside oral medications. During a concurrent interview, LVN 1 confirmed that the items in the controlled medication compartment were residents' valuables, and the printed red pouch contained her own personal belongings.During an inspection of Medication Cart #1 on 5/6/26 at 11:41 AM with Registered Nurse (RN) 3, it was observed that personal items including iPad, hearing aids, eyeglasses, dentures, batteries, and cellphone charger were stored in the controlled medication compartment. During a concurrent interview, RN 3 confirmed that the items in the controlled medication compartment were residents' valuables.During an interview on 5/6/26 at 12:16 PM, the Director of Nursing (DON) stated that personal belongings should not be kept in the medication cart because of concerns about infection control and the risk of drug diversion.Review of the facility's policy and procedures titled, Storage of Medication, dated 09/2018, indicated, .The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications .

Based on observation, interview, and record review, the facility failed to implement their smoking policy and procedures (P&P) when it allowed two of eight residents (Resident 4 and Resident 81) who smoked in the facility to keep possession of their own lighters and cigarettes inside the resident care area.This failure posed an increased risk for combustion and/or fire, resulting in the potential for serious injury and/or death to residents, staff, and visitors.During an interview on 05/06/2026, at 12:20 PM, at Resident 4's room with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, the orange plastic tube with liquid inside found on the overbed table beside the resident's bed is a disposable cigarette lighter used by Resident 4 for smoking. LVN 2 further stated, there is a smoking schedule, but Resident 4 does not follow it. LVN 2 stated, Resident 4 keeps his cigarette in his room. LVN 2 is not sure about the facility's policy regarding safekeeping of cigarettes and lighters and if Resident 4 was educated about smoking and the use of lighters. During an interview on 05/06/2026, at 12:30 PM, at Resident 4's room with Certified Nursing Assistant (CNA) 2, CNA 2 is assigned to Resident 4 three times a week. CNA 2 stated, Resident 4 goes out by wheelchair, to the front of the facility to smoke. CNA 2 further stated, cigarettes and lighters are supposed to be kept in the nurses' station, but Resident 4 is keeping it with him and not inform staff when he wants to smoke. Resident 4 does not follow the policy and becomes agitated when reminded about the policy. Resident is independent and ambulates using his wheelchair without assistance. During an observation on 05/07/2026 at 1:54 PM, Surveyor went back to Resident 4's room to speak with the resident, but resident was sleeping. While in Resident 4's room, Surveyor saw two disposable cigarette lighters on the overbed table of the resident, the same place where the first disposable cigarette lighter was seen on 05/06/2026 at 12:12 PM. During an interview on 05/06/2026, at the facility's Conference Room with RN 1, RN 1 stated, cigarette lighters for smokers should always be kept at the nurse's station. During a review of the facility's Smoking Policy-Residents, dated 06/22/2022, the Smoking Policy-Residents indicated 12. Smoking articles for residents with independent smoking privileges: b. Residents may not keep even disposable lighters. All other forms of lighters, including matches, shall be prohibited. During a review of Resident 4's Care Plan Report, dated 10/16/2024, the Care Plan Report indicated, the lighter should be kept by the nursing station. During a review of Resident 4's Care Plan Report, dated 03/05/2026, the Care Plan Report indicated, 3. Educate resident of smoking policy and safety hazard. 6. Keep smoking paraphernalia secured at all times. Review of Resident 38's admission record indicated, was admitted to the facility on [DATE] with diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities) with other behavioral disturbance, nicotine dependence, high blood sugar, and high blood pressure. Review of Resident 33's Minimum Data Set (MDS) assessment dated [DATE] indicated in the Staff Assessment for Mental Status section that Resident 38 has a memory problem and demonstrated modified independence—some difficulty in new situations only when it comes to Cognitive Skills for Daily Decision Making. During an observation on 5/4/26 at 2:10 PM, in resident's room, Resident 38 was seen sitting and smoking on the patio outside his room. Resident 38 had two lighters, three cigarette packs, and a glass container holding dried, greenish leaves. During an interview on 5/4/26 at 2:12 PM, Resident 38 stated that he keeps his own smoking paraphernalia. During concurrent record review and interview with the MDS nurse on 5/6/26 at 3:26 PM, Resident 38's Smoking Assessment indicated resident was a safe, independent smoker. The MDS nurse stated that, per facility policy, lighters are not allowed at the bedside. Resident 38 received education and a copy of the smoking policy and demonstrated understanding. Review of Resident 38's smoking care plan revised on 9/4/25 indicated, .the lighter should be kept by the nursing station.

Based on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA, is a comprehensive assessment for a resident that must be completed when the IDT (interdisciplinary team, a collaborative group of professionals from diverse fields who work together interdependently to achieve shared goals) has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of 19 sampled residents (Resident 73) who was admitted to hospice care on 11/5/25.This failure could potentially delay the provision of appropriate treatment and services for Resident 73.Review of Resident 73's admission record indicated, was admitted to hospice on 11/5/25 with diagnoses including heart failure, high blood pressure, and dementia (a group of symptoms affecting memory, thinking and social abilities).Review of Resident 73's Minimum Data Set (MDS, a resident assessment tool) with an Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) 11/12/25, indicated, a SCSA was completed when Resident 73 was enrolled to hospice care.11/12/25 Significant Change in Status MDS for Hospice - completed 1/24/26 (supposed to be completed on 11/25/25During concurrent interview and record review on 5/6/26 at 3:02 PM, MDS nurse stated that residents placed on hospice will need a significant change in status assessment and should be completed 14 days from the day resident was admitted to hospice. During concurrent record review, Resident 73's SCSA MDS was signed by the RN assessment coordinator as complete on 1/24/26, 81 days after Resident 73 was admitted to hospice. Additionally, the MDS nurse stated that it should have been completed on 11/25/25.Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than) . The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met .

Based on interview and record review, the facility failed to ensure the annual Minimum Data Set (MDS, a resident assessment tool) was completed within the required period of 14 calendar days of Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) for two of 19 sampled residents (Resident 73 and Resident 111).Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 73 and Resident 111.1. Review of Resident 73's admission record indicated, was admitted to the facility on [DATE].Review of Resident 73's annual MDS assessment with an ARD of 2/11/26, indicated, the assessment was signed by the Registered Nurse (RN) assessment coordinator as complete on 5/5/26, 83 days after the ARD. During a concurrent record review and interview on 5/6/26 at 3:06 PM, the MDS nurse reviewed Resident 73's annual MDS assessment with an ARD of 2/11/26 and confirmed the MDS was completed late. The MDS nurse stated that Resident 73's annual MDS assessment should have been completed and signed on 2/25/26.2. Review of Resident 111's admission record indicated, was admitted to the facility on [DATE].Review of Resident 111's annual MDS assessment with an ARD of 11/28/25, indicated, the assessment was signed by the Registered Nurse (RN) assessment coordinator as complete on 12/24/25, 26 days after the ARD. During concurrent interview and record review on 5/6/26 at 3:12 AM, the MDS nurse reviewed Resident 111's quarterly MDS and stated, the MDS should have been completed and signed on 12/12/25.According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, dated October 2024, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA or an SCPA has been completed since the most recent comprehensive assessment was completed. Its completion dates (MDS/CAA(s)/care plan) depend on the most recent comprehensive and past assessments' ARDs and completion dates . The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) .

Based on interview and record review, the facility did not ensure proper notification when residents are discharged , when one of three residents, Resident 158 went home, Ombudsman was not notified. This failure could put a resident with no protection and an advocate to inform them of options and rights with regards to discharge.Findings:During a review of Resident 158's admission Record, dated 5/8/26, indicated, admitted [DATE] with diagnoses including Cellulitis( infection of wound) of back, Depression ( a health condition with feeling of sadness, low energy). During a concurrent interview and record review on 5/7/26 at 11 AM, with RN 1, per RN 1, resident is alert and oriented x 4. Went out of facility on 2/2/26, did not return, did not sign Out On Pass (OOP) form. Staff calling patient and son but not answering. On 2/3/26, no call and not returned yet till 2/3/26 at 11 AM, resident came back to gather her belongings and does not want to stay. Per patient, she went to her friend's house, fell asleep coz she cannot sleep at the noise in the facility. SW and nurse trying to let her stay for wound care needs, patient decided to leave against medical advise (AMA). Police was called before patient came back. Patient signed AMA form, understand the consequence of no Home Health follow up. Asked RN1 for the discharge notification, no notification sent to Ombudsman. RN1stated, there is specific form for Ombudsman notification. RN1 unable to find form. During a review of Resident 158's Against Medical Advise (AMA) form, dated 2/3/26, the AMA form indicated resident certify leaving the facility Against Medical Advise. During a review of Physician's Progress Notes, dated 2/4/26, indicated, the progress notes indicated, resident was admitted for long term care after completion of rehab services and IV (intravenous) antibiotics and wound care. IV antibiotics completed on 1/25/26 and was switched to oral doxycycline for 3-6 months. Wound care no new skin issues noted .Homelessness, social work consult. Follow up with PCP(primary care physician), [NAME] ID(Infectious Doctor) clinic and neurosurgery clinic. 2/2/26 left without OOP (out on pass). 2/3/26 patient decides to leave against medical advise. Tried to get patient to stay, about sending Doxycycline, but patient is signed out against medical advise and wants to leave asap . During a review of facility's Policy and Procedure titled, Transfer and Discharge, dated 12/16, indicated, Purpose: The transfer and discharge process must provide sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility. Procedure: 4. At least 30 days prior to transfer or discharge, notify the resident, and if known the family member, surrogate, or resident representative of the transfer and the reason for the move. c. Provide the name, address, and phone number of: the state long term care ombudsman.

Based on interview and record review, the facility failed to conduct a thorough investigation of an allegation of abuse involving Resident 160.This failure had the potential to place residents at risk for unaddressed harm and compromised the facility's duty to protect residents' health and safety.Review of Resident 160's admission record indicated, was admitted to the facility on [DATE] with diagnoses that included a heart attack, a urinary tract infection, type 2 diabetes (high blood sugar), left lower leg closed fracture, and Alzheimer's disease (memory loss and confusion).Review of the Minimum Data Set (MDS) dated [DATE] indicated the Resident 160's cognition was moderately impaired.During a concurrent interview and record review on 5/8/26 at 1:29 PM, the Registered Nurse Supervisor (RNS) reviewed Resident 160's progress notes titled Nurses Notes. The entry dated 3/15/26 at 3:15 PM indicated the resident was discharged home with the daughter on 3/15/26 at 2:40 PM.Further review of the Nurses Notes dated 3/15/26 at 2:42 PM indicated, Upon discharge, daughter [Name] brought up a concern and asked the writer to asked her mom directly on what happened. Per resident, an incident happened between Monday 3/9 - Thursday 3/12 where two workers came to her room to clean her and one of the workers stuck his finger inside her rectum so hard that she screamed. Resident stated that it hurt very bad and she was in pain. When he pulled his finger out, he showed it to her and stated, you have a lot of poop, then resident told him not to touch her again. Per resident, this happened in the evening. The concern was brought up to the DSD (Directo of Staff Development) and daughter was assured that we will do a follow up on the incident.During a concurrent interview on 5/8/26 at 1:29 PM, the Registered Nurse Supervisor (RNS) stated the Nurses Notes documented an allegation that required immediate reporting and investigation. The RNS was unable to locate documentation showing the allegation was reported or investigated, as required.During an interview on 5/8/26 at 1:50 PM, the Administrator stated they were not aware of the allegation and confirmed that the alleged incident was not investigated.Review of the facility's policy and procedures titled, Abuse and Neglect Prohibition Policy, dated 06/2022, indicated, .F. Reporting of Incidents, investigations and facility's response to the investigation: 1.Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, neglect, or exploitation the Administrator or designee will perform the following: i. All alleged violations-Immediately but not later than: 1. 2 hours - if the alleged violation involves abuse or results in serious bodily injury. 2. 24 hours-if the alleged violation does not involve abuse and does not result in serious bodily injury. ii. Report the incident to the local Ombudsman or the local law enforcement agency by telephone as soon as possible, and; iii. Submit written report to the local Ombudsman or the local law enforcement agency using the California Report of Suspected Dependent Adult/Elder Abuse Form (SOC 341) . iv. The Licensing and Certification Program Distric Office is required to receive these reports .

Based on observation, interview and record review the facility failed to develop a person-centered care plan for two of two sampled residents (Resident 1, and Resident 2) when:Smoking and going out on pass (when a resident leaves the facility temporarily) was not addressed for Resident 1.Going out on pass was not addressed for Resident 2. The facility failure had the potential for the residents not to receive necessary care and services. A review of the face sheet indicated Resident 1 was admitted with diagnoses including heart failure (when the heart muscles do not pump as strong as it should) and diabetes (abnormally high blood sugar level).A review of the Minimum Data Set (MDS, a standard assessment tool) dated 1/15/26, indicated Resident 1 was cognitively intact. The MDS further indicated Resident 1 was independent with all aspects of activities of daily living (ADL).During a concurrent interview and record review on 1/28/26, at 1:47 PM, with Registered Nurse (RN) 1, the physician order for 1/2026, indicated Resident 1 may smoke. The physician order further indicated Resident 1 may go out on pass. RN 1 reviewed the care plan and stated that there was no care plan completed to address smoking. On further review of the care plan, RN 1 stated that there was no care plan completed to address going out on pass for Resident 1. 2. A review of the face sheet indicated Resident 2 was admitted with diagnoses including cellulitis of the back. A review of MDS dated [DATE], indicated Resident 2 had little to no cognitive impairment. The MDS further indicated Resident 2 was independent with all aspects of ADLs.During a concurrent interview and record review on 1/28/26, at 2 PM, with RN 1, the physician order for 1/2026, indicated Resident 2 may smoke. RN 1 reviewed the care plan and stated that there was no care plan completed to address smoking for Resident 2. During an interview on 1/28/26, at 3 PM, the Administrator stated the Director of Nursing (DON) was responsible for ensuring that resident care plans were completed.The DON was not available for interview. A review of the facility Policy and Procedure titled Comprehensive Plan of Care dated 12/2016, indicated, .It is the policy of this facility to provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs identified during comprehensive assessment. The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.The comprehensive plan of care will include: Address resident's individual needs, strengths, and preferences; reflect current standards of practice; reflect interventions to meet both short- and long-term objectives . include interventions to attempt to manage risk factors; be developed by the interdisciplinary team (IDT) that includes the attending physician, a registered nurse, and other appropriate staff as determined by the resident's needs; be periodically reviewed and revised by IDT as changes in the resident care and treatment occur; reflect participation of the resident.

Based on observation, interview, and record review, the facility failed to update the care plan for one of one sampled resident (Resident 3) after Resident 3 had two fall incidents.The failures had the potential to put the resident at risk of not receiving appropriate care. A review of the face sheet indicated Resident 3 was admitted with diagnoses including dementia (decline in memory or decision-making ability), muscle weakness, and abnormalities in gait (how a person walks) and mobility.A review of the Interdisciplinary Team notes dated 1/20/26, indicated Resident 3 had two fall incidents on 1/14/26.During a concurrent observation and interview on 1/28/26, at 12:49 PM, with Resident 3, Resident 3 was sitting up in a wheelchair in the hallway, alert, verbally responsive, calm and pleasant. Resident 3 was able to state his name. Resident 3 did not know his current location and the reason for residing in the facility. When asked about the fall incidents, Resident 3 stated he was feeling sleepy, had tried to walk, and needed to use the bathroom. During an interview on 1/28/26, at 1:17 PM, the Licensed Vocational Nurse (LVN)1 stated that care plans are initiated when there is a change in condition like a fall incident. LVN 1 further stated that care plans are reviewed and updated after each fall incident. LVN 1 stated she has not received an in-service on care planning.During a concurrent interview and record review on 1/28/26, at 1:26 PM, with LVN 2, LVN 2 reviewed the care plan for Resident 3 and stated that the care plan did not address the two fall incidents that occurred on 1/14/26. LVN 2 stated she has not received an in-service on care planning. During an interview on 1/28/26, at 3 PM, the Administrator stated the Director of Nursing (DON) and the Director of Staff Development (DSD) were responsible for providing in-services to the licensed nurses.On 1/28/26, the DON and the DSD were not available for interview. A review of the facility policy and procedure titled Person Centered Plan of Care dated 12/2016, indicated .The person-centered care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental and psychological well-being that will accommodate resident need. The person centered care plan will include: reflect current standards of professional practice.reflect interventions to meet both short- and long-term resident goals; include interventions to prevent avoidable decline in function or functional level;, include interventions to attempt to manage risks factors. be developed by an interdisciplinary team (IDT) that includes the attending physician, a registered nurse, and other appropriate staff as determined by the resident's needs; be periodically reviewed and revised by the IDT as changes in the resident's care and treatment occur; reflect participation of the resident, resident's family, or the resident's legal representative.A review of the facility Policy and Procedure titled; Post Fall Management Program dated 12/2016, indicated .Plan of Care Revision: A resident's condition and the effectiveness of the plan of care interventions will be evaluated if revisions are necessary to justify for continuing the existing plan based upon the following: The outcome and/or effects of goals and interventions, Resident failure to comply with the plan of care and interventions.

Based on observation, interview, and record review, the facility failed to effectively assess weight loss, revise, and implement therapeutic interventions for one of one sampled resident (Resident 19) when Resident 19 had an unplanned weight loss. The facility's failure resulted to Resident 19 to experience a gradual, unintended, progressive weight loss overtime. Findings: A review of the facility's Policy and Procedure (P&P) titled Weight and Assessment Interventions dated 11/2017, indicated, the threshold for significant and unplanned and undesired weight loss will be 5% after a month, 7.5% after 3 months, and 10% after 6 months. The P&P further indicated, .Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation .nursing will immediately notify the Registered Dietitian (RD). The RD will review the unit weight record every month to follow individual weight trends overtime. Negative trends will be evaluated by the interdisciplinary team. Individualized care plan shall address to the extent possible the identified causes of weight loss . Interventions for undesirable weight loss shall be based on careful consideration of the following: residents' choice and preferences; nutrition and hydration needs The policy did not address undesired weight loss in residents who do not meet the suggested thresholds. A review of the face sheet indicated, Resident 19 was admitted with diagnoses including dementia (a decline in memory or other thinking skills) and osteoarthritis (pain and stiffness of the joints). A review of the Minimum Data Set (MDS, a standard assessment tool) for Resident 19, dated 12/6/23, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning [mental abilities, includes remembering, thinking,problem solving])score of 8 indicated moderate cognitive impairment. The MDS Section K (Swallowing/Nutritional Status) indicated, Resident 19 was not on physician-prescribed weight loss regimen. Admission weight documented was 125 pounds (lbs). The Admission diet order dated 7/31/21, indicated Resident 19 had a regular diet, regular texture, regular consistency. During an observation and interview on 12/19/23, at 1:13 PM, Resident 19 was alert, pleasant, verbally responsive in a foreign language. Resident 19 was sitting up at the edge of her bed feeding self with lunch. Certified Nurse Assistant (CNA, care giver) 3 stated, that Resident 19 usually eats a 100% of her meals. CNA 3 further stated, She's smaller now. She walks around a lot during the day and at night, and she takes a couple of rounds every time. CNA 3 also stated that Resident 19 will not ask for food but will accept and eat the food that was offered to her. During an observation on 12/20/23, at 2:36 PM, Resident 19 had walked the hallways in three rounds. During an interview on 12/20/23, at 3:12 PM, LVN(Licensed Vocational Nurse) 4 stated, (Resident 19 named) walks around all the time. You will always see her walking. LVN 4 as interpreter stated that Resident 19 likes to walk especially after meals, and that walking helps relieve her joint pains. During an interview on 12/20/23, at 4:35 PM, The Infection Preventionist (IP) stated, they were not able to find the Initial Nutritional Assessment for Resident 19. A review of the RD notes dated 11/8/22 indicated, Resident 19's weight had trend down gradually. A review of the RD (Registered Dietitian) notes dated 12/10/23, indicated, Resident 19 had a weight loss of 8 lbs. in 3 months and has a current weight of 98 lbs. During an interview and review of the nurses notes on 12/21/23, at 10:15 AM, the nurses' notes dated 12/11/23 indicated, Resident 19 had an 8 lbs. loss in 90 days and there were recommended supplements, Prostat (nourishment, protein supplement) 30 milliliter (ml, a unit of measurement) two times a day and Health shake (nourishment, nutritional supplement drink) daily. RN 1 stated, Weight loss is a change in condition and it should be monitored for 72 hours. The meal intake and nourishments should be charted. I don't see that the recommendation was followed up. During an interview and review of the nutrition plan of care (POC) on 12/21/23, at 11:02 AM, the POC initiated on 9/13/21, indicated Resident 19 was at risk for potential nutritional problem and malnutrition (caused by not having enough food to eat) related to Alzheimer dementia. Interventions included to monitor, evaluate and record of meal percentage intake, provide medpass, 120 ml with meals, multivitamin daily, report to Medical Doctor as needed (PRN) signs and symptoms (s/s) of malnutrition , serve diet as ordered, one ounce (oz) butter/olive oil added to entrees, RD to evaluate and make diet change recommendation as needed (PRN). Registered Nurse (RN) 2 reviewed the POC and acknowledged the POC further indicated on 11/8/22, Resident 19 weighed 103 lbs., a 14 lbs weight loss from 5/2022 weight of 117 lbs. And on 12/10/23, Resident 19 had a current weight of 98 lbs. a further weight loss of 8 lbs. from 9/2023 weight of 106 lbs. RN 2 stated, The care plan should be updated when she losses weight. There should be new interventions, example are supplements and what the dietician's recommended. The Director of Nursing and the MDS nurse reviews and updates the care plans. LVN 2 stated, I don't review care plans. LVN 3 stated, I don't review careplans. The POC did not address Resident 19's weight had trend down gradually as noted by the RD, and the interventions were last revised on 1/31/22. During an interview on 12/21/23, at 2:50 PM, RD stated, The supplement intake was documented by the nurses in the Medication Administration Record (MAR). Snacks, Sandwiches, juice, and cookies are available for the residents between meals and at bedtime. Regarding Resident 19's walking a lot during the day and at night as claimed by staff, RD stated that she needed to check on it. During an interview and review of the MAR on 12/21/23, at 3:02 PM, Licensed Vocational Nurse (LVN) 1 review the MAR and stated , The supplements were not given to Resident 19. During an interview on 12/21/23, at 3:20 PM, Social Services Designee stated, the social services have a backlog and the last care conference for Resident 19 was in 2022. During an interview on 12/21/23, at 3:48 PM, regarding Resident 19's weight loss, the Administrator stated that she need to check on it. During an interview and review of the Resident Daily Care Flow sheet (CNA flow sheet, Activity of Daily Living, ADL, documentation, includes eating, bathing) on 1/11/24, at 10:10 AM, the December 2023 entries indicated that Snack/Supplement was both not offered nor accepted by Resident 19. CNA 3 stated, We were told that if there is a nourishment (Supplement/nutritional drink) on the meal tray, we have to chart it as snacks. It is confusing. LVN 2 reviewed the CNA flow sheet, and stated that the entries were confusing and cannot tell if the resident was given the snack and supplement. During further an interview and review of the CNA flow sheet, on 1/11/24, at 10:14 AM, 11/2023 flow sheet indicated Snacks/nourishment was not offered, the 10/2023 flow sheet indicated Snacks/Supplement was not offered, and the 9/2023 flow sheet indicated Snacks/nourishment was not offered. Numerous omitted meal intake entries were found on the flow sheets for 9/2023,10/2023, 11/2023 and 12/2023. CNA 3 stated, that some of the registry staff (temporary replacement staff) were not completing the Activity of Daily Living (ADL, includes eating, bathing, bathroom use) documentation. CNA 3 further stated, They don't know the residents. They don't know the routine. They just leave after the shift. During an interview on 1/11/24, at 1:20 PM, the Director of Staff Development stated that he was not aware of the registry staff not completing the ADL documentation and has not address weight loss. A review of the physician's visit notes dated 12/13/23, did not address the weight loss of 8 lbs. in 3 months, from 9/2023 weight of 106 lbs down to 98 lbs. on 12/2023 for Resident 19. There was no assessment done to rule out any condition that might potentially cause the weight loss. The Director of Nursing was currently off work, and was not available for interview. Weight loss in nursing home residents is linked to poor outcomes, including higher rates of hospitalization and death (American Journal of Nursing 2008). A review of the Policy and Procedure titled, Comprehensive Plan of Care dated 12/16, indicated, .It is the policy of this facility to provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during comprehensive assessment. The comprehensive care plan must describe the services that are provided to the resident to attain or maintains the resident's highest practicable physical, mental, and psychosocial wellbeing. The comprehensive plan of care will include, reflect interventions to meet both short- and long-term resident goals, interventions to prevent avoidable decline in function .include interventions to attempt to manage risk factors, be periodically reviewed and revised by interdisciplinary team as changes in the resident's needs .Reevaluate and modify care plans as necessary to reflect changes in care, services and treatment, quarterly and with significant change in status . A review of the Policy and Procedure titled Documentation Guidelines dated 11/21, indicated, .Guidelines .Promptly record as the events or observations occur . When a documentation error has been made in the record: dram a line through the error . Enter a new note or other documentation as specified . Do not leave blank spaces on forms .

Based on observation, interview, and record review, the facility failed to effectively assess or develop therapeutic interventions including but not limited to implementation of a therapeutic diet for one of two sampled residents (Resident 35). This failure resulted in Resident 35 experiencing severe weight loss. Findings: Weight loss in nursing home residents is linked to poor outcomes, including higher rates of hospitalization and death (American Journal of Nursing, 2008). Facility policy titled Weight Assessment & Interventions dated 11/17 described the threshold for significant unplanned and undesired weight loss as 5% (percent) after 1 month; 7.5% within 3 months and 10% within 6 months. The facility policy also guided staff that if any documented weight change was 5% or more since the last weight assessment, a reweigh would occur and the Registered Dietitian (RD) would be immediately notified. The process also indicated the RD will review unit weight records monthly and follow individual trends over time. The policy did not address undesired weight loss in residents who do not meet the suggested thresholds. Additionally, the policy indicated, .6. Interventions for undesirable weight loss shall be based on careful consideration of the following: 7. Resident choice and preferences; a. Nutrition and hydration needs of the resident; . f. The use of supplementation and/or feeding tubes . Weight loss greater than the described parameters are suggestive of severe weight loss (Centers for Medicaid/Medicare (CMS), Appendix PP, 2017). Additionally, insidious weight loss is defined as a gradual, unintended, progressive weight loss over time (CMS, Appendix PP, 2008). Resident 35 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission diet order dated 2/19/21, indicated, Resident 35 had the regular diet with regular consistency and regular thin liquid consistency. Facility document titled Admission Record dated 2/19/21, indicated Resident 35 was admitted from a board and care/assisted living facility and the responsible party was a public guardian. During a review of facility document titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation on 11/29/21, at 2:46 PM, Resident 35 was in the dining room. Her meal intake was estimated by the surveyor as 20%. During an observation on 12/01/21, at 12:34 PM, in the kitchen, Resident 35's snack ticket indicated, one Cookie for 10 AM snack and half of a sandwich as a bedtime snack. During an observation on 12/01/21, at 1:17 PM, in hallway near the Resident 35's room, Resident 35's lunch tray was reviewed. The surveyor estimated Resident 35 ate 10% of beef cubes, bites of pasta, bites of ice cream, 2 ounces (60 milliliter) of milk, one third of salad, and half cup of coffee. There was also an unopened cookie package with a sticker indicating it was for Resident 35. In a concurrent interview with Certified Nursing Assistant (CNA) 5, CNA 5 stated, cookie was Resident 35's mid-morning snack. During an interview on 12/02/21, at 9:20 AM, in hallway, with CNA 6, CNA 6 stated, Resident 35 ate breakfast later and generally ate 75% of breakfast, however, at times ate only 15-20% of breakfast, 75-80% of dinner, and drank 1 bottle of ensure before dinner or after dinner. During a review of the Nutrition Initial Assessment with an effective date of 2/25/21, the assessment indicated, admitted [DATE] and admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Registered Dietician (RD) recommended the addition of hi-cal (high calorie) foods, such as cookies, a magic cup (a nutritional supplement), and ½ sandwich two times a day, for an estimated 590 additional calories and 15 grams of protein per day. During a review of the Nutrition/Dietary Note dated 3/2/21, the dietary note indicated, Resident 35's weight on 3/1/21 was 152 pounds, physician ordered regular diet; a documented weight loss of 5 pounds (3% weight change) and an average meal intake of 35%. During a review of facility document titled Fall Menus dated 11/29/21, 11/30/21, and 12/1/21, the menus indicated regular diet contained 2100-2400 calories. During a review of facility document titled Weights and Vital Summary dated 12/1/21 for Resident 35, the document indicated, Resident 35 lost 12 pounds (7.64 %) of her weight one month after admission (3/22/21); lost 20 pounds (12.74 %) within 3 months (5/24/21) of admission, and lost 27 pounds (17.2 %) within 6 months (8/23/21) of admission. From 8/23-11/15/21, Resident 35 lost an additional 6 pounds for a total weight loss of 33 pounds (19%) since admission. During a review of the Resident 35's clinical records, the nursing progress notes indicated the following: On 3/13/21, poor intake, resident refusing snacks; 3/22/21, refused lunch, no mention of current weight loss; 4/5/21, current weight of 144 pounds, no indication the weight loss was recognized or acted upon. On 5/31/21, Resident 35's weight was 134 pounds. On 5/31/21, nursing documented Resident 35 was on monitoring for weight loss, however there was no documentation of evaluation of existing interventions or recommendations for new interventions. On 6/28/21 nursing staff documented a weight of 128 pounds with no other notations. An additional nursing entry on 8/10 noted a 3-pound weight loss with a notation to continue to monitor. While there was recognition of progressive weight changes there were no documented reweighs or notification to the Registered Dietitian in accordance with the facility weight policy. During a review of facility documents dated 3/2/21, 3/9/21, 4/6/21, 6/1/21 and 9/7/21 titled Wt [Weight] Variance IDT [Interdisciplinary Team] Review, documents indicated, the team continued to identify weight loss, the interventions were limited to the addition of high calorie foods with and between meals as well as an update of food preferences. No documentation the IDT committee evaluated the effectiveness of the interventions. It was also noted there was no IDT committee evaluation for Resident 35 between 6/1 and 9/7/21. During a review of Resident 35's clinical order, the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review on 12/01/21, at 1:20 PM, with CNA 5, Resident 35's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA 5 stated, 1 bottle is about 240 milliliter. During a concurrent interview and record review on 12/1/21, at 1:21 PM, with LVN 3, Resident's 35's MAR, dated June 2021 was reviewed. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No record of the amount eaten by Resident 35. When asked how staff evaluated the effectiveness of the supplement, LVN 3 stated, I see what you mean. During a review of a facility document titled Feeding, Food Intakes: Recording Percentage/Nutritional Assessment, undated, the document indicated, while the process was to record supplements/nourishments if a meal is refused, there was no guidance to record supplements given by nursing staff as part of medication administration. During a review of a facility document titled Resident Daily Care Flow Sheet from 2/20/21 to 10/31/21, the document indicated, most meal intakes were 50% or less with multiple refusals at breakfast. The document also indicated, that if breakfast was consumed the percentage recorded was often 40% or less. During a review of Resident 35's RD's initial nutrition assessment, dated 3/2/21, the assessment indicated, Resident 35's consumption would need to consistently be 100% for weight maintenance. During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool), dated 8/27/21, the MDS's BIMS (Brief Interview of Mental Status, a standardized test of cognitive function) score of 7 indicated, Resident 35 had severely impaired cognition. The MDS's section K (Swallowing/Nutritional status) indicated, Resident 35 was not on physician-prescribed weight-loss regimen for weight loss. During a concurrent interview and record review on 12/02/21, at 9:32 AM, with Registered Dietitian (RD), Resident 35's Nutrition/Dietary Note, dated 3/2/21, 6/2/21, and 9/7/21 were reviewed. The Nutrition/Dietary Note indicated, there were only these 3 entries. The RD stated, nurses usually get recommendations from doctor. RD stated, hi-cal (high calorie) food was started on 3/2/21 for intervention of Resident 35's weight loss. RD stated, there was no evaluation of the effectiveness of the intervention. The RD also stated, she was on a leave during the months of July and August 2021. The Dietary Note, dated 6/2/21, indicated, Resident 35 refused supplements and was on a continual downward weight trend. No modification of the current interventions or initiation of different interventions. The Dietary Note, dated 9/7/21, indicated, the document was a review of weights, meal intakes, estimated energy needs and current interventions. No plan to modify interventions. When asked about the frequency of resident reviews if weight loss was an issue, RD stated, residents with weight loss should be reviewed weekly. RD acknowledged the nutritional needs for Resident 35 were not fully addressed, the frequency of evaluation was not adequate and there was no evaluation of the effectiveness of the current plan. During a review of Resident 35's Order dated 6/13/21, the order indicated, Resident 35 had high protein ensure 1 bottle two times a day for supplement with meal, there were no other diet order update for Resident 35. During a concurrent interview and record review on 12/02/21, at 10:29 AM, with the Director of Nursing (DON), DON stated, nurses will give supplement like Ensure in the facility, and notify the Doctor and RD right away for weight loss. The DON also stated, . All depends on the recommendation from the doctor . She wakes up past 10AM . They need to be aware and make sure the patient is eating . When asked about the facility's expectation for documentation of supplements and snacks, DON stated, nursing staff document supplement consumption and CNA document snacks. Concurrent review of Resident 35's documents titled Resident Daily Care Flow Sheet beginning 3/21 through 10/21, the flow sheet indicated, during this time period while snacks were part of Resident 35's intervention for weight loss, the morning snack was frequently documented as O indicating it was not offered on 5/1/21, 5/2/21, and 5/3/21 in May 2021 for example. When the PM (post meridiem, after midday) snack was marked with a T for taken on 5/15/21, 5/16/21, 5/17/21, 5/18/21, 5/19/21, 5/20/21, 5/21/21, 5/22/21, 5/23/21, 5/24/21, 5/25/21, 5/26/21, 5/27/21, 5/28/21, 5/29/21, 5/30/21, and 5/31/21 in May 2021 for example, there was no indication of the type and percentage consumed. The instructions printed on the flow sheet guided staff to Document Type and % in notes. During an interview on 12/2/21, at 12:06 PM, with DON, DON stated, there was no RD during July and August 2021. DON stated, We interviewed, but could not find. when asked why the facility did not have an RD in July and August while RD was on family leave.

Based on interview and record review, the facility failed to ensure Resident 1 received care and treatment in accordance with the plan of care when: Resident 1's [DEVICE] (wound vac, a therapeutic technique using a suction pump, tubing and a dressing to remove excess fluids and promote healing) therapy was not administered as ordered by physician. This failure resulted in Resident 1 developing gangrene (death of body tissue) in her right foot, requiring transfer to acute care facility for surgery. Findings: The clinical record for Resident 1, indicated a 64- year-old female, with a history of osteo[DIAGNOSES REDACTED] (bone infection) of right ankle, foot, and amputation (removal) of right great (big) toe, admitted on [DATE] for antibiotics (drugs to treat an infection) and wound vac therapy. During a review of Resident 1's Minimum Data Set, (MDS, a resident assessment tool), dated 6/14/19, the MDS indicated a Brief Interview for Mental Status (BIMS, a brief scanner to detect cognitive impairment) score of 15, which indicated cognitively intact. During a review of Resident 1's Physicians Orders (PO), dated 6/7/19, the PO indicated wound vac on right 1st toe (big toe on the right foot), @ (at) 125 mm hg (millimeters of mercury, measurement of amount of negative pressure) . monitor (right) 2nd, 3rd, and 4th toe for signs and symptoms of infection, skin breakdown, and increase in size . During a review of Resident 1's Nurse's Notes (NN), dated 6/7/19, at 10 PM, the NN indicated right first toe amputation site 3.5 centimeter (cm, a unit of measurement) long x 2 cm wide x 0.5 cm deep, beefy (red, moist tissue, indicating wound healing) wound bed . necrotic (dead tissue) toes 2nd, 3rd, and 4th digits). During a review of Resident 1's Pain Care Plan (PCP), dated 6/7/19, the PCP indicated . wound vac therapy as ordered . There was no evidence of a care plan for wound vac therapy for the right foot. No evidence of care plan for right toe wound amputation site. During a review of Resident 1's Skilled Daily Nurses Note (SDNN), dated 6/28/19, at 12:20 PM, the SDNN indicated . right great toe with wound vac, machine keeps on beeping . always saying leak, nurses tried to reinforce it, still leaking . During a review of Resident 1's Skin Condition Record (SCR), for right foot 1st toe amputation site, dated 7/4/19, the SCR indicated wound measured 2 cm long x 2.3 cm wide x 0.4 cm deep, blackish colored wound bed. Skin condition record dated 7/10/19, indicated right foot 1st toe amputation site measured 5 cm long x 4 cm wide, blackish wound bed, no indication of documentation of wound depth. Skin condition record, dated 7/13/19, indicated right foot 1st toe amputation site measured 5 cm long x 5 cm wide, blackish wound bed, no indication of documentation of wound depth. During a review of Resident 1's Situation, Background, Assessment, Recommendation Communication Form (SBAR, a form used to report changes in resident's condition to physician), dated 7/8/19, by nursing, the SBAR indicated worsening of pain to the right foot, rated as an 8 out of 10 on a 0 to 10 scale (numeric scale where a person rates their pain on a scale of 0 to 10. 0 means no pain, and 10 means the worst possible pain). During a review of Resident 1's Nurse's Notes (NN), dated 7/12/19, the NN indicated wound . very foul smelling. Wound bed necrotic (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply) . NN dated 7/13/19, indicated . R (right) great toe wound . 4 cm X 4 cm 100% necrosis . During a review of Resident 1's physician progress notes [REDACTED]. During a review of Resident 1's physician progress notes [REDACTED]. Patients daughter did not want to wait for surgeon . called 911 to the facility to transfer patient to ED (Emergency Department . During a review of Resident 1's acute care ED (Emergency Department) Provider Notes (EDPN), dated 7/14/19, at 12:30 PM, by MD 2, the EDPN indicated . chief complaint . foot pain . ost(eo)[DIAGNOSES REDACTED] of her right foot requiring irrigation of the great toe presents with worsening signs of infection at same site with appears to be gangrenous changes at the dilatation site with surrounding swelling and [DIAGNOSES REDACTED] (redness of the skin that occurs with any skin injury, infection, or inflammation) consistent with [MEDICAL CONDITION] (infection of the skin and the soft tissues underneath) and likely worsening osteo[DIAGNOSES REDACTED] based on elevated C-Reactive Protein (CRP, a protein present in the blood in various abnormal states (such as inflammation), and Erythrocyte Sedimentation Rate (ESR, a blood test that measures how quickly erythrocytes (red blood cells) settle at the bottom of a test tube. A faster than normal rate indicates inflammation in the body). Vascular (relating to, affecting, or consisting of a vessel or vessels, especially those which carry blood) surgery was consulted in the ED. During an interview on 7/23/19, at 11:10 AM, the wound care nurse (WCN) stated she observed Resident 1's wound vac was turned off on 6/26/19, at the start of her 7 AM shift, after RN (Registered Nurse) 1 had been assigned to care for Resident 1 on the 11 PM- 7AM shift. WCN stated she informed the Director of Nursing (DON). WCN stated she observed the wound vac of Resident 1 turned off and the wound vac dressing (foam that is placed over the wound site) was dislodged (to force out of a secure or settled position), in the first week of July, at 7:00 AM, after RN 1's shift had ended. WCN stated she changed the dressing, turned the wound vac back on, and instructed the nursing staff to never turn the wound vac off. The WCN stated she thought the nurses were turning the wound vac off because maybe they don't know how to fix the cause of the wound vac alarm (a noise produced by the wound vac to get immediate attention). The WCN further stated she was upset and talked face to face with the DON because the staff were not asking for help for the wound vac, and she was concerned about the impact on Resident 1's wound healing, because the doctor intended for the wound vac to be on and suctioning all the time, 24 hours a day. The WCN further stated she instructed Resident 1 to call her daughter if the wound vac was found to be turned off again. During an interview on 7/23/19, at 1:10 PM, with the DON, the DON stated, when I asked night shift licensed nurses if they were turning off the wound vac at night, I was told that they would turn it off for ten minutes, and then turn it back on in 10 minutes. During an interview on 7/24/19, at 11:35 AM, with RN 2, RN 2 stated during her rounds, she observed the wound vac was turned off and not suctioning when RN 1 was assigned to care for Resident 1 on the night shift three weeks ago. RN 2 stated she informed RN 3. During an interview on 7/24/19, at 11:40 AM, with RN 3, RN 3 stated that for the first few days of Resident 1's admission, the wound vac machine kept beeping, alarming due to leaking (air leak when seal between dressing and vacuum is not tight around wound and interferes with suctioning). RN 3 stated she was aware night shift nursing staff were turning off the wound vac. RN 3 further stated some nurses were able to figure out how to trouble shoot the wound vac, and others asked for education for how to manage the wound vac, due to being unable to fix the cause of the wound vac alarms. During a review of the facility's policy and procedure (P&P) titled, Negative Pressure Wound Therapy, dated 2/2004, the P&P indicated . follow manufacturer's directions for usage and alarms . reporting 1. Any problems with the procedure. Review of the document titled KCI (manufacturer) V.A.C. (Vacuum Assisted Closure) ® Therapy (Trademark) Clinical Guidelines, A Reference Source for Clinicians, dated 1/2005, indicated wound vac not to be turned off for more than 2 hours in a 24 -hour period and troubleshooting needed if a steady decrease in wound measurements does not occur.

Based on observation, interview and record review, the facility failed to implement and maintain an effective infection control program when: 1. Nurses were improperly disinfecting glucometers (a device used to measure sugar levels in the blood) used for 28 of 28 residents (Residents 10, 117, 31, 89, 121, 24, 271, 33, 119, 111, 70, 78, 85, 100, 21, 322, 323, 58, 53, 115, 101, 43, 114, 6, 25, 8, 75, 14) who were on fingerstick blood sugar monitoring. On 8/1/18 at 3:40 PM, the survey team determined that staff were improperly disinfecting glucometers (a device used to measure sugar levels in the blood) used for 28 of 28 residents on fingerstick blood glucose (sugar) monitoring. An Immediate Jeopardy (IJ) was declared and the Administrator, Regional Nurse Consultant (RNC), and Director of Nursing (DON) were verbally informed. On 8/3/18 at 4:15 PM, after a Plan of Correction (P[NAME]) was accepted and its implementation verified by the survey team, the IJ was removed and the Administrator, RNC, and DON were verbally informed. The P[NAME] included the following: a. Removed all six glucometers from the medication carts on 8/1/18 at 4 PM. b. Medication carts were provided two glucometers for fingerstick procedures. c. The Medication Administration Records were printed for residents on fingerstick procedures. d. The RNC and DON inserviced and trained on glucometer cleaning and decontamination the CN 1 and CN 2 on 8/1/18. CN 1 and CN 2 performed fingerstick procedures on residents on 8/1/18 at 4:30 PM and 9 PM until all nurses have passed competency training. e. Facility had designated RN 2 and CN 1 to perform fingerstick procedures until all nurses have passed competency training on proper disinfection of glucometer. f. Facility submitted addendum to P[NAME] on 8/3/18 which included the use of Super Sani Cloth to decontaminate (disinfect) the glucometer. The survey team observed nurses were using the Super Sani Cloth to disinfect the glucometers properly after each use. 2. One staff member, Certified Nurse Assistant (CNA) 6, did not wear personal protective equipment (PPE) upon entering Resident 37's room, who was on contact precaution. 3. Pre-employment and annual health exam records were incomplete for 14 of 14 staff members; 5 CNAs, 5 License Vocational Nurses (LVN), 2 Registered Nurses (RN), 1 Activity Personnel, and 1 Kitchen Personnel. 4. The facility failed to develop an infection control program that reflected the depth and scope of food service observations. The deficient practice had the potential to jeopardize the health and safety of residents by cross-contamination, causing communicable and infectious diseases, including food-borne illness. Findings: 1. During a medication pass observation on 8/1/18 at 8:11 AM, Licensed Vocational Nurse (LVN) 6 did not disinfect the [MEDICATION NAME] glucometer after a fingerstick procedure (when a license nurse pierces a resident's finger using a lancet, in order to obtain a sample of blood on a strip, the strip is then inserted in the glucometer and a reading of the sugar level is obtained). During an interview on 8/1/18 at 2:45 PM, LVN 6 stated, I use this disinfecting wipes (Micro-kill with bleach brand) to clean it (glucometer) and let it (glucometer) air dry for three minutes, and then wipe with paper towel. When asked regarding not disinfecting the glucometer after use on 8/1/18 at 8:11 AM, LVN 6 did not offer a response. Review of the [MEDICATION NAME] Owner's Booklet (YEAR), indicated, True Track is an in vitro (outside body) quantitative system that is used for self testing and point of care (bedside) testing of human blood. The [MEDICATION NAME] Blood Glucose Monitoring System is for one person use only. Do not share your meter with anyone, Do not use on more than one person. All parts of Blood Glucose Monitoring System could carry blood-borne diseases after use, even after cleaning and disinfection .Do not use bleach to clean the meter .instructions for use of the System in a professional multi-patient setting are included in the Quality Assurance/Quality Control Manual, or call (phone number redacted .). During an interview on 8/1/18 at 2 PM, a [MEDICATION NAME] Customer Care Representative, (CCR) 1 stated, Yes, it is correct, the [MEDICATION NAME] meter is intended for one person use only. In a concurrent interview CCR 2 stated, We recommend the meter be used one per resident, however, if it used for multi -use residents, they (facilities) have to clean and disinfect with super sani-cloth. Review of the Product Information indicated the following: Micro-kill bleach wipes - is a product that can be used as a one-step cleaner and disinfectant. It kills [MEDICAL CONDITION] spores in three minutes. Super sani - cloth wipes - is a product that is effective against 30 microorganisms in 2 minutes. It cleans and disinfects in one step and is bactericidal (substance that kills bacteria), tuberculocidal (kills [DIAGNOSES REDACTED]), virucidal ( destroys viruses). During an interview on 8/1/18 at 1:40 PM, Charge Nurse (CN) 1 stated, We use the meter for everybody on fingersticks, we use the micro-kill wipes with bleach to clean and disinfect. During an interview on 8/1/18 at 2:45 PM, LVN 8 stated, I wipe it with this (Micro-kill with bleach wipe), let it dry for a while. LVN 8 did not offer response when asked how long the meter should be in contact with the disinfectant wipe. During an interview on 8/1/8 at 2:50 PM, CN 2 stated, I use the moist towelette to disinfect the meter, and let it dry after. During an interview on 8/1/18 at 4:12 PM, LVN 7 stated, We use Micro- kill wipes with bleach for cleaning and I use it (glucometer ) for everybody with fingerstick in my assignment. Review of undated facility Policy and Procedure under Section Infection Control .Cleaning and Disinfection of Glucometer, indicated, .Disinfect (after each use) after cleaning the exterior surfaces following the manufacturers' directions .Fingerstick devices should never be used for more than one person. (CDC Transmission of [MEDICAL CONDITION] Virus Among Persons .in Long Term Care Facilities .LA County 2003-2004 . During an interview on 8/7/18 at 11:30 AM, CCR 3 stated, Bleach wipes is not used in disinfecting the [MEDICATION NAME] meter because bleach affects the responsiveness and the accuracy of the results. It can also damage the meter. These are the reasons why we recommend using super sani-cloth. According to the Centers for Disease Control (CDC), Infectious agents, such as HBV ([MEDICAL CONDITION] virus) can be transmitted through indirect contact transmission, even in the absence of visible blood. Indirect contact transmission is defined as the transfer of an infectious agent from one patient to another through a contaminated intermediate object (such as a blood glucose meter). If blood is transferred from patient to the meter, and the meter is not cleaned and disinfected after use, subsequent patients can be exposed to this blood when the meter is used on them .an excerpt from FDA (Food and Drug Administration) reads, the disinfection solvent you choose should be effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION] viruses .Whenever possible, blood glucose meters should not be shared. During an interview on 8/3/18 at 2:05 PM, the RNC stated, I cannot find anything with regards to training about the glucometer use. The nurses should have at least yearly training on this. In a concurrent interview, the DON acknowledged lack of training for nurses on glucometer use, cleaning and disinfection. 2. Resident 37 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 37's physician's order, dated 7/27/18, indicated an order for [REDACTED]. According to the CDC Guidelines for Isolation Precaution, retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html, on 8/9/18, .Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment . During an observation, on 7/30/18, at 2:13 PM, Certified Nursing Assistant (CNA) 6 walked inside the room of Resident 37 without wearing personal protective equipment (PPE). CNA 6 touched the bed and sheets of Resident 37. During concurrent interview, CNA 6 stated, I should wear gown, gloves, and mask. I did it before (wearing PPE) but I have to check her now. During an interview, on 7/30/18, at 2:15 PM, Registered Nurse (RN) 2 instructed CNA 6 to wear PPE and stated, She (Resident 37) is on isolation still. The Occupational Safety and Health Administration (OSHA), retrieved from https://www.osha.gov/SLTC/personalprotectiveequipment, on 8/9/18, indicated, .Personal protective equipment, commonly referred to as PPE, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses .Personal protective equipment may include items such as gloves, safety glasses and shoes, earplugs or muffs, hard hats, respirators, or coveralls, vests and full body suits . The CDC Management of Patients with [MEDICAL CONDITION] (Shingles), retrieved from https://www.cdc.gov/shingles/hcp/hc-settings.html, on 8/9/18, indicated, .If the patient is immunocompromised with localized [MEDICAL CONDITION], then standard precautions plus airborne and contact precautions should be followed until disseminated infection is ruled out. Then standard precautions should be followed until [MEDICAL CONDITION] are dry and crusted 3. During a random review of 14 personnel files on 8/02/18, at 2:12 PM, in the Director of Staff Development's office, the following were noted: 1) There was no proof of vaccinations or blood test for immunity for Certified Nurse Assistant (CNA) 1, 2, 3, 4, and 5 2) There was no proof of vaccinations or blood test for immunity for Licensed Vocational Nurse (LVN) 1, 2, 3, 4, and 5 3) There was no proof of vaccinations or blood test for immunity for Registered Nurse (RN) 1 and 2 4) There was no proof of vaccinations or blood test for immunity for Activity personnel 1 5) There was no proof of vaccinations or blood test for immunity for Kitchen Personnel 1 During an interview on 8/2/18, at 2:45 PM, the Director of Staff Development (DSD) confirmed the above findings. Review of the facility policy and procedure titled, Hiring: Confidential Physical Examination: . The employee is free of communicable diseases, but needs to be seen by a physician to continue in this position. Review of the undated facility policy and procedure titled, Infection Control, indicated: .Routine Health Surveillance .After receiving training about blood borne diseases and within 10 working days of initial assignment, each employee will be offered the [MEDICAL CONDITION] vaccine series.A history and physical examination [REDACTED]. [MEDICAL CONDITION] Screening . [MEDICAL CONDITION] - a serious liver infection caused by the [MEDICAL CONDITION] virus [MEDICAL CONDITION] - an infectious disease caused by a bacteria that usually affects the lungs 4. During the annual recertification survey from 7/31-8/2/18, there were lapses in safe food handling practices putting residents at risk for foodborne illness and physical contamination of food (Cross Reference F812, Findings 1 through 5). In an interview on 7/31/18 at 12:30 p.m., the Director of Staff Development (DSD) 1 and 2 stated that DSD 1 provided 2-3 hours of daily consultation and training to DSD 2 who was new to the position. DSD 1 stated the facility infection control program consisted of surveillance of infections, antibiotics, and sick employees. DSD 1 stated the facility's typical infections were respiratory, wound and skin. DSD 1 described kitchen oversight as the use of hairnets, handwashing, employee illness, dented cans, freshness of fruits/vegetables; refrigerator/freezer temperatures. DSD 1 stated the Dietary Supervisor oversees food production. There was no documentation for rounding within the dietary department. There was no documentation of evaluation of food production activities that may result in food borne illness or physical contamination from an Infection Control Nurse. DSD 1 also stated there were weekly infection control meetings. Concurrent review of the documents with DSD 1 revealed there were no documented meetings after (MONTH) (YEAR).

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect and abuse when one of 32 sampled residents (Resident 63) was not offered assistance with toileting. Instead, Resident 63 was told to urinate in her underwear and was not offered a bedpan or commode. The deficient practice resulted in Resident 63's discomfort and feeling awful sitting with wet diaper. Findings: Resident 63 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 63's Minimum Data Set (MDS - an assessment tool), dated 6/13/18, indicated, Resident 63 was cognitively intact and continent of bowel and bladder. During an interview, on 7/31/18, at 10:02 AM, in the presence of the Director of Nursing (DON), Quality Assurance Nurse (QAN), and Regional Nurse Consultant (RNC), Resident 63 stated, I wet the pads because they don't come on time (staff), they (staff) say do it (urinate) in diapers. All night specially, I wear diapers. It's not the same when you know you can do it (urinate in the bathroom). I don't want the feeling of being wet. I feel awful because I have to go to the diapers, wet the diaper all night. Resident 63 explained that it happens not only to her but also to her roomate. Resident 63 added, When she (staff) leaves (end of shift) that's the only time she changes us. It happens all the time even in the morning. Review of Resident 63's Skilled Daily Nurses Notes indicated a check mark that diaper or pads were utilized on the following dates: 7/22/18; 7/23/18; 7/24/18; 7/25/18; 7/26/18; 7/27/18; 7/28/18; 7/29/18; 7/30/18; and 7/31/18. Review of Resident 63's Incontinence Care Plan, dated 7/30/18 indicated, .Assist for toileting needs. Anticipate elimination needs. During an interview, on 7/31/18, at 10:42 AM, the QAN stated, If the resident is able to use the bedpan or commode, the staff should not let them use diaper. The QAN also stated that management will investigate the incident. Review of the DON's preliminary investigation letter, dated 8/3/18, indicated, .Resident complained about the CNA member talking to her that she is busy, when the Resident asked for assistance to go to bathroom. CNA told the Resident to use her briefs .Staff CNA apologized and said she was with another resident. And said she will not repeat it . Review of an undated facility policy titled, Abuse Program, indicated, .Neglect: A failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . According to the California Advocates for Nursing Home Reform (CANHR), a Long Term Care Justice and Advocacy, retrieved from http://www.canhr.org/factsheets/nh_fs/html/fs_CareStandards, on 8/7/18, . Incontinence and lack of toileting assistance cause many serious problems, including discomfort, skin rashes, pressure sores, falls, isolation and psychological harm .Many nursing home residents are not incontinent but do need help with toileting. For example, a resident with limited mobility may need help to reach the toilet. Or a resident with dementia may need reminders to use the toilet on a regular basis. Nursing homes must help these residents use the toilet as often as needed . Review of the Resident Assessment Instrument (RAI) Manual, dated (MONTH) (YEAR), under Section H, indicated, .Incontinence can interfere with participation in activities, be socially embarrassing and lead to increased feelings of dependency, increase risk of long-term institutionalization, increase risk of skin rashes and breakdown, increase risk of repeated urinary tract infections, and increase the risk of falls and injuries resulting from attempts to reach a toilet unassisted .

Based on observation, interview, and record review, the facility failed to ensure food storage, preparation, and distribution under safe and sanitary conditions when: 1a. There was a presence of multiple live flies in the kitchen area such as food preparation area, dry food storage, and staff bathroom inside the kitchen; b. Numerous dead flies were observed on the floor and sink area of the staff bathroom inside the kitchen; c. The toilet seat inside the staff bathroom was missing and the hole was covered with a piece of wood. d. Multiple brown stain with fecal like smell were observed on the floor of the staff bathroom inside the kitchen; e. Strong smell of feces and sewage inside the kitchen; 2. The facility did not adhere to sanitary requirements on manual washing and sanitizing of dishware according to facility policy and national standard. 3. There was no air gap at three compartment sink and two compartment sink. Air gap is a space in the plumbing system to prevent backflow. 4. The facility Emergency And Disaster Procedures policy, dated (YEAR), did not address procedures in handling sewage backup emergency situation. An Immediate Jeopardy (IJ) was declared on 5/17/18, at 5:18 PM, in the presence of Administrator, Dietary Consultant (DC), and Dietary Manager (DM). IJ is a situation wherein the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. Unsanitary kitchen environment including food storage, preparation, and dishwashing areas increases the risk for food contamination and risk of foodborne illness that could jeopardize the health and safety of the residents and staff. Findings: During the kitchen tour with the DC and DM, on 5/17/18, at 2:09 PM, the main entrance of the kitchen was closed. The DM stated, They're working underneath at the storage area to fix the broken pipe. The staff were using the door by the activity room to access the kitchen area. There was a strong fecal and sewage smell, and flies were observed inside the kitchen including dry storage rooms. The DM stated, The smell is overwhelming, while covering her nose with the scarf. The DC stated that she noticed the smell since (MONTH) and it got worse. The DC and DM also stated that flies came out since they start digging the hole. During an observation, on 5/17/18, at 2:16 PM, there was a toilet inside the kitchen in between the dry storage rooms. There were numerous dead flies on the floor and at the sink area. Live flies were also observed freely flying inside the toilet. A visible brown stain was observed on the floor with an overwhelming fecal-sewage smell. The toilet seat was missing and the hole of the toilet was covered with a piece of brown wood. There was a black cable stuck in the hole of the toilet. During concurrent interview, the DM stated, The Rooters (plumber) check the pipe and use the camera (black cable) but the camera got stuck. During an interview, on 5/17/18, at 2:22 PM, the Dietary Staff (DS) 1 stated, The flies come and go for almost a week or two and the sewage smell, it had been for a while. The DC stated, Today the smell is better, now the flies. I'm not comfortable with flies in the kitchen. The DM added that on 5/12/18, We (kitchen staff) were told by the Restoration Contractor (plumber) not to use the water and the sink. The DM and DC explained, We used disposable plates and utensils last Sunday, Monday, Tuesday, and Wednesday (5/13/18 to 5/16/18). During an observation, on 5/17/18, at 2:35 PM, with the Maintenance Manager (MM) the main entrance of the kitchen in front of room [ROOM NUMBER] and 33 was covered with white plastic with a red zipper in the middle. The buttom of the white plastic was loose with orange electrical cords on the floor coming out from inside. A signage that reads, Keep Out Restricted Area was taped on the tarp. The MM opened the tarp and showed the Storage closet where the contractor drilled a hole to access the subfloor beams to do the pipe repair. When the MM opened the door there was an overwhelming fecal-sewage smell. During an observation, on 5/17/18, at 3:02 PM, Resident 1 and her son went outside the patio. Resident 1's son was holding fruits in a plastic bag. During an interview, Resident 1 stated that they (residents) were using paper plates and disposable utensils since Sunday. Resident 1 also stated, The room (room [ROOM NUMBER]) stinks all the time. The restroom stinks really bad. I don't want to eat it there. I have no appetite. Resident 1 also stated that she does not want to stay in her room because of the smell. During an interview, on 5/17/18, at 3:30 PM, DS 2 stated that there were flies inside the kitchen. During an interview, on 5/17/18, at 4:01 PM, the MM stated, the smell started two weeks ago and the Administrator was aware. The MM explained that there was a broken pipe in the dishwasher machine. During an interview, on 5/17/18, at 4:10 PM, the Administrator described the smell inside the kitchen as Smell like gas mixed with something fumy and dirty since around mid April. The Administrator also stated, The (name of the contractor) came to remove 150 gallons of water underneath the kitchen pipe that is broken. The guys say we cannot use the dish (washer) machine, we've been using disposable (plates and utensils). The Administrator also stated that a pest control contractor came in to spray the area. The Administrator confirmed that during this time, there is no interference of service. The kitchen continues to run as usual, there's no disruption of service. During an interview, on 5/17/18, at 5:01 PM, the Lead Technician from the restoration company stated that there was flooding at the back (from) the kitchen sink leakage and nasty smell in the kitchen. He explained that they did the clean up and suctioned out sludge to create pathway for the plumber. Review of Consultant Dietician Monthly Report under Sanitation/Food Safety, indicated the following: On 4/26/18, .Recurring Issues: overwhelming smell of unknown origin remains in dry storeroom and handwashing sink - maintenance to f/u (follow-up) . On 5/3/18, .Maintenance working on origin of unknown overwhelming odor in dry storeroom, handwashing sink, and dietary office . On 5/10/18, .Maintenance working on origin of unknown overwhelming odor in dry storeroom, handwashing sink, and dietary office . Review of the Pest Control service ticket number 4099, dated 5/7/18, indicated, .fly activity found in the interior area, particularly in the bathroom in the kitchen area where the toilet was removed, and there was construction drainage work taking place. A large pipe was left exposed, which cost (sic) hundreds of thousands of flies to come out and breathe inside the single use bathroom. The flies were also escaping from this area and getting into the kitchen and dining area and affecting the overall facility, but particularly affecting the kitchen and dining areas. I provided spray crack and crevice perimeter treatment partially in the kitchen .Sprayed floors walls cracks crevices and ceiling. Treatment consists of a strong [MEDICATION NAME] affect chemical designed to have a residual with a [MEDICATION NAME] affect .The treatment residual will provide some deterrent to prevent infestation from getting out of hand, but the residual only last about three weeks . Review of the facility policy, titled Food Preparation dated (YEAR), indicated, .10. Do not use cleaning products or sanitizer in the food preparation or food storage areas in any way that could result in contamination of exposed food items. This includes spraying or pouring cleaning products near food items during preparation or cooking . Review of the facility policy, titled Storage of Food Supplies dated (YEAR), indicated, .1. The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times .2. Storage areas should be free from exposed pipes, drains . 2. During an interview, on 5/17/18, at 2:09 PM, the DM stated, We used plastic and paper plates since Sunday until yesterday (5/12/18 to 5/16/18) because we cannot use the sink. During an interview, on 5/17/18, at 3:16 PM, the DM stated, (We use) big pans to wash vegetables and meat with water. Empty the water in the big trash can and take it (water) outside in the big drain. The DM also stated, Wash with still water. As soon as it gets dirty we empty the water and redo the process. The DM did not mention that temperature of the water was checked and the concentration of the sanitizer was tested with test strip. During an interview, on 5/17/18, at 3:33 PM, the DS 2 explained that she used the three compartment method using a huge bucket to wash the dishes. The DS 2 stated, I scrape the food (left over), wash (the dishes) with water and soap, rinse with clean water, and sanitize. As soon as you see it's dirty, I put it (water) in the garbage (container) and throw the water outside at the back. The DS 2 did not mention that temperature of the water and the concentration of the sanitizer was tested with test strip. During an interview, on 5/17/18, at 3:37 PM, DS 1 stated, I used bins in batches to rinse the food and throw away the water if it's a bit cloudy. When asked where are the staff throwing used water, the DS 1 replied, At the storm drain outside the facility. Review of the facility Quaternary Ammonium Log for (MONTH) (YEAR), indicated the concentration of sanitizer was tested three times a day when the staff was using the three compartment sink method on 5/12/18 to 5/16/18. There was no log for checking of water temperature provided. During an interview, on 5/23/18, at 3:36 PM, the DM stated that the sanitizer was tested three times when the three compartment sink method was used. The DC confirmed that there was no log for checking of the water temperature when the three compartment sink method was used. Review of the facility policy titled, 3 Compartment Procedure For Manual Dish Washing dated (YEAR), indicated, .Three compartment sink washing procedures are to be initiated when the dishwasher is inoperable .Immediately begin using disposable dishes .Step 1: Clean and sanitize all work surfaces .Step 2: Rinse, scrape, or soak all items before washing .Step 3: The first compartment is for washing. Fill the first compartment with detergent .and hot water (110-120 Fahrenheit). Record on temperature log. Replace water when it becomes cloudy or dirty, the suds are gone, or when temperature falls below 110 (Fahrenheit). The second compartment is for rinsing. Fill the second compartment with clean clear hot water .Record temperature on log .Step 5: The third compartment is for sanitizing. Fill the third compartment with clean, clear water to the fill line (25 gallons) .Then add 12.5 (ounces) of quaternary sanitizer .Record on log. Must read 200 ppm (parts per million) .Before wash-rinse-sanitize procedure begins, take the temperature of each solution and test strip of the sanitizer. Record on the Emergency 3 Compartment Washing Log. Temperature and test strip need to be retaken every 30 minutes . Review of Food and Drug Administration (FDA) Food Code 2013, indicated, .4-204.116 Manual Warewashing Equipment, Heaters and Baskets. If hot water is used for sanitation in manual warewashing operations, the sanitizing compartment of the sink shall be: (A) Designed with an integral heating device that is capable of maintaining water at a temperature not less than 77 degree Celsius (171 degree Fahrenheit); and (B) Provided with a rack or basket to allow complete immersion of equipment and utensils into the hot water . 3. During kitchen observation, on 5/18/18, at 10:20 AM, the three compartment sink and the two compartment sink did not have an air gap. During concurrent interview, the MM confirmed the findings and stated, No air gap, I don't see it. Review of Food and Drug Administration (FDA) Food Code 2013, indicated, .5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the plumbing fixture equipment, or non food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). 5-202.14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device .5-203.14 Backflow Prevention Device . A plumbing system shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use . 4. Review of the facility policy, titled Emergency And Disaster Procedures policy, dated (YEAR), did not indicate procedures to follow in the event of sewage backup emergency situation. During an interview, on 5/17/18, at 5:24 PM, the DC acknowledged that there is no policy specific for sewage backup emergency and stated, We will follow the emergency disaster policy. An Immediate Jeopardy was declared on 5/17/18, at 5:18 PM, with the Administrator, Dietary Consultant, and Dietary Manager. The Administrator, Dietary Consultant, and Dietary Manager were informed of the facility's failure to ensure safe and sanitary food storage, preparation, and distribution. A plan of correction (P[NAME]) was requested. The Immediate Jeopardy was abated (lifted) on 5/18/18, at 4:35 PM, after an acceptable plan of correction was presented and verified by the survey team with the Administrator, Dietary Consultant, and Dietary Manager. The Plan of Correction include the following: 1. Kitchen will be closed and no food will be prepared until County Public Health clears. 2. Emergency supply 3 day menu will be use. 3. Facility policy for modified diets and therapeutic diets. 4. Residents and/or Responsible party will be informed by Social Services of the changes on the menu. 5. Staff in-service of the implementation of the Disaster Menu. 6. Disposable table services to be use until clear by Health Agency. 7. Emergency water supply will use for meal preparation. 8. The conference room area will be utilize for safety food preparation. 9. (Name of the company) Rooters will remove the camera (snake cable) left in the bathroom so Maintenance can finish the repairs. 10. Bathroom repairs to be done and complete on 5/17/18. 11. OSHPD (Office of Statewide Health Planning and Development) representative was informed. 12. San Mateo County Public Health was informed. 13. Bathroom was cleaned and disinfected on 5/18/18. 14. All kitchen areas went under deep cleaning starting 5/17/18 and continued on 5/18/18. 15. Medical Director was updated regarding kitchen issues.

Based on observation, interview, and record review, the facility failed to maintain a sanitary, comfortable and homelike environment when the facility had a strong fecal-sewage odor. The deficient practice resulted to Resident 1 to lost appetite and not wanting to stay in her room. Exposure to unpleasant odor could affect mood, anxiety and stress level of the residents, staff, families, and visitors in the facility. Findings: During the kitchen tour on 5/17/18, at 2:09 PM, there was a strong fecal and sewage smell, and flies were observed inside the kitchen including dry storage rooms. The Dietary Manager (DM) stated, They're working underneath at the storage area to fix the broken pipe .The smell is overwhelming, while covering her nose with the scarf. The Dietary Manager (DC) stated that she noticed the smell since (MONTH) and it got worse. During an observation, on 5/17/18, at 2:35 PM, with the Maintenance Manager (MM) the main entrance of the kitchen in front of room [ROOM NUMBER] and 33 was covered with white plastic with a red zipper in the middle. The bottom of the white plastic was loose with orange electrical cords on the floor coming out from inside. A signage that reads, Keep Out Restricted Area was taped on the tarp. The MM opened the tarp and showed the Storage closet where the contractor drilled a hole to access the subfloor beams to do the pipe repair. When the MM opened the door there was an overwhelming fecal-sewage smell. 1. Resident 1 was admitted in the facility with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS an assessment tool) dated 5/13/18, indicated Resident 1 was cognitively intact. During an observation, on 5/17/18, at 3:02 PM, Resident 1 and her son was outside the patio. Resident 1's son was holding fruits in a plastic bag. During an interview, Resident 1 stated that they (residents) were using paper plates and disposable utensils since Sunday. Resident 1 also stated, The room (room [ROOM NUMBER]) stinks all the time. The restroom stinks really bad. I don't want to eat it there. I have no appetite. Resident 1 also stated that she does not want to stay in her room because of the smell. Resident 1's son stated, When they mopped, the water that they use stinks. (The) water stinks too, probably they don't change the water. It stinks so much. It's not clean here. During an observation, on 5/17/18, at 5:40 PM, Resident 1 was with her son and a lady in the patio eating dinner. Review of the facility floor plan, indicated room [ROOM NUMBER] was located beside the Storage closet used by the contractor to do the pipe repair. 2. Resident 2 was admitted with a [DIAGNOSES REDACTED]. Review of Resident 3's MDS dated [DATE], indicated Resident 3 was cognitively intact. During an interview, on 5/17/18, at 7:02, Resident 3 stated, The smell is not good. People are wearing mask. I can't do anything, they don't like it when I complain. Many people smelled it. Some people go outside (the facility). During an interview, on 5/17/18, at 6:49 PM, the License Vocational Nurse (LVN) 2 stated, When I passed by this hallway (referring to where kitchen entrance was located), it smells like poop. LVN 2 explained that she's been smelling the odor for more than a week. During an interview, on 5/17/18, at 6:59 PM, LVN 1 stated, Smells like sewage specially at the station and the hallway. During an interview, on 5/17/18, at 7:02 PM, the Certified Nursing Assistant (CNA) 1 stated, It's smells like a rotten food (since) last week. During an interview on 5/18/18, at 3:09 PM, Registered Nurse (RN) 1 stated, We (staff) offered them (residents and families) mask because we smell it. During an interview on 5/18/18, at 4:05 PM, Family Member (FM) 1 stated, Smell of pooh, very very bad smell. According to the article, retrieved from http://www.fwr.org/sewage/uklq09a.htm., on 5/25/18, .Ambient odours may produce health effects by direct irritation and/or toxicological routes, through responses which genetically coded or learned aversions or may be due to co-pollutant exposure(s) that is part of the odorant mixture. It is also generally accepted that unpleasant odours act as warning signs or as indicators of potential risk to health .It is likely that such odours will affect the quality of life to those regularly albeit intermittently exposed . Review of an article, titled Odors and Health retrieved from https://www.health.ny.gov/publications/6500/index.htm, on 5/24/18, indicated, .Smelling an odor doesn't tell how much exposure you have. It also doesn't tell you whether or not what you are smelling will cause health effects .Exposure to odors could result in health effects ranging from none, to mild discomfort, to more serious symptoms. Some chemicals with strong odors may cause eye, nose, throat or lung irritation. Strong odors may cause some people to feel a burning sensation that leads to coughing, wheezing or other breathing problems. People who smell strong odors may get headaches or feel dizzy or nauseous. If an odor lasts a long time or keeps occurring, it also could affect mood, anxiety and stress level .

Based on observation, interview and record review, the facility failed to provide the necessary care and language assistance services to maintain the highest practicable psychosocial well being for three of 36 non-English speaking residents (Res. 14, 18, 19, and 28) in accordance with their plans of care. For Resident 14, the lack of bedside materials, a communication book, and socialization/personal contact in her spoken language resulted in depression and suicidal ideation. For Residents14, 18, 19 and 28, the absence of communication boards potentially resulted to social isolation and diminished their ability to communicate their needs to the staff. Findings: 1. Resident 14 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Following a hospitalization for pneumonia, she was readmitted to the facility on [DATE]. Record review of her Minimum Data Set (MDS), an assessment tool, dated 10/16/12 noted the following: a. Section B Self Understood - (0) understood b. Section D Mood/Behavior - (7) mild depression c. Section F Activities - (1) very important daily preferences included groups of people. Record review of her MDS dated [DATE] noted the following: a. Section B Self Understood - (1) difficulty communicating due to language b. Section D Mood/Behavior - (12) moderate depression c Section F Activities - (1) very important daily preferences included groups of people. Record review of her Activities Program Information form dated 12/21/12 indicated Resident 14 was alert and oriented, verbally responsive, pleasant, speaks Cantonese only. Record review of care plan dated 12/21/12 identified the problem of "Potential for emotional distress & depression". The interventions listed included, "staff to introduce self, allow resident to express her wants and needs, coordinate with family." Record review of care plan dated 12/21/12 also identified the problem of "Potential mood & behavior issues". The interventions listed to address the problem included, "resident speaks only Cantonese. Resident will use communication board ...qd (daily), utilize family ... to meet resident needs qd." Record review of care plan for Activity dated 12/21/12 stated that "resident speaks & understands Cantonese language only. Needs .... help of Cantonese speaking staff. Resident will .... attend/participate in group activities, provide res. communication book, provide res. in room calendar, Cantonese speaking staff/family to explain, invite to attend group activities, involve in group activities with .....Chinese speaking residents , movies or TV with socialization, sit her with other Chinese residents, provide Chinese reading materials." During initial tour of facility on 4/8/13 at 7:20 AM with LVN 1, Resident 14 was observed in bed. The personal living area was decorated sparsely. Her bedside walls were bare of any pictures or calendars. Her bedside table lacked personal items, reading materials or a communication board. During observation and interview on 4/9/13 at 12:15 PM , CNA 1 said the Resident 14 could stand and go to bathroom by herself, needed some assist with the shower and dressing, could eat by herself and could ambulate with her walker. "I don't speak Cantonese so I use motion (hand signals) with her." During interview on 4/9/13 at 3:35 PM, LVN 1 stated, "I call her daughter from our phone, she calls her mother on the cell phone, and then calls back to facility to say what her mother wants. Sometimes the daughter tells her mother to give me the cell phone and we speak that way. Sometimes it takes a long time. Yes it could happen that I can't reach the daughter." During the same interview, LVN 1 stated that during the day there was a physical therapist who spoke Cantonese, that there was one CNA on PM shift who spoke Cantonese and one CNA on night shift who spoke Cantonese. She acknowledged "No they are not here every day, evening or night." LVN 1 also stated,"She points and says word 'tong' to me when she is in pain." When the surveyor asked how the staff assessed her pain level and response to medication, LVN 1 answered, "It's hard to do. I told Social Services we need a communication book." During interview on 4/9/13 at 3:46 PM, Physical Therapist (PT) 1 said that he had worked with Resident 14 last year when she required physical therapy services. He said, "When she has something she needs she comes to find me. If I can help her out I try but sometimes she speaks too fast and my Cantonese is not very good. Yes a communication board might help her. Friday is Chinese movies but I don't see her in there." He had not seen her that day. He worked Monday-Friday 8:00 AM - 5:00 PM. During interview on 4/10/13 at 9:45 AM, Activity Director (AD) stated she could not provide Chinese newspapers. "I have requested Chinese papers be delivered to facility but that has not happened. I am scared to take too many papers (from the newspaper racks)." She didn't know what happened to the communication book, other reading materials or calendar. When asked how they provide the interventions in the activity plan requiring groups, AD said they cannot as "sometimes she is tired and doesn't join in groups." During interview on 4/10/13 at 9:50 AM, Activity Aide (AA) explained that the individual resident activity log for March and April 2013 showed resident had in-room activities of radio/movie, reading and crossword. She could not state where in the room were the radio, reading materials or crossword puzzles. During an interview on 4/10/13 at 10:25 AM, when asked how they communicate with Resident 14, Social Services Assistant (SSA) stated "I call her daughters. One speaks more English but I can communicate with both. I will get her a communication book replacement. She had one before but sometimes they need replacing." During a telephone interview on 4/10/13 at 11:30 AM , with the daughter of Resident 14, she stated "mom used to be active and social. She walked and shopped in Chinatown, watched TV and listened to the radio. There's no TV here. She liked to talk to people. Here she has changed. She feels lonely because she can't talk to the staff. She would like to talk to other people who speak Chinese. I feel a little frustrated because mom complains to me that they don't understand her. Sometimes mom gets emotional and unhappy about that especially when she is in pain. I understand that not everyone can talk that language but I would like more." Record review of physician orders [REDACTED]." Record review of nurses notes dated 4/10/13 5 PM read "that during an interview of Resident 14 via an interpreter, the Admin had learned "resident had suicidal ideation. Resident expressed her desire of wanting to kill self by banging her head on the wall." Record review of MDS dated [DATE] indicated in Section D Mood/Behavior - I. (1) / (1) -thoughts that you would be better off dead, or of hurting yourself in some way / symptom frequency for several days. During interview on 4/11/13 at 10:00 AM, RNCM 1 confirmed that "problems with communication could be part of the problems this resident is having." During interview on 4/11/13 at 2:50 PM, Admin reviewed events of previous afternoon. While starting the quarterly MDS assessment with CNA 5 as interpreter, she began asking the mood questions. Resident 14 said "she's depressed and sleeping poorly because the ghost comes at night...Feels her medical condition is going down." She stated "she wants to kill herself. Her plan is to bang her head against the wall." When Admin had question asked again, Resident 14 repeated the same response, "I want to kill myself....bang my head against the wall." 2. Resident 19 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Preferred language: Cantonese. During a Medication Pass observation on 4/9/13 at 9:10 a.m., Resident 19 was in bed, eyes closed. Licensed Vocational Nurse (LVN 1) touched Resident 19, talked in English language to give the medications which Resident 19 took and LVN turned to go back to the med cart. One of the surveyors who spoke the same language as Resident 19 talked to Resident 19 who wanted more water to drink following the administration of the medications. When LVN 1 was asked how staff communicated with the resident, LVN 1 stated that the staff used a communication board. She opened the bedside drawer to look, but, did not find the communication board. LVN 1 stated the facility used staff as interpreters. During a review of the Care Plan dated 3/18/13 identified "Concerns & problems, Activity, >Res speaks & understand Chinese language only ..., Resident Goals, >Res will be able to make self understood..., Approach Plan, >Provide communication book to use ..." During an interview with the SSA on 4/12/13 at 11:45 a.m., SSA stated that the facility has communication board in Chinese language, which she placed the in Resident 19's room. SSA explained that when residents were admitted , she looked at the face sheet and checked the language preference, then, she placed the communication board in the room for the staff to use. SSA could not explain why the communication board could not be found in Resident 19's room. The facility Policy Statement for Use of Interpreters dated 12/10/11 read "...will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility." 3. During a review of Resident 18's clinical record showed was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. One of the approaches was to use a communication book to communicate with the resident... During an observation and interview with the resident on 4/10/13 at 11:28 AM, he sat in a wheelchair in his room. When interviewed the resident responded in hand gestures that he could not understand what was said. During an interview on 4/10/13 at 11:30 with RN 4, she said a communication book is provided. During an interview on 4/10/13 at 1:30 PM with the DON, she showed a piece of paper that was posted on the wall as one of the communication tools. The DON opened the bedside table of Resident 18. The DON found the communication book at the bottom of the drawer not accessible. During an interview with CNA 9 on 4/10/13 at 1:35 PM, while the DON was present, CNA 9 said she did not know that the communication book was available and where it was stored. 4. Resident 28 was admitted to the facility on [DATE]. During an interview with the Registered Nurse Case Manager 2 (RNCM 2) on 4/12/1 3 at 9:50 a.m., RNCM 2 acknowledged that Resident 28 preferred language was Spanish, but "understands a little English". RNCM 2 stated that staff used communication board and facility staff as interpreters. During a review of the Care Plan dated 12/27/12, re- eval date 3/13, Activity, >Res speaks Spanish Language only..., Approach Plan, >Provide communication book..., During an observation on 4/12/13 at 10:00 a.m., Resident 28 was in her room, awake and alert. Certified Nurse Assistant 4 (CNA 4), was in Resident 28's room and was requested to locate the communication board for Resident 28. CNA 4 looked around, opened the bedside drawer where she stated the staff usually placed it, but, did not find the communication board. At around 10;12 a.m., Laundry Services staff (LS 1) came to interpret for Resident 28. LS 1 looked around in the room, at the bedside table and searched the stacks of paper on the bedside table of Resident 28, but did not find the communication board. LS 1stated that Resident 28 said it was, "hard to communicate with the CNAs because they don't speaks Spanish". During an interview with the Licensed Vocational Nurse 1 (LVN 1) on 4/12/13 at 10:30 a.m., LVN 1 explained that staff were used as interpreters, but during the night shift when there may not be staff that spoke Spanish, the staff would need to use the communication board. During an interview with the SSA on 4/12/13 at 11:40 a.m., SSA stated that she put the communication board in the resident's room when Resident 28 was admitted . SSA stated that she did not routinely checked for the communication board in the resident's room but was thinking of starting a log or a binder.