Every finding on record at Napa Community Health Center

Based on observation, interview and record review, the nursing staff failed to provide care that met professional standards of nursing for two residents (Resident 3 and Resident 8) of 16 sampled residents when:1. Nurses did not assess, prevent, and identify the development of a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on Resident 3's left cheek; and,2. Nurses did not notify the physician when Resident 8 experienced significant and progressive weight loss.These failures resulted in Resident 3 obtaining a facility-acquired Stage 2 pressure injury (a partial-thickness loss of skin, presenting as a shallow open sore or wound) and Resident 8 unhappy and concerned about her weight loss. Cross Reference F684, F692.Findings:1. A review of Resident 3's admission record indicated she was admitted to the facility in February 2021 with the diagnosis of long-term use of anticoagulants (medication used to prevent blood clots from forming or getting larger), protein-calorie malnutrition (an inadequate intake of protein or calories), rosacea (a chronic inflammatory skin condition which causes redness and swollen bumps), congestive heart failure (a condition where the heart pumps ineffectively), cerebral infarction (stroke), atherosclerotic heart disease of the coronary artery (coronary artery disease, a narrowing of arteries which reduces blood flow and oxygen flow to the heart), chronic embolism and thrombosis of deep veins in the left leg (an old blood clot located in the deep veins of the lower leg), chronic kidney disease (damage to the kidneys which affects their ability to filter waste and excess fluid from the blood), and chronic obstructive pulmonary disease (a progressive lung condition that restricts airflow and causes breathing difficulties).A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/10/26, indicated she had mild memory impairment.A review of Resident 3's integrity skin assessment documented by a Licensed Nurse (LN) and dated 6/1/26 at 10:46 a.m. indicated Resident 3 had redness to her bilateral breast folds and was receiving ongoing treatment but did not have any new skin issues.A review of Resident 3's care plan regarding skin conditions, last revised on 1/26/26 and reviewed on 3/16/26, indicated she was at risk for impaired skin integrity due to her history of having pressure ulcers and diagnosis of rosacea. Resident 3's goal was for her skin to remain intact daily through 3/16/26. To assist Resident 3 to meet her goal, nursing staff were expected to conduct a Braden scale assessment (an evidence-based assessment tool used by healthcare professionals to predict a resident's risk of developing a pressure injury) every quarter and as needed, monitor her skin by conducting skin observations, keep her skin clean and dry, reduce friction and shear, and certified nursing assistants (CNA) were to immediately notify licensed nurses of any skin breakdown.In an observation of Resident 3 in Resident 3's room on 6/2/26 at 7:51 a.m., Resident 3 was sitting up in bed with a nasal cannula (a flexible plastic tube used to deliver oxygen from a machine directly into the nostrils) in place which lay just below her nostrils and across both of her cheeks to wrap behind both ears. A scabbed wound was seen on her left cheek just under where the nasal cannula tubing lay. There was no padding, dressings, or gauze seen on Resident 3's cheeks or ears to prevent pressure injury from the nasal cannula.A review of Resident 3's electronic medical chart 6/3/26 roughly between 8 a.m. and 9 a.m. indicated the following:A review of Resident 3's progress notes between 5/24/26 and 6/1/26 showed no documented evidence of Resident 3 having any pressure injuries.A review of Resident 3's medical chart between 5/24/26 and 6/1/26 showed no documented evidence of a change of condition notification to the physician regarding Resident 3 having a skin concern on her face.In an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 6/3/26 at 10 a.m., the ADON stated if a CNA identified a new skin issue, the CNA was expected to notify the licensed nurse. The licensed nurse is then expected to conduct an assessment, document the assessment, notify the physician and request treatment orders. The ADON further stated it was important for licensed nurses to conduct assessments and document them accurately as part of the monitoring process to determine the progression of the skin issue. If the skin issue worsens, the treatment plan would need to be re-evaluated and changed. Communication between the nurses is important when monitoring the concern. The ADON reviewed Resident 3's medical chart between 5/24/26 and 6/1/26:There were no skin issues identified by CNAs and verified by an LN on Resident 3's shower sheets dated 5/24/26 or 5/27/26;There were no new skin issues identified by LNs on Resident 3's skin assessment dated [DATE]; and,There were no new skin issues documented in the skin log at the nurse's station for Resident 3.The ADON confirmed Resident 3 had no documented skin issues on her shower sheets, the skin log, or her most recent skin assessment.In a concurrent observation and interview with the ADON on 6/3/26 at 10:14 a.m., the ADON assessed Resident 3's left cheek and determined it was a Stage 2 pressure injury. The DON stated the pressure injury was likely from the oxygen tubing which she often used. The DON further stated the skin on the cheek was really susceptible to breakdown and infection; if the tubing continuously provided pressure and moved, it could cause friction which can result in the injury getting larger or reopening. The DON added, This [the pressure injury] is not new. This has been here for a few days. No one charted this.In an interview with CNA 3 on 6/4/26 at 4:37 p.m., CNA 3 stated she had not noticed a skin issue on Resident 3's cheek.In an interview with Licensed Nurse 2 (LN 2) on 6/4/26 at 4:39 p.m., LN 2 stated she was unaware Resident 3 had a skin concern on her cheek.In an interview with the Assistant Administrator (AADM) on 6/5/26 at 9:33 a.m., the AADM stated the facility did not have a policy and procedure for skin tears or skin assessments. The AADM stated the closest document she had was a document titled Braden Scale- For Predicting Pressure Sore Risk.A review of an article titled Pressure Ulcers in the Long-Term Care Setting dated 2008 and published by the American Medical Directors Association indicated, Examine the patient's skin thoroughly to identify existing pressure ulcers.Inspect the patient's skin at least once weekly during routine care (e.g., during a bath). Direct caregivers should be aware of the signs and symptoms.of pressure ulcers as well as predisposing factors.A history of pressure ulcers is a primary risk factor for the development of new pressure ulcers. Patients with a history of pressure ulcers are more than five times as likely to develop another pressure ulcer.The patient's history of pressure ulcers can be obtained from.the plan of care.Conditions related to these risk factors should be evaluated.Risk factors that increase a patient's susceptibility to developing pressure ulcers.include.Comorbid conditions (e.g.end-stage renal disease.drugs that may affect ulcer healing [anticoagulants]. Impaired diffuse or localized blood flow [atherosclerotic heart disease of the coronary artery and chronic embolism and thrombosis of deep veins in the left leg].Increase friction.Undernutrition, malnutrition [protein-calorie malnutrition].regardless of an individual's score on a pressure ulcer assessment instrument, when a patient has any of the risk factors for a pressure ulcer.a pressure ulcer prevention plan should be implemented.Other risk factors that should be assessed include.congestive heart failure.complications (e.g., cellulitis.pain.presence of depression.A review of an article titled Preventing Pressure Injuries updated March 2022 and published by The Joint Commission (an independent, non-profit organization that accredits and certifies healthcare organizations in the United States) indicated, The presence of pressure injuries.may contribute to premature mortality in some patients.The majority of the following strategies are based on the NPIAP's [National Pressure Injury Advisory Panel] 'Pressure Injury Prevention Points'. The earlier a risk is identified, the more quickly it can be addressed.Refine the assessment by identifying other risk factors [such as the use of a nasal cannula].Protecting and monitoring the condition of the patient's skin is important for preventing pressure sores and identifying Stage 1 sores early so they can be treated before they worsen. Inspect the skin.at least daily for signs of pressure ulcers. Assess pressure points.and the skin beneath medical devices.Educate and train all members of the interdisciplinary team. Make sure they are aware of the plan of care and that all care is documented in the patient's record. Ensure leadership support, oversight, and allocation of adequate resources.2. A review of Resident 8's admission record indicated Resident 8 was admitted to the facility on [DATE] with Acute on Chronic Systolic and Diastolic Heart Failure (a long-term condition in which the heart is too weak to pump efficiently and too stiff to fill with blood) and chronic kidney disease. A review of Resident 8's care plan, dated 9/3/25, indicated Resident 8 was at risk for nutritional complications related to her nutritional deficiency. The care plan included a goal for Resident 8 to have no significant weight changes (10% weight loss over a six-month period). To meet this goal, the nursing staff were directed to administer ondansetron (a fast-acting medication used to prevent nausea and vomiting) before meals, weigh Resident 8 monthly, monitor meal intake in percentages, notify licensed staff when intake was below 50% and document food substitutes, and provide a calorie and protein dense nutritional supplement. A review of Resident 8's documented meal percentage intake, dated 5/6/26 to 6/4/26, indicated Resident 8 was served 87 meals. Of these meals, 21 meals reflected 50% or less consumed. Some meals were marked as refused or were not recorded because Resident 8 was unavailable.A review of Resident 8's monthly weights indicated the following:12/1/25: 123 lbs.;1/5/26: 120 lbs.;2/1/26: 116.4 lbs.;3/1/26: 112.4 lbs.;4/1/26: 109.2 lbs.; 5/2/26: 107.2 lbs.; and,6/1/26: 104.6 lbs.A review of the physician progress notes dated 12/30/25 through 3/11/26 revealed no documentation from Physician 1 (MD 1) addressing new concerns, orders or an assessment of Resident 8's ongoing weight loss. The physician entries only documented weight data without comment. No additional physician documentation was found until 6/3/26, when a new physician (MD 2) began providing care. However, the note documented by MD 2 did not address Resident 8's current weight or the amount of weight loss that had occurred.A review of Resident 8's nutritional risk assessment dated [DATE] indicated Resident 8 had no significant weight loss during the previous six months. The Registered Dietitian (RD) calculated Resident 8's estimated caloric needs to be 1,325-1,590 calories per day, which required the resident to consume at least 75% of each meal daily to meet these needs. During the assessment, the RD documented Resident 8 had consumed only 58% of meals. A goal was established to increase the resident's intake, acknowledging Resident 8's current consumption was insufficient to meet her caloric requirements. The RD also documented that Resident 8's family preferred she be served food she enjoyed and not be placed on a restrictive diet.A review of Resident 8's quarterly nutritional assessments indicated the following:1/6/26: Resident 8 consumed an average of 48% of meals over a 14 day period. Resident 8 had a 3 lb weight loss from December 2025, which was not considered significant at that time.5/29/26: Resident 8 consumed an average of 58% of meals over a 14 day period. Resident 8 had a 4 lb weight loss, representing a 10.67% weight loss over the previous six months.A review of the facility's weight meeting and progress note dated 4/16/26 indicated the RD documented Resident 8's weight had decreased to 109.2 lbs., representing a 9% weight loss over the previous 90 days. The RD also noted Resident 8 consumed an average of 69% of meals and reported improvement in nausea and stomach pain. The notes further documented that Resident 8 requested the discontinuation of the nutritional supplement, believing it contributed to her nausea and abdominal discomfort.During an interview in Resident 8's room on 6/2/26 at 8:54 a.m., Resident 8 stated the food was often too spicy and did not taste good to her. Resident 8 further stated the food gave her a stomachache.During an interview on 6/4/26 at 9:05 a.m., the CNA 2 stated Resident 8 would often pick at her meals and rarely finished them. CNA 2 stated she did not report unfinished meals to the licensed nurse because it is documented in the electronic medical record (EMR).During a phone interview on 6/4/26 at 9:10 a.m., the RD stated she worked as a consulting RD for the facility through an outside agency. The RD reported she had visited the facility twice per month to assess residents and provide recommendations. The RD stated her supervisor informed her she could no longer provide services to the facility due to non payment for her work over the past three to four months. The RD stated her last day at the facility was either 4/25/26 or 4/26/26.During an interview on 6/4/26 at 9:54 a.m., the Dietary Assistant/Manager (DM) acknowledged Resident 8 did not like spicy food and stated the kitchen had prepared a bland diet for her, but she still did not like it. The DM then described the process used by the facility to monitor residents at nutritional risk and explained the EMR system flagged residents when a significant weight loss was calculated. This flag was intended to trigger an RD assessment and recommendation, followed by a physician assessment and order. The DM further stated he had not yet received his certification in dietary management and still needed to complete the required examination to become fully certified. Therefore, the DM stated he did not possess the necessary credentials to assess Resident 8 or to make recommendations related to her significant weight loss.During an interview on 6/4/26 at 10:01 a.m., LN 1 stated Resident 8 has had stomach issues, mainly nausea for the past few months. LN 1 stated ondansetron and over the counter antacid (relieves acid indigestion and upset stomach) were ordered upon admission and administered when necessary. LN 1 stated she had noticed Resident 8 had appeared thinner recently. During an interview on 6/4/26 at 10:05 a.m., the ADON stated the DON, or the RD was responsible for notifying the physician when a resident experienced weight loss. The ADON explained weight changes were typically identified during the monthly weight variance meeting, where each resident was reviewed, recommendations were developed, and the physician was expected to be notified along with the RD's clinical recommendations. The ADON confirmed Resident 8 had experienced significant and progressive weight loss since January 2026. She also acknowledged MD 1 had not issued any orders or documented any mention of the resident's weight in the physician progress notes, other than the actual weight recorded. The ADON further stated the DON left the facility in mid May, MD 1 also departed during the same timeframe, and the RD had not provided services throughout the month of May. The ADON reported she was new to her role since the DON left and did not plan to remain in the position permanently. The ADON stated collectively, these circumstances resulted in no qualified clinical oversight, no physician notification, and no timely intervention for Resident 8's ongoing significant weight loss.During an interview on 6/5/26 at 7:48 a.m., the AADM stated due to the pending sale of the facility, staff that held critical positions within the facility had decided to leave. The AADM admitted the facility was behind on payments to the agency providing the facility with a consultant RD, though she would attempt to call and see if arrangements could be arranged. The AADM stated she had been relying on the DM for the RD duties, though he was not yet certified and would be unable to perform nutritional assessments.During an interview on 6/5/26 at 11:35 a.m., MD 2 stated he had just started working with the facility a few weeks prior. The MD 2 stated he did not receive any type of resident hand-off report from MD 1 before starting. MD 2 reported he had just assessed Resident 8 a few days ago and understood she had a poor appetite. MD 2 stated he was unaware of Resident 8's significant weight loss and would speak with the RD. When MD 2 was informed there was no RD to consult, MD 2 stated he would look into the weight loss and determine the best route to prevent further weight loss.During an interview on 6/5/26 at 12:54 p.m., the DM stated he normally reported to the RD but now he was required to report to the MDS Supervisor since the RD was no longer at the facility. The DM stated he completed the quarterly nutrition assessment for Resident 8 on 5/29/26. Though the normal process would have been for the RD to review the quarterly nutrition assessment, assess the resident and make recommendations with significant weight loss, the DM stated he was now relying on someone to contact someone so appropriate action could be taken. The DM acknowledged the important role an RD held in that the RD was able to take immediate action to intervene.During an interview on 6/5/26 at 1:24 p.m., Resident 8 stated about her weight loss Lord no, I'm not happy! I'm too bony! Resident 8 stated she was concerned about her weight loss and added What can I do about it? She stated her clothes were too baggy, but she did not feel up to go shopping for new clothes. A review of the facility's clinical protocol titled, Nutrition (Impaired)/Unplanned Weight Loss, revised September 2012, indicated, The staff will report to the physician significant weight.losses.The physician will review for medical causes of weight.loss before ordering interventions. Conditions such as heart failure and renal failure [kidney failure] .the physician, with the help of the multidisciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss.

Based on interview and record review, the facility failed to ensure one resident (Resident 8) of four sampled residents received necessary care and services to prevent continued weight loss when:Resident 8's weight loss went unaddressed;Nursing staff did not notify the physician of Resident 8's weight loss; and,There was no Registered Dietician to provide oversight.These failures decreased the facility's potential to maintain Resident 8's nutritional status (the state of health determined by balance of nutrient intake, absorption, and the body's physiological needs) which placed Resident 8 at risk for worsening malnutrition, further weight loss, and a decline in overall health. Cross Reference F658, F835Findings:A review of Resident 8's admission record indicated Resident 8 was admitted to the facility on [DATE] with Acute on Chronic Systolic and Diastolic Heart Failure (a long term condition in which the heart is too weak to pump efficiently and too stiff to fill with blood) and Chronic Kidney Failure (a condition in which the kidneys gradually lose the ability to filter waste and excess fluid from the blood). A review of Resident 8's care plan, dated 9/3/25, indicated Resident 8 was at risk for nutritional complications related to her nutritional deficiency. The care plan included a goal for Resident 8 to have no significant weight changes (10% weight loss over a six-month period). To meet this goal, the nursing staff were directed to administer ondansetron (a fast-acting medication used to prevent nausea and vomiting) before meals, weigh Resident 8 monthly, monitor meal intake in percentages, notify licensed staff when intake was below 50% and document food substitutes, and provide a calorie and protein dense nutritional supplement. A review of Resident 8's documented meal percentage intake, dated 5/6/26 to 6/4/26, indicated Resident 8 was served 87 meals. Of these meals, 21 meals reflected 50% or less consumed. Some meals were marked as refused or were not recorded because Resident 8 was unavailable.A review of Resident 8's monthly weights indicated the following:9/2/25 (Upon admission): 118.2 lbs.;10/1/25: 117.2 lbs.;11/2/25: 121.4 lbs.;12/1/25: 123 lbs.;1/5/26: 120 lbs.;2/1/26: 116.4 lbs.;3/1/26: 112.4 lbs.;4/1/26: 109.2 lbs.; 5/2/26: 107.2 lbs.; and,6/1/26: 104.6 lbs.A review of the physician progress notes dated 12/30/25 through 3/11/26 revealed no documentation from Physician 1 (MD 1) addressing new concerns, orders or an assessment of Resident 8's ongoing weight loss. The physician entries only documented weight data without comment. No additional physician documentation was found until 6/3/26, when a new physician (MD 2) began providing care. However, the note documented by MD 2 did not address Resident 8's current weight or the amount of weight loss that had occurred.A review of Resident 8's nutritional risk assessment dated [DATE] indicated Resident 8 had no significant weight loss during the previous six months. The Registered Dietitian (RD) calculated Resident 8's estimated caloric needs to be 1,325-1,590 calories per day, which required the resident to consume at least 75% of each meal daily to meet these needs. During the assessment, the RD documented Resident 8 had consumed only 58% of meals. A goal was established to increase the resident's intake, acknowledging Resident 8's current consumption was insufficient to meet her caloric requirements. The RD also documented that Resident 8's family preferred she be served food she enjoyed and not be placed on a restrictive diet.A review of Resident 8's quarterly nutritional assessments indicated the following:1/6/26: Resident 8 consumed an average of 48% of meals over a 14 day period. Resident 8 had a 3 lb weight loss from December 2025, which was not considered significant at that time.5/29/26: Resident 8 consumed an average of 58% of meals over a 14 day period. Resident 8 had a 4 lb weight loss, representing a 10.67% weight loss over the previous six months.A review of the facility's weight meeting and progress note dated 4/16/26 indicated the RD documented Resident 8's weight had decreased to 109.2 lbs., representing a 9% weight loss over the previous 90 days. The RD also noted Resident 8 consumed an average of 69% of meals and reported improvement in nausea and stomach pain. The notes further documented that Resident 8 requested the discontinuation of the nutritional supplement, believing it contributed to her nausea and abdominal discomfort.During an interview in Resident 8's room on 6/2/26 at 8:54 a.m., Resident 8 stated the food was often too spicy and did not taste good to her. Resident 8 further stated the food gave her a stomachache.During an interview on 6/4/26 at 9:05 a.m., the Certified Nursing Assistant 2 (CNA 2) stated Resident 8 would often pick at her meals and rarely finished them. CNA 2 stated she did not report unfinished meals to the licensed nurse because it is documented in the electronic medical record (EMR).During a phone interview on 6/4/26 at 9:10 a.m., the RD stated she worked as a consulting RD for the facility through an outside agency. The RD reported she had visited the facility twice per month to assess residents and provide recommendations. The RD stated her supervisor informed her she could no longer provide services to the facility due to non payment for her work over the past three to four months. The RD stated her last day at the facility was either 4/25/26 or 4/26/26.During an interview on 6/4/26 at 9:54 a.m., the Dietary Assistant/Manager (DM) acknowledged Resident 8 did not like spicy food and stated the kitchen had prepared a bland diet for her, but she still did not like it. The DM then described the process used by the facility to monitor residents at nutritional risk and explained the EMR system flagged residents when a significant weight loss was calculated. This flag was intended to trigger an RD assessment and recommendation, followed by a physician assessment and order. The DM further stated he had not yet received his certification in dietary management and still needed to complete the required examination to become fully certified. Therefore, the DM stated he did not possess the necessary credentials to assess Resident 8 or to make recommendations related to her significant weight loss.During an interview on 6/4/26 at 10:01 a.m., Licensed Nurse 1 (LN 1) stated Resident 8 has had stomach issues, mainly nausea for the past few months. LN 1 stated ondansetron and over the counter antacid (relieves acid indigestion and upset stomach) were ordered upon admission and administered when necessary. LN 1 stated she had noticed Resident 8 had appeared thinner recently. During an interview on 6/4/26 at 10:05 a.m., the Assistant Director of Nursing/Clinical Coordinator (ADON) stated the Director of Nursing (DON), or the RD was responsible for notifying the physician when a resident experienced weight loss. The ADON explained weight changes were typically identified during the monthly weight variance meeting, where each resident was reviewed, recommendations were developed, and the physician was expected to be notified along with the RD's clinical recommendations. The ADON confirmed Resident 8 had experienced significant and progressive weight loss since January 2026. She also acknowledged MD 1 had not issued any orders or documented any mention of the resident's weight in the physician progress notes, other than the actual weight recorded. The ADON further stated the DON left the facility in mid May, MD 1 also departed during the same timeframe, and the RD had not provided services throughout the month of May. The ADON reported she was new to her role since the DON left and did not plan to remain in the position permanently. The ADON stated collectively, these circumstances resulted in no qualified clinical oversight, no physician notification, and no timely intervention for Resident 8's ongoing significant weight loss.During an interview on 6/5/26 at 7:48 a.m., the Assistant Administrator (AADM) stated due to the pending sale of the facility, staff that held critical positions within the facility had decided to leave. The AADM admitted the facility was behind on payments to the agency providing the facility with a consultant RD, though she would attempt to call and see if arrangements could be arranged. The AADM stated she had been relying on the DM for the RD duties, though he was not yet certified and would be unable to perform nutritional assessments.During an interview on 6/5/26 at 11:35 a.m., MD 2 stated he had just started working with the facility a few weeks prior. The MD 2 stated he did not receive any type of resident hand-off report from MD 1 before starting. MD 2 reported he had just assessed Resident 8 a few days ago and understood she had a poor appetite. MD 2 stated he was unaware of Resident 8's significant weight loss and would speak with the RD. When MD 2 was informed there was no RD to consult, MD 2 stated he would look into the weight loss and determine the best route to prevent further weight loss.During an interview on 6/5/26 at 12:54 p.m., the DM stated he normally reported to the RD but now he was required to report to the Minimum Data Set (MDS) Supervisor since the RD was no longer at the facility. The DM stated he completed the quarterly nutrition assessment for Resident 8 on 5/29/26. Though the normal process would have been for the RD to review the quarterly nutrition assessment, assess the resident and make recommendations with significant weight loss, the DM stated he was now relying on someone to contact someone so appropriate action could be taken. The DM acknowledged the important role an RD held in that the RD was able to take immediate action to intervene.During an interview on 6/5/26 at 1:24 p.m., Resident 8 stated about her weight loss Lord no, I'm not happy! I'm too bony! Resident 8 stated she was concerned about her weight loss and added What can I do about it? She stated her clothes were too baggy, but she did not feel up to go shopping for new clothes. A review of the facility's clinical protocol titled, Nutrition (Impaired)/Unplanned Weight Loss, revised September 2012, indicated, The staff will report to the physician significant weight.losses.The physician will review for medical causes of weight.loss before ordering interventions. Conditions such as heart failure and renal failure [kidney failure] .the physician, with the help of the multidisciplinary team, will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss.

Based on observations, interviews, and document review, the facility failed to ensure resident rights were exercised when:1. A census of 24 residents and/or their Responsible Parties (RP) were not informed about their right to vote on June 2, 2026 for a primary election for state government elected officials; and,2. One resident (Resident 22) of three sampled residents did not have their final wishes followed when staff allowed family members to sign their Physician Order for Life Sustaining Treatment (POLST) forms when they did not have the legal authority to do so.These failures resulted in 24 residents not being informed of their right to vote by the facility, and Resident 22 being consented as Do Not Resuscitate (DNR) by people who were not authorized to make that decision. Cross Reference F942 Findings: 1. During the Resident Council meeting on 6/3/26 at 11 a.m., attended by Residents 1, 3, 6, 11, 12, 14, 16, 21, 26, and 27, the interim Activities Director (IAD), the Ombudsman, and this surveyor. All residents in attendance stated they had not voted yesterday. During an interview with the Social Services Designee (SSD) on 6/3/26 at 2:37 p.m., the SSD stated none of the residents came to ask for transportation to be able to vote. The SSD stated she was not following the election and stated she was unaware of the California Primary election on 6/2/26. During an interview with the IAD on 6/3/26 at 3:45 p.m., the IAD stated she did not know who was responsible for informing the residents that there was an upcoming election. The IAD acknowledged residents had not received information about the election yesterday from the Activities Department. The IAD stated residents were not asked if they wanted to vote yesterday. The IAD stated no vote-by-mail ballots were received by the facility for any of their residents. She stated she did not know if families of residents brought their vote-by-mail ballots and if other residents were able to vote. During an interview with the Assistant Administrator (AADM) on 6/3/26 4:13 p.m., the AADM stated past elections were posted on the activity calendar. The AADM acknowledged yesterday's California election was not on the activity calendar. The AADM stated she was not aware if the activity staff asked residents if they wanted to participate in yesterday's elections. A picture of the Activities Department calendar of activities dated June 2026 was taken on 6/4/26 at 7:33 a.m. and did not indicate the June 2, 2026, California primary election as an offered activity for residents to participate in on 6/2/26. During an interview on 6/3/26 at 3:55 p.m., Resident 8 stated the facility did not inform her about the election yesterday. During an interview on 6/3/26 at 3:56 p.m., Resident 7 stated she liked to vote and has done so in the past. Resident 7 stated she did not know that there was an election yesterday, that the facility did not talk to her about voting, and was not able to vote. During an interview on 6/3/26 at 3:58 p.m., Resident 27 stated she liked to vote and has done so in the past. Resident 27 stated knew about the election yesterday, the facility did not talk to her about voting and was not able to vote. During an interview on 6/3/26 at 3:59 p.m., Resident 13 stated she liked to vote and has done so in the past. Resident 13 stated she did not know about the election yesterday, the facility did not talk to her about voting and was not able to vote. During an interview on 6/3/26 at 4:01 p.m., Resident 21 stated she liked to vote and has done so in the past. Resident 21 stated she knew about the election yesterday, the facility did not talk to her about voting and was not able to vote. During an interview on 6/3/26 at 4:01 p.m., Resident 24 stated she liked to vote and has done so in the past. Resident 24 stated she did not know about the election yesterday, the facility did not talk to her about voting and was not able to vote. During an interview on 6/3/26 at 4:13 p.m., Resident 20 stated he liked to vote and has done so in the past. Resident 20 stated he was aware of the election yesterday; the facility did not talk to him about voting and was not able to vote. During an interview on 6/3/26 at 4:15 p.m., Resident 19 stated she liked to vote and has done so in the past. Resident 19 stated she did not know about the election yesterday, the facility did not talk to her about voting and was not able to vote. During an interview on 6/3/26 at 4:16 p.m., Resident 11 stated she liked to vote and has done so in the past. Resident 11 stated she did not know about the election yesterday, did not like to vote in the past, and that facility did not talk to her about voting. During an interview on 6/3/26 4:27 p.m., with Resident 5, she stated she knew about the election yesterday, the facility did not talk to her about voting and was not able to vote. In an observation on 6/4/26 at 7:52 a.m., there were no posted copies of resident rights throughout the facility as indicated on the facility's policy and procedure (P&P) on Resident Rights. During a concurrent observation and interview on 6/4/26 at 7:55 a.m., the AADM stated copies of the residents' rights may be at the back dining room. The back dining room was inspected with Certified Nursing Assistant 1 (CNA 1) who confirmed she did not see any copies of the residents' rights posted at the back dining room. During an interview on 6/4/26 at 7:58 a.m., the AADM stated she had not read the P&P requirements and stated copies of residents' rights were not posted throughout the facility but are located in a binder. A review of the facility's P&P titled, Resident Rights, dated 3/31/26, indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Copies of resident rights are posted throughout the facility, and a copy is provided to each employee upon hire.Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our resident's rights. Inquiries concerning resident's rights should be referred to the Social Services Director. 2. A review of Resident 22's admission record indicated she was admitted in September 2019 with diagnoses of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/6/26, indicated she had complete memory impairment. A review of Resident 22's POLST prepared on 3/24/19 indicated Resident 22's Financial RP (someone who is legally allowed to make financial decisions for someone who is no longer able to for themselves) signed the document, but the Financial RP's signature was not dated nor was the Financial RP's relationship to Resident 22 filled out. The POLST also indicated Resident 22's Financial RP had consent to sign the POLST from an Advanced Directive that had been signed and dated on 9/13/17. A review of Resident 22's document titled Uniform Statutory Form Power of Attorney, dated 9/13/17 indicated, This document does not authorize anyone to make medical and other healthcare decisions for you. During an interview with the SSD on 6/5/26 at 8:58 a.m., the SSD stated, This [POLST] is not correct. The signer did not have consent based on the POA. I must not have read it. A review of the facility's P&P titled, Informed Consent Policy and Procedure, revised 6/5/26, indicated, Purpose.Protect resident rights and autonomy.Ensure informed decision-making regarding medical care and treatment.The practitioner shall determine whether the resident possess decision-making capacity. If the resident lacks capacity.Consent shall be obtained from the legally authorized representative. Documentation supporting incapacity and surrogate authority shall be maintained in the medical record.Quality Assurance.The Director of Nursing or designee shall.Audit consent documentation quarterly.

Based on interview and record review, the facility's Administration failed to ensure the Dietary Manager (DM) had the required qualifications to manage the facility's kitchen in a skilled nursing facility in California.This failure decreased the facility's potential to ensure safe food handling and the prevention of food-borne illness in a highly susceptible population of 24 residents. Cross Reference F835Findings:In an interview on 6/4/26 at 9:45 a.m., DM stated he had been employed at the facility for six years and had been in the position of DM for approximately three months when the previous DM resigned. The DM stated he had a ServeSafe(R) Manager certificate (a nationally accredited certificate in food safety that is required by law in many states) but did not have a Certified Dietary Manager (CDM) certification. The DM stated he qualified for the Certified Dietary Manager examination, was in the process of registering, but he currently did not have a date to take the exam. The DM further stated he was not a nutritionist, stating, I have not done the 900 hours. In an interview on 6/5/26 at 9:33 a.m., the Assistant Administrator (AADM) stated, The CDM left because she didn't want to work for the new owner. I can't hire a new one because the new owner wants to make that decision. I have [the DM] stepping into the Dietary Manager position. He is qualified; he just hasn't taken the test. He cannot make assessments, though - that is the problem. In an interview with the previous Registered Dietitian (RD) on 6/4/26 at 9:10 a.m., the RD stated she was employed by a third-party company and contracted to work at the facility. The RD stated the previous CDM left the faciity on 4/17/26 and the RD's last day at the facility was 4/25/26. The RD stated she was instructed not to return to the facility until they paid their bill in full.A review of the facility's job description titled, Director of Food & Nutrition Services, dated 3/16/23, stipulated, Being a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program.

Based on observation, interview and record review, the facility's dietary staff failed to store food in a sanitary manner for a census of 24 when:Multiple boxes in the dry pantry were either misdated or not dated;Multiple food items in the food pantry were stored improperly, not dated, or expired;Multiple food items in the walk-in refrigerator were stored improperly, not dated, or expired;Multiple spices on the spice shelf were undated or expired;Food being prepared to be cooked was expired;The floor and blender were found dirty; and,The Dietary Manger (DM) did not adhere to the hair containment policy.These failures decreased the facility's potential to prevent the transmission of foodborne illnesses throughout the facility.Findings:1. In an initial observation of the dry pantry on 6/2/26 at 5:41 a.m., this surveyor observed no dates to indicate when the item was received and two cans of cranberry sauce which were labeled 11/15.In a concurrent observation and interview with the DM on 6/2/26 at 10:26 a.m., the DM stated, I inspect the food, unpackage them, and make sure there are no items expired. The DM confirmed not all boxes had delivery stickers with received dates on them, so he was unable to state when they were received and did not know when they needed to be discarded. The DM also acknowledged he did not know what year the two cans of cranberry sauce were received because it was not written on the cans.A review of the facility's document titled Dry Goods Storage Guide dated 2023, stipulated unopened canned foods had a shelf life of 12 months. 2. In an initial observation of the food pantry on 6/2/26 at 5:41 a.m., this surveyor observed:- several clear plastic bags of sliced bread and bread rolls without received and use-by dates on them; and,- a white cardboard box with a stain from liquid having spilled on its lid had plenty of red potatoes with sprouts growing out of them.In a concurrent observation and interview with the facility [NAME] on 6/2/26 at 7:09 a.m., the [NAME] stated the bread in the pantry should have been dated and added I know they came in Thursday. The [NAME] also stated the cook who works at night was supposed to write the dates on the bread and fresh produce when they were received. The [NAME] confirmed the cardboard box the potatoes were stored in should not have had a stain on top of it and acknowledged the potatoes were not good. The [NAME] added he was going to throw them away.In a concurrent observation and interview with the DM on 6/2/26 at 10:26 a.m., the DM stated, I was told the bread guy was going to label and rotate the bread for us.We should have been doing it too. The DM stated he was unaware that fresh produce had to be labeled and said he would start doing that right away.A review of the facility's policy and procedure (P&P) titled Food Storage revised 12/1/21 indicated, All open food items will have an open date and use-by-date per manufacturer's guidelines.A review of the facility's guide titled Refrigerated/Freezer Storage Guide, dated 2023 stipulated fresh fruits or vegetables received by the facility were good for 14 days.A review of the facility's guide titled Dry Goods Storage Guide dated 2023 indicated bread on the shelf (opened and unopened) was good for 5 days.3. In an initial observation of the walk-in refrigerator on 6/2/26 at 5:41 a.m., this surveyor observed:- one stainless-steel sheet pan with red gelatin and cut up strawberries inside of it sat on a shelf without a cover to protect it from bacteria, mold, or debris and labeled Regular.Prepared 6/1/26.Use By 6/2/26;- one stainless-steel sheet pan with red gelatin sat adjacent to the other sheet pan with gelatin and strawberry on the shelf without a cover to protect it from bacteria, mold, or debris and labeled SF [sugar Free] [Brand Name gelatin].Prepared 6/1/26.Use By 6/2/26;- several cardboard boxes and plastic bags that contained fresh vegetables (potatoes, carrots, white mushrooms, peas, tomatoes, strawberries, blueberries, and green leafy vegetables) did not have received dates on them;- A transparent, plastic container with cut garlic inside of it was labeled Garlic.Prepared 5/24/26.Use By 5/31/26 was on a shelf;- A transparent, plastic container with cut pineapple inside of it was labeled Pineapple.Prepared 5/31/26.Use By 6/10/26 was on a shelf;- A transparent, plastic container with cut cantaloupe inside of it was labeled Cantaloupe.Prepared 5/31/26.Use By 6/15/26 was on a shelf;- A transparent, plastic container with cut honeydew inside of it was labeled Honeydew.Prepared 5/31/26.Use By 6/10/26 was on a shelf; and,- A transparent, plastic container with a pinkish mixture inside of it was labeled Tuna Salad.Prepared 5/25/26.Use By 5/30/26 was on a shelf.In an interview with the DM on 6/2/26 at 10:26 a.m., the DM stated cut fruit should be good for 5 days. The DM also stated there is a higher risk for food borne illness each day an item goes beyond its expiration date. The DM acknowledged the gelatin had been sitting uncovered since 6/1/26 and should have been covered.A review of the facility's guide titled, Refrigerated/Freezer Storage Guide, dated 2023 stipulated fresh fruits or vegetables received by the facility were good for 14 days; when fresh vegetables or fruit are cut or prepared, they were good for 7 days; when house prepared foods (i.e. tuna salad) were made, they were good for 3 days in the refrigerator.4. In an initial observation of the spice shelf on 6/2/26 at 5:41 a.m., this surveyor observed the following:- a clear plastic container of whole tarragon leaves dated 3/10/25 [and] 9/10/25;- a clear plastic container of Italian seasoning without opened and discard dates;- a clear plastic container of ground cumin seeds without opened and discard dates;- a clear plastic container of rubbed sage without opened and discard dates;- a clear plastic container of ground cinnamon without opened and discard dates;- a clear plastic container of granulated garlic without opened and discard dates;- a clear plastic container of granulated onion without opened and discard dates;- a clear plastic container of ground black pepper without opened and discard dates; and,- a clear plastic container of whole basil leaves without opened and discard dates.In an interview with the DM on 6/2/26 at 10:26 a.m., the DM acknowledged the bottles of spices were not properly dated and should have been. The DM also acknowledged the bottle of tarragon was expired and should have been discarded.A review of the facility's guide titled Dry Goods Storage Guide dated 2023 indicated opened spices on the shelf were good for 12 months.5. In a concurrent observation and interview at the preparation (prep) table on 6/2/26 at 5:56 a.m. with the facility Cook, the [NAME] stated she planned to cook cut carrots that were inside a transparent plastic container labeled Carrots.Prepared Date 5/27/26.Use By 6/1/26 located on top of the prep table for that day's lunch. The [NAME] stated, They look good. The carrots looked dehydrated even though there was condensation on the inside of the plastic container to indicate they had been stored inside a refrigerator.In an interview with the DM on 6/2/26 at 12:28 p.m., the DM stated, Consuming expired foods is something that can lead to further complications. The residents here are of a weakened status so spoiled food can aggravate a resident and impede healing.6. In an initial observation of the kitchen on 6/2/26 at 5:41 a.m., this surveyor observed the main kitchen floor appeared dirty.In a concurrent observation and interview with DM on 6/3/26 at 12:37 p.m., the blender was found to have a gooey substance on top of it. The DM stated, That's this morning's apple sauce. It never got cleaned. In an interview with the Assistant Administrator (AADM) on 6/3/26 at 1:36 p.m., the AADM stated, The floor is clean, they mop it every day, it just looks bad because it's old.In an observation in the facility kitchen on 6/4/26 at 4:44 p.m., the kitchen floor looked brighter and cleaner after it had been power washed. A review of the facility's policy titled, Kitchen Equipment Cleaning Schedule Guide, dated 2023 stipulated, the blender was to be cleaned after each use by the person who used it. This policy did not list the frequency the kitchen floor was to be cleaned nor who was responsible for cleaning it.A review of the Food & Drug Administration [FDA] Food Code 2022 indicated Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils.Equipment, food contact surfaces, and utensils shall be clean to sight and touch.Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.A review of the FDA Food Code 2022 indicated, Cleaning, Frequency and Restrictions.PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.7. In an observation with the DM on 6/2/26 at 9:03 a.m., the DM wore a baseball cap, turned around, with exposed hair and no beard cover.In an observation on 6/3/26 at 4:25 p.m. the DM wore a baseball cap, turned around, with exposed hair and no beard cover. In an observation on 6/5/26 at 12:51 p.m. the DM wore a baseball cap, turned around, with exposed hair and no beard cover. In an interview on 6/5/26 at 12:54 p.m., the DM confirmed he wore a baseball hat in the kitchen and food prep areas. The DM stated he was told it was acceptable to wear a baseball hat. The DM also acknowledged hair was exposed on the sides of his head where the hat did not cover. The DM also verified he had not worn a beard cover to cover his beard and stated he should wear one.A review of the FDA Food Code indicated, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.

Based on observation, interview, and record review, the facility failed to ensure trash was stored in a sanitary manner for a census of 24 residents when trash dumpsters were observed left open.This failure decreased the facility's potential to prevent a nuisance or breeding ground for insects and rodents.Findings:In an observation on 6/2/26 at 5:41 a.m., Trash Dumpster 1 (TD 1) was observed open with no one in attendance, and TD 2 had a four-inch gap between the lids; furthermore, the lid was cracked and broken. In a concurrent observation and interview the Dietary Manager (DM) on 6/2/26 at 10:34 a.m., the DM stated, Someone forgot to close this, as he closed TD 1. The DM stated trash dumpsters were expected to be closed when not in active use. The DM also stated the lids should be intact. During multiple observations on 6/2/26 at 5:41 a.m., 10:34 a.m., and at 11:40 am; on 6/3/26 at 4:26 p.m.; on 6/4/26 at 12:17 p.m. and 4:45 p.m.; and on 6/5/26 at 7:22 a.m., 12:51 a.m., and 1:37 p.m., TD 1 was observed open and unattended.A review of the facility's policy titled, General Waste (Garbage) Disposal, dated 6/4/26 indicated, Waste shall be managed in a way that prevents transmission of communicable disease, minimizes odors, and eliminates conditions that may attract insects, rodents, or other vermin .outdoor waste containers shall .Have tight fitting covers .Be leakproof .Be maintained in good repair .Be rodent resistant .Outdoor dumpsters or movable bins shall .remain closed except during loading. Be maintained in sanitary condition .

Based on interview and record review, the facility failed to ensure the electronic submission of the Payroll Based Journal (PBJ, a system by which skilled nursing facilities submit staffing information to the Centers for Medicare and Medicaid) data as required quarterly for a census of 24 residents when the Certification and Survey Provider Enhanced Reporting system (CASPER, an assortment of real-time reports that allows SNFs the opportunity to pinpoint areas where changes in care and operations are necessary to improve performance) report indicated there was no information for the first quarter (Q1-1/26 through 3/26). This failure prevented regulatory agencies, residents, and residents' families from being able to verify that facilities had enough staff to provide necessary care to residents. Findings: During an interview on 6/4/26 at 1:30 p.m., the Social Services Designee (SSD) stated she was responsible for submitting the PBJ data. The SSD stated when she attempted to submit the first quarter data, she ran into internet related issues which prevented her from transmitting the data. The SSD stated when the connection was finally established, It was too late to submit the data. During an interview on 6/5/26 at 8:04 a.m., the Assistant Administrator (AADM) stated PBJ staffing information had to be reported quarterly. The AADM stated they tried to submit the data as required but encountered technical difficulties. The AADM stated she understood the necessity and importance of submitting the data. The AADM stated there is no facility policy regarding PBJ.

Based on observations, interviews, and record reviews, the laundry staff failed to prevent the development and transmission of communicable diseases and infections for a census of 24 residents when clean linens were not transported by methods that protected from dust, soil, moisture, and infectious organisms during transport within the facility.This failure decreased the facility's potential to prevent the transmission of infectious pathogens (tiny organisms that can make you sick if they get inside your body) residents in the facility.Findings:During a concurrent observation and interview on 6/5/26 at 9:04 a.m., with Housekeeping Staff 1 (HS 1), HS 1stated the person who usually did the laundry was on leave. HS 1 showed this surveyor a gray container labeled cube truck and stated the container was used to transport clean linen to the clean linen storage inside the facility. An observation of the container found it had a gaping hole on one side of it as it sat outside of the laundry room over pavement which had soil and small rocks within a foot of the container. The HS 1 acknowledged this container had clean linen inside it and had a white blanket on top of it to protect the clean linen from getting dirty. The HS 1 showed the surveyor a second clean linen container which also had a hole on one side but did not have clean linens inside it during the time of the observation. Pictures were taken during this observation.During a concurrent observation and interview with the ADON (Assistant Director of Nursing) on 6/5/26 at 9:33 a.m., the ADON observed the container with clean linens inside which had a hole on the side of it as it sat outside of the laundry room, exposed to the elements and possible pathogens on the ground. The ADON verified the hole on the side of the container exposed the residents' clean linens to pathogens that could contaminate the linens and could possibly affect the residents.A review of the facility's policy and procedure (P&P) titled, Infection Control and Laundry Services. dated 6/1/26, indicated, Purpose.To establish procedures for the safe handling, collection, transport, processing, storage, and distribution, of linen and clothing while maintaining infection prevention standards throughout the facility. Transport clean linens in covered carts. Protect clean linen from dust, moisture, and contamination.

Based on interviews, observation, and document review, the facility failed to maintain an effective pest control program when a cockroach was seen inside the facility's beauty shop. This failure decreased the facility's potential to prevent contamination of food supplies and respiratory distress among residents when cockroach droppings are inhaled.Findings: During a concurrent observation and interview with Licensed Nurse 1 (LN 1) inside the facility's beauty shop on 6/2/26 at 9:35 a.m., a live cockroach lying on its back was seen on the floor. LN 1 stated, I think it is a cockroach .Residents can get an infection if cockroaches are in the facility. During an interview with the Maintenance Worker (MW) on 6/2/26 at 9:50 a.m., the MW stated there were complaints of cockroaches in room [ROOM NUMBER] three weeks ago and room [ROOM NUMBER], one week ago. The MW stated traps were set and checked weekly. The MW stated the last time he checked the two traps he placed in room [ROOM NUMBER], there was a cockroach found in each trap. A review of the facility's policy and procedure (P&P) titled, Pest Control, dated May 2008, indicated, Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free from insects and rodents.

Based on interviews, observations, and document review, the facility failed to ensure staff members were educated on residents' rights for a census of 24 residents , when the Social Services Designee (SSD), the Interim Activities Director (IAD), and the Assistant Administrator (AADM) unaware they were responsible for providing residents the ability and option to vote during an election. This failure denied eligible and willing residents who wanted to exercise their right to vote as citizens of the United States. Cross reference F550, F942Findings:During the Resident Council meeting on 6/3/26 at 11 a.m., attended by Residents 1, 3, 6, 11, 12, 14, 16, 21, 26, and 27, the interim Activities Director (IAD), the Ombudsman, and this surveyor. All residents in attendance stated they had not voted yesterday. During an interview with the Social Services Designee (SSD) on 6/3/26 at 2:37 p.m., the SSD stated none of the residents came to ask for transportation to be able to vote. The SSD stated she was not following the election and stated she was unaware of the California Primary election on 6/2/26.During an interview with the IAD on 6/3/26 at 3:45 p.m., the IAD stated she did not know who was responsible for informing the residents that there was an upcoming election. The IAD acknowledged residents had not received information about the election yesterday from the Activities Department. The IAD stated residents were not asked if they wanted to vote yesterday. The IAD stated no vote-by-mail ballots were received by the facility for any of their residents.During an interview with the Assistant Administrator (AADM) on 6/3/26 4:13 p.m., the AADM stated past elections were posted on the activity calendar. The AADM acknowledged yesterday's California election was not on the activity calendar. The AADM stated she was not aware if the activity staff asked residents if they wanted to participate in yesterday's elections.A picture of the Activities Department calendar of activities dated June 2026 was taken on 6/4/26 at 7:33 a.m. and did not indicate the June 2, 2026, California primary election as an offered activity for residents to participate in on 6/2/26. In an observation on 6/4/26 at 7:52 a.m., there were no posted copies of resident rights throughout the facility as indicated on the facility's policy and procedure (P&P) on Resident Rights.During a concurrent observation and interview on 6/4/26 at 7:55 a.m., the AADM stated copies of the residents' rights may be at the back dining room. The back dining room was inspected with Certified Nursing Assistant 1 (CNA 1) who confirmed she did not see any copies of the residents' rights posted at the back dining room. During an interview on 6/4/26 at 7:58 a.m., the AADM stated she had not read the P&P requirements and stated copies of residents' rights were not posted throughout the facility but are located in a binder.A review of the facility's P&P titled, Resident Rights, dated 3/31/26, indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Copies of resident rights are posted throughout the facility, and a copy is provided to each employee upon hire.Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our resident's rights. Inquiries concerning resident's rights should be referred to the Social Services Director.

Based on observations and interviews, the facility did not maintain hot water temperatures within safe regulatory limits when water temperatures in multiple resident-use restrooms were measured above 120 degrees Fahrenheit (F, a unit measurement of heat) for 16 residents out of a facility census of 24. This failure decreased the facility's potential to provide a hazard-free environment and prevent thermal injury. Cross Reference F835Findings:During a concurrent interview and observation in Resident 8's room on 6/3/26 at 8:15 a.m., Resident 8 stated she was bothered by not having any cold water in her restroom. Upon entering Resident 8's restroom and turning on the cold-water tap, the surveyor observed the water was lukewarm. When the hot water tap was turned on, the water became too hot to safely hold hands under, even briefly. A calibrated thermometer was obtained, and the hot water temperature measured 128.5 degrees F.During observations on 6/3/26 between 8:15 a.m. and 8:45 a.m., hot water temperatures were measured in the facility's remaining 12 resident-use restrooms:room [ROOM NUMBER]: Surveyor Thermometer (ST) Temperature (Temp.) 124.9 F;room [ROOM NUMBER]/105 (shared restroom): ST Temp 128.5 F;room [ROOM NUMBER]/106 (shared restroom): ST Temp 122.4 F;room [ROOM NUMBER]/109 (shared restroom): ST Temp 124 F;room [ROOM NUMBER]/110 (shared restroom): ST Temp 120.1 F;room [ROOM NUMBER]/112 (shared restroom): ST Temp 129.3 F;room [ROOM NUMBER]/116 (shared restroom): ST Temp 129.3 F;room [ROOM NUMBER]/119 (shared restroom): ST temp 122.6 F;room [ROOM NUMBER]/120 (shared restroom): ST Temp 124 F;room [ROOM NUMBER]/123 (shared restroom): ST Temp 123.8 F;room [ROOM NUMBER]/124 (shared restroom): ST Temp 127.6 F; and,room [ROOM NUMBER]/126 (shared restroom): ST Temp 117 F. During a concurrent interview and observation on 5/3/26 at 10:07 a.m., the Maintenance Worker (MW) confirmed that lukewarm warm water ran from cold water tap in Resident 8's restroom. The MW measured the hot water in Resident 8's restroom and obtained a reading at 123.1 degrees F. The MW stated the hot water temperature should be between 115-120 degrees F and acknowledged temperatures above 120 degrees F had the potential to scald the residents. The surveyor accompanied the MW to the boiler room and verified the hot water tank thermostat was set at 120 degrees F. The MW stated he was unsure why the water temperature was running above 120 degrees F and stated, I'm not a plumber. The MW stated he would adjust the thermostat to lower the temperature on the hot water tank after speaking with his supervisor.During a concurrent interview, observation, and record review on 6/3/26 at 12:45 p.m., the surveyor and the MW measured the water temperatures in two resident-use restrooms.room [ROOM NUMBER]/119 ST Temp 130.3, Facility Maintenance Thermometer (FMT) Temp 136 F, and Facility Kitchen Thermometer (FKT) Temp 137.3 F; and,room [ROOM NUMBER]/120 ST Temp 125.2 F, FMT Temp 123.6 F, FKT Temp 128.1 F.The MW stated he checked water temperatures Monday through Friday and recorded them in a maintenance binder. A review of the facility's Room Water Temperature log, dated 5/1/26 through 6/2/26, excluding weekends and one holiday, indicated consistent documented temperatures of 115 degrees F with only one-to-two-degree variances for a period of five days. The same resident restroom in room [ROOM NUMBER] was used to measure temperatures on all days except for three. The MW stated he had not calibrated his thermometer since starting his position as an MW one and a half years ago. He further stated he did not know how or how often calibration was required.On 6/3/26 at 4:15 p.m., the AADM acknowledged the facility understood the necessity to keep residents from harm from temperatures above 120 degrees F. The AADM stated the facility's plan to remove the immediacy of the IJ included turning off the hot water to resident restrooms that continued to measure above 120 degrees F and using alternative methods for residents to wash their hands and faces. The AADM further stated the facility would purchase and install a new mixer valve for the hot water tank on 6/4/26.On 6/4/26, at 9:30 a.m., the AADM stated the mixer valve had been replaced on the hot water tank. During an interview and observations on 6/4/26 at 1:58 p.m., the MW and surveyor measured temperatures in six resident restrooms:room [ROOM NUMBER]/119 ST Temp 116.8 F, FMT Temp 115.3 F, FKT Temp 116.4 F;room [ROOM NUMBER]/120 ST Temp 121.2 F, FMT Temp 121.7 F, FKT Temp 122.2 F;room [ROOM NUMBER]/126 ST Temp 120.7 F, FMT Temp 121.2 F, FKT Temp 120.7 F;room [ROOM NUMBER]/112 ST Temp 121.5 F, FMT Temp 121.3 F, FKT Temp 121.6 F;room [ROOM NUMBER]/106 ST Temp 121.5 F, FMT Temp 120.8 F, FKT Temp 120.9 F; and,room [ROOM NUMBER] ST Temp 121.5 F, FMT Temp 121.5 F, FKT Temp 121.6 F.The MW stated he would adjust the valve one-quarter turn to reduce temperatures within a safe range. On 6/4/26 at 3:04 p.m., the MW and surveyor measured temperatures in six resident restrooms:room [ROOM NUMBER]/119 ST Temp 106.6 F, FMT Temp 106.3 F, FKT Temp 107.2 F;room [ROOM NUMBER]/120 ST Temp 96.8 F, FMT Temp 97.5 F, FKT Temp 97.7 F;room [ROOM NUMBER]/126 ST Temp 101.4F, FMT Temp 104.2 F, FKT Temp 102.2 F;room [ROOM NUMBER]/112 ST Temp 98.6 F, FMT Temp 102.6 F, FKT Temp 99.5 F;room [ROOM NUMBER]/106 ST Temp 104.4 F, FMT Temp 107.3 F, FKT Temp 107.3 F; and,room [ROOM NUMBER]/105 ST Temp 106.9 F, FMT Temp 103 F, FKT Temp 106.7 F.A review of facility's policy titled, Water Temperatures, Safety of, dated 2001, indicated, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents.Water heaters that service resident rooms, bathrooms, common areas, and tub, shower areas shall be set to temperatures of no more than 120 degrees F.Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log.

Based on interview and record review, the facility failed to obtain informed consent for one resident (Resident 3) of three sampled residents when Resident 3's Responsible Party (RP) did not have legal authorization to provide consent.This failure decreased the facility's potential to provide Resident 3 the ability to make her own medical decisions.Findings:A review of Resident 3's admission record indicated she was admitted in February, 2021 with the diagnosis of unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety. A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/10/26, indicated she had mild memory impairment.A review of Resident 3's informed consent for psychotropic medications, Trazadone, dated 3/19/25 by the physician, indicated it was signed by Resident 3's son on 3/24/25. A review of Resident 3's informed consent for psychotropic medications, Lexapro, dated 6/20/25 and Buspirone, dated 10/7/25, indicated they were signed by Resident 3. A review of Resident 3's order summary report, May, 2026, indicated an order for and daily administration of Trazadone, Buspirone and Lexapro.A review of Resident 3's Advanced Directive indicated it was signed on 3/19/2026. An interview on 6/05/2026 at 8:58 am with the Social Services Designee (SSD), the SSD stated, No, technically, the son does not have consent to make medical decisions for [Resident 3]. This consent is not correct. [ Resident 3] was the Responsible Party. It should have been signed by [Resident 3] A review of the facility's policy and procedure titled, Informed Consent . dated 6/5/26 indicated, Purpose .Protect resident rights and autonomy .Establish a consistent process for obtaining, documenting, and maintaining informed consent .Psychotherapeutic and Antipsychotic Medications .Prior to initiation or increase of a psychotherapeutic or antipsychotic medication .Written informed consent shall be obtained from the resident or representative. The consent form shall describe .The Director of Nursing or designee shall .Audit consent documentation quarterly .Provide education to staff regarding informed consent requirements annually .

Based on interview and record review, the facility failed to ensure Advance Directives (AD - a legal document indicating resident preference on end-of-life treatment decisions) and Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life) were formulated for five of 16 residents (Resident 3, Resident 22, Resident 5, Resident 7, and Resident 6).This failure increased the risk for the residents to receive unwanted, aggressive and invasive life-sustaining treatment during a sudden medical crisis and exclude the resident and resident's family from crucial decision making. Cross Reference F835 Findings: A review of Resident 3's admission record indicated she was admitted in February 2021 with the diagnosis of unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety. A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/10/26, indicated she had mild memory impairment. A review of Resident 3's POLST indicated there was no documentation of a discussion with the resident regarding AD. A review of Resident 22's admission record indicated she was admitted in September 2019 with diagnoses of Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and dementia. An MDS assessment, indicated she had complete memory impairment. A review of Resident 22's POLST indicated Resident 22's Financial RP signed the document, without dating or identifying her relationship to the resident. The POLST indicated Resident 22's Financial RP had consent from an Advanced Directive dated 9/13/17, identifying her as Power of Attorney (POA). A review of the POA dated 9/13/19 indicated, This document does not authorize anyone to make medical and other healthcare decisions for you. An interview and concurrent record review on 6/5/2026 at 8:58 am with the Social Services Designee (SSD), the SSD stated, When a resident is admitted , I ask them if the resident is the Responsible Party (RP) or if they have a designee. If they do [have an RP], I ask for a copy [of the legal documents designating the RP] and put it in the file. If they don't, I ask them to do the form I have here. It's in the admissions packet. The SSD reviewed Resident 3's POLST and stated, It doesn't look like we had the Advanced Directive conversation with [Resident 3]. The SSD reviewed Resident 22's POLST and stated, Based on this POA, Resident 22's Financial RP did not have the power to make medical decisions for [Resident 22]. This DNR is not valid. We are not in compliance at the moment. A review of Resident 5's admission record indicated she was admitted to the facility on [DATE] with a diagnosis of Polymyositis (a rare, chronic condition that causes swelling, heat, and pain to the skeletal muscles). A review of Resident 5's physician order for 1/20/25 indicated Resident 5 had a Full Code Status (a medical order for the medical team to attempt all medically appropriate measures to save life if the heart stops beating). No evidence of an AD or POLST was found in Resident 5's chart. A review of Resident 7's admission record indicated she was admitted to the facility on [DATE] with a diagnosis of Acute on Chronic Systolic Heart Failure (a pre-existing condition in which the weak heart is unable to pump blood with sudden worsening symptoms). A review of Resident 7's POLST indicated there was no documentation of a discussion with the Resident 7 regarding AD. During a concurrent interview and record review, on 6/4/26, at 11 a.m., the Medical Record Supervisor (MRS) confirmed there was no evidence of a POLST or AD in Resident 5's chart and no evidence of an AD in Resident 7's chart. A review of Resident 6's admission record indicated she was admitted to the facility on [DATE] with a diagnosis of chronic obstructive lung disease and diabetes. A review of Resident 6's physician order summary for 6/26 indicated Resident 6 had a Full Code Status (a medical order for the medical team to attempt all medically appropriate measures to save life if the heart stops beating). During an interview with the Assistant Director of Nursing (ADON) on 6/5/26 at 11:21 AM, the ADON stated if they do not have an AD, the facility will not know who the decision maker for the resident is, they could not provide the proper care for the resident, and the patient might die in their care. During a concurrent interview with Medical Records Supervisor (MRS) and review of Resident 6's chart on 6/5/26 at 11:30 AM, the MRS confirmed there is no POLST or AD in the chart and stated she already called Resident 6's daughter to request the documents. During a follow-up interview on 6/5/26 at 12:21 PM, the MRS stated she is unable to provide the AD and POLST of Resident 6. A review of the facility's policy titled, Provision of Written Information on Advanced Directives, revised 6/4/26, the policy stated, To ensure that all residents/responsible parties have been provided with written information regarding Advanced Directives, all newly admitted residents/responsible parties will be provided with this information upon admission. The Administrative Assistant will ensure that the form, entitled, 'Advanced Directives Policy and Information' is signed by the resident/responsible party at the time of admission.

Based on interview and record review, the medical and nursing staff failed to ensure one resident (Resident 5) out of four sampled residents received a gradual dose reduction (GDR) and behavioral interventions when Resident 5 was given a psychotropic (medication that alter brain chemistry to affect mood, thoughts, behavior and perception) drug.This failure decreased the facility's potential to ensure Resident 5 was not given unnecessary psychotropic medication without evaluating its effectiveness or necessity. Cross Reference F835Findings:A review of Resident 5's admission record indicated she was admitted to the facility on [DATE] with diagnoses of Polymyositiis (a rare, chronic condition that causes swelling, heat, and pain to the skeletal muscles) and major depressive disorder (a mood disorder characterized by feelings of sadness, emptiness and a loss of interest in activities).A review of Resident 5's care plan, revised on 11/20/25, indicated Resident 5 was receiving a psychotropic medication. The plan established a goal for Resident 5 to experience no complications from the medication. To achieve this goal, the nursing staff were directed to document Resident 5's moods, behaviors, and medication side effects every shift.A review of Resident 5's physician orders, dated 7/25/25, indicated Resident 5 was ordered Citalopram Hydrobromide [a psychotropic drug taken for depression] oral tablet 10 milligrams [mg-a unit of measure] give one tablet by mouth one time a day. A review of Resident 5's medication administration record (MAR) dated May 2026 indicated a GDR was completed on 5/14/26.A review of Resident 5's GDR form, dated 5/14/26, indicated, As per State and Federal Regulations, residents on psychotropic drugs need to be evaluated every six (6) months. Suggestions include taper down the dose or if there is a continued need, then document the rationale to continue therapy. Resident 5's name was written on the form along with the name and dose of the drug, Citalopram 10 mg po [by mouth] daily for depression. However, there was no physician's response documented, and the physician's signature did not indicate the date and time it was signed.During a phone interview on 6/5/26 at 9:35 a.m., the pharmacy consultant (PharmD) stated GDRs must occur at least every six months. The PharmD stated monthly pharmacy reviews are sent to nursing staff and the Administrator, but the PharmD expressed concern the nursing staff appeared to be going by [NAME] [completing a task through habit rather than understanding the purpose of the task]. The PharmD further explained the nursing staff send the forms to the physician without behavior monitoring or attempts at dose reduction. The PharmD stated he has not seen any evidence of psychotropics doses being lowered at the facility. During a concurrent interview and record review on 6/5/26 at 10:05 a.m., the Assistant Director of Nursing (ADON) stated GDRs were performed three times a year: monthly, quarterly and annually in addition to an as needed basis. The ADON stated the GDR form was filled out and faxed to the physician for completion and return. The ADON confirmed Resident 5's returned GDR form lacked the physician's indication to continue or taper the citalopram and was not dated. The ADON also confirmed there was no evidence of behavior monitoring. She identified that behavior monitoring for citalopram should include increased confusion, increased weakness, crying, agitation, and suicidal thoughts. The ADON was unaware of the occurrence of any monthly meeting in which GDRs were reviewed.A review of facility's policy titled Psychotropic Medication Use, revised July 2022, indicated, Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions) .in an effort to discontinue these medications.

Based on observation, interview and record review, the nursing staff failed to assess, prevent, and identify the occurrence of pressure injury for one resident (Resident 3) of three sampled residents, when Resident 3 obtained a facility-acquired pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on her left cheek.This failure had the potential for the facility acquired Stage 2 pressure injury (a partial-thickness loss of skin, presenting as a shallow open sore or wound) to worsen and placed Resident 3 at risk of complications including infection and pain. Cross Reference F658, F835Findings:A review of Resident 3's admission record indicated she was admitted to the facility in February 2021 with the diagnosis of long-term use of anticoagulants (medication used to prevent blood clots from forming or getting larger), protein-calorie malnutrition (an inadequate intake of protein or calories), rosacea (a chronic inflammatory skin condition which causes redness and swollen bumps), congestive heart failure (a condition where the heart pumps ineffectively), cerebral infarction (stroke), atherosclerotic heart disease of the coronary artery (coronary artery disease, a narrowing of arteries which reduces blood flow and oxygen flow to the heart), chronic embolism and thrombosis of deep veins in the left leg (an old blood clot located in the deep veins of the lower leg), chronic kidney disease (damage to the kidneys which affects their ability to filter waste and excess fluid from the blood), and chronic obstructive pulmonary disease (a progressive lung condition that restricts airflow and causes breathing difficulties).A Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/10/26, indicated she had mild memory impairment.A review of Resident 3's integrity skin assessment documented by a Licensed Nurse (LN) and dated 6/1/26 at 10:46 a.m. indicated Resident 3 had redness to her bilateral breast folds and was receiving ongoing treatment but did not have any new skin issues.A review of Resident 3's care plan regarding skin conditions, last revised on 1/26/26 and reviewed on 3/16/26, indicated she was at risk for impaired skin integrity due to her history of having pressure ulcers and diagnosis of rosacea. Resident 3's goal was for her skin to remain intact daily through 3/16/26. To assist Resident 3 to meet her goal, nursing staff were expected to conduct a Braden scale assessment (an evidence-based assessment tool used by healthcare professionals to predict a resident's risk of developing a pressure injury) every quarter and as needed, monitor her skin by conducting skin observations, keep her skin clean and dry, reduce friction and shear, and certified nursing assistants (CNA) were to immediately notify licensed nurses of any skin breakdown.In an observation of Resident 3 in Resident 3's room on 6/2/26 at 7:51 a.m., Resident 3 was sitting up in bed with a nasal cannula (a flexible plastic tube used to deliver oxygen from a machine directly into the nostrils) in place which lay just below her nostrils and across both of her cheeks to wrap behind both ears. A scabbed wound was seen on her left cheek just under where the nasal cannula tubing lay. There was no padding, dressings, or gauze seen on Resident 3's cheeks or ears to prevent pressure injury from the nasal cannula.A review of Resident 3's medical chart 6/3/26 roughly between 8 a.m. and 9 a.m. indicated the following:A review of Resident 3's progress notes between 5/24/26 and 6/1/26 showed no documented evidence of Resident 3 having any pressure injuries.A review of Resident 3's medical chart between 5/24/26 and 6/1/26 showed no documented evidence of a change of condition notification to the physician regarding Resident 3 having a skin concern on her face.In an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 6/3/26 at 10 a.m., the ADON stated if a CNA identified a new skin issue, the CNA was expected to notify the licensed nurse. The licensed nurse is then expected to conduct an assessment, document the assessment, notify the physician and request treatment orders. The ADON further stated it was important for licensed nurses to conduct assessments and document them accurately as part of the monitoring process to determine the progression of the skin issue. If the skin issue worsens, the treatment plan would need to be re-evaluated and changed. Communication between the nurses is important when monitoring the concern. The ADON reviewed Resident 3's medical chart between 5/24/26 and 6/1/26:There were no skin issues identified by CNAs and verified by an LN on Resident 3's shower sheets dated 5/24/26 or 5/27/26;There were no new skin issues identified by LNs on Resident 3's skin assessment dated [DATE]; and,There were no new skin issues documented in the skin log at the nurse's station for Resident 3.The ADON confirmed Resident 3 had no documented skin issues on her shower sheets, the skin log, or her most recent skin assessment.In a concurrent observation and interview with the ADON on 6/3/26 at 10:14 a.m., the ADON assessed Resident 3's left cheek and determined it was a Stage 2 pressure injury. The DON stated the pressure injury was likely from the oxygen tubing which she often used. The DON further stated the skin on the cheek was really susceptible to breakdown and infection; if the tubing continuously provided pressure and moved, it could cause friction which can result in the injury getting larger or reopening. The DON added, This [the pressure injury] is not new. This has been here for a few days. No one charted this.In an interview with CNA 3 on 6/4/26 at 4:37 p.m., CNA 3 stated she had not noticed a skin issue on Resident 3's cheek.In an interview with Licensed Nurse 2 (LN 2) on 6/4/26 at 4:39 p.m., LN 2 stated she was unaware Resident 3 had a skin concern on her cheek.In an interview with the Assistant Administrator (AADM) on 6/5/26 at 9:33 a.m., the AADM stated the facility did not have a policy and procedure for skin tears or skin assessments. The AADM stated the closest document she had was a document titled Braden Scale- For Predicting Pressure Sore Risk.A review of an article titled Pressure Ulcers in the Long-Term Care Setting dated 2008 and published by the American Medical Directors Association indicated, Examine the patient's skin thoroughly to identify existing pressure ulcers.Inspect the patient's skin at least once weekly during routine care (e.g., during a bath). Direct caregivers should be aware of the signs and symptoms.of pressure ulcers as well as predisposing factors.A history of pressure ulcers is a primary risk factor for the development of new pressure ulcers. Patients with a history of pressure ulcers are more than five times as likely to develop another pressure ulcer.The patient's history of pressure ulcers can be obtained from.the plan of care.Conditions related to these risk factors should be evaluated.Risk factors that increase a patient's susceptibility to developing pressure ulcers.include.Comorbid conditions (e.g.end-stage renal disease.drugs that may affect ulcer healing [anticoagulants]. Impaired diffuse or localized blood flow [atherosclerotic heart disease of the coronary artery and chronic embolism and thrombosis of deep veins in the left leg].Increase friction.Undernutrition, malnutrition [protein-calorie malnutrition].regardless of an individual's score on a pressure ulcer assessment instrument, when a patient has any of the risk factors for a pressure ulcer.a pressure ulcer prevention plan should be implemented.Other risk factors that should be assessed include.congestive heart failure.complications (e.g., cellulitis.pain.presence of depression.A review of an article titled Preventing Pressure Injuries updated March 2022 and published by The Joint Commission (an independent, non-profit organization that accredits and certifies healthcare organizations in the United States) indicated, The presence of pressure injuries.may contribute to premature mortality in some patients.The majority of the following strategies are based on the NPIAP's [National Pressure Injury Advisory Panel] 'Pressure Injury Prevention Points'. The earlier a risk is identified, the more quickly it can be addressed.Refine the assessment by identifying other risk factors [such as the use of a nasal cannula].Protecting and monitoring the condition of the patient's skin is important for preventing pressure sores and identifying Stage 1 sores early so they can be treated before they worsen. Inspect the skin.at least daily for signs of pressure ulcers. Assess pressure points.and the skin beneath medical devices.Educate and train all members of the interdisciplinary team. Make sure they are aware of the plan of care and that all care is documented in the patient's record. Ensure leadership support, oversight, and allocation of adequate resources.

Based on observation, interview, and record review, the facility failed to store food in a safe and sanitary manner in the resident refrigerator for a census of 24 when food was found unlabeled and undated. This failure decreased the facility's potential to prevent foodborne illnesses in a vulnerable resident population.Findings:In an observation of the resident refrigerator with the Dietary Manger (DM) on 6/3/26 at 4:07 p.m., a bowl with a half-eaten burrito in it and bottles of drinks and supplements were found unlabeled with a resident name to identify whose food it was and undated to identify when it was placed in the refrigerator and when it was expected to be discarded. The DM stated the items were likely a resident's who treated the resident refrigerator as her own personal refrigerator. The DM stated it was not good to have the items in the resident refrigerator unlabeled and undated.A review of the facility's policy titled, Food Brought in by an Outside Source Policy, dated 4/11/23, indicated, All food or beverages brought in from the outside will be labeled with the resident's name, room number and dated by staff with the current date the items are brought into the facility. Food or beverage items may be stored in the resident designated pantries, refrigerators or freezers. All cooked or prepared food brought in for a resident and stored in the resident designated pantries, refrigerators or freezes will be dated when accepted for storage and discarded after 72 hours/3 days.

Based on observation, interview and record review, the licensed nurses failed to ensure expired and discontinued prescription medication were properly stored and disposed of when:Discontinued medications were observed overflowing from a large, uncovered cardboard box in front of shelves of prescription medications and medical supplies; and,Easily accessible undestroyed medication pills were found in a pharmaceutical waste container.These failures reduced the licensed nurses' ability to safely administer medication and decreased the facility's potential to prevent prescription drug diversion (the illegal redirection of prescription or controlled medication from their intended medical use to unauthorized or illicit use). Cross Reference F835Findings:During a concurrent interview with the Assistant Director of Nursing (ADON) and observation of the medication room on [DATE] at 8:42 a.m., the following were noted:An uncovered, cardboard box measuring 15 inches high by 16 inches wide by 25 inches long was overflowing with bubble packs (a card with clear plastic compartments that hold doses of prescribed medication) of discontinued residents' prescription medication and placed in front of shelves of other prescription medications and medical supplies were stored; and,Six discontinued bubble packs of prescription medications were placed on a metal basket located on the opposite side of the room away from the uncovered box of discontinued medications and between a resident's tote bag which contained medication brought in by the resident and stacked white container baskets.A receptacle designed to safely segregate and dispose of pharmaceutical waste was overfilled which made the dry, whole, loose pills inside of it easily accessible to anyone who had access to the receptacle. Further observation of the inside of the receptacle showed no undesirable substance used to inactivate the whole, loose pills to make them unusable. The ADON stated discontinued prescribed medication were supposed to be stored in the box until they could be destroyed. The ADON stated she was unaware of how often the medications were supposed to be destroyed because the Director of Staff Development (DSD) used to help the Director of Nursing (DON) destroy the medication. The ADON stated the last time she was aware medications were destroyed was in [DATE] before the DON left. The ADON stated the current system of storing discontinued medication was dangerous because anyone with access to this room can take the medications and possibly give them to other patients.During an interview with the DSD on [DATE] at 10:37 a.m., the DSD confirmed she used to help the DON destroy prescription medications weekly before the DON left. The DSD showed this surveyor destruction documentation dated [DATE] which was the last day medication was destroyed prior to the DON leaving. The DSD stated after the DON left, medication destruction had not been done because she had not received guidance or direction to resume the task; however, the Administrator instructed her to resume the medication destruction last week The DSD stated she and the Infection Preventionist (IP) destroyed medication on [DATE]. The DSD added that all nurses had easy access to the discontinued medication in the medication room.A review of the facility's policy titled Discarding and Destroying Medications revised [DATE] indicated, For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA [Environmental Protection Agency] recommends destruction and disposal of the substance with other solid waste following the steps below.Take the medication out of the original containers.Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage.Staff shall contact the provider pharmacy if unsure of proper disposal methods for a medication.

Based on interviews and record reviews, the licensed nurses failed to develop a baseline care plan within 48 hours of admission and provide written copies of the baseline care plan summaries to two residents (Resident 14 and Resident 16) of three sampled residents.These failures decreased the facility's potential to effectively communicate resident needs among facility staff to promote a continuity of care and prevent adverse events from occurring right after admission.Findings:A review of Resident 14's admission record indicated admission to the facility on 5/14/26. This document also indicated Resident 14 was her own Responsible Party (RP, able to make decisions for herself).A review of Resident 14's Minimum Data Set (MDS, an assessment tool) dated 5/20/26 indicated Resident 14 had a Brief Interview for Mental Status (BIMS) score of 15 which meant she had no cognitive (mental processes like memory, learning, concentration, or decision-making) impairment. ).A review of Resident 14's baseline care plan provided to this surveyor by the Medical Records Director on 6/4/26, at 11:30 a.m., indicated it had not been signed by Resident 14 or any staff member.A review of Resident 16's admission record indicated admission to the facility on 5/22/26. This document also indicated Resident 15 was her own RP.A review of Resident 16's MDS dated [DATE] indicated a BIMS score of 14 which meant Resident 16 had no cognitive impairment.A review of Resident 16's baseline care plan provided to this surveyor by the Medical Records Director on 6/4/26, at 11:30 a.m., indicated it had not been signed by Resident 16 or any staff member.During an interview with Resident 14 on 6/4/26 at 4 p.m., Resident 14 stated she did not receive a copy of her baseline care plan summary, nor did she remember signing her baseline care plan summary. Resident 14 stated she did not know how the facility would provide care for her.During an interview with Resident 16 on 6/5/26 at 8:18 a.m., Resident 16 stated she was not provided a copy of her baseline care plan summary. Resident 16 stated she yelled at the staff all the time because she wanted to know what was going on.During an interview with the ADON (Assistant Director of Nursing) on 6/5/26 at 9:43 a.m., the ADON stated the baseline care plan should be developed within 48 hours of the resident's admission to the facility. The ADON stated if the baseline care plan was not signed by the staff who did the assessment, it would be incomplete. The ADON stated the facility should provide a copy of the baseline care plan to the residents. The ADON stated after the resident was provided with a summary of their baseline care plan, the resident should acknowledge that he/she received a copy of the summary by signing the baseline care plan summary.A review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated March 2022, indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.The resident and /or representative are provided a written summary of the baseline care plan. that includes, but is not limited to the following.The stated goals and objective of the resident.A summary of the resident's medications and dietary instructions.Any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and Any updated information based on the details of the comprehensive care plan as necessary.

Based on observation, interview and record review, the licensed nurses failed to ensure expired medication was properly stored when expired multivitamins and pain medication were not removed from one of two medication carts.This failure reduced the facility's ability to ensure administered medications are safe and effective.Findings:During a concurrent observation of the East medication cart and interview on [DATE] at 11:16 a.m. with Licensed Nurse 3 (LN 3), LN 3 confirmed the cart contained:One bottle of calcium 600 milligram (mg) with Vitamin D, expired on 6/26;One bottle of Daily Vite(R) multivitamin, expired on 5/26; and,Four acetaminophen 650 mg suppositories, expired on [DATE].LN 3 confirmed the medications were expired and removed them from the medication cart.During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 4:38 p.m., the ADON stated licensed nurses were expected to check the expiration dates of medication prior their administration. The ADON stated licensed nurses should remove the medication from the cart and place the medication where it belongs for disposal. The ADON further stated expired medication may cause harm to a resident, or the medication may be not effective since it is expired.A review of the policy titled Discarding and Destroying Medications revised [DATE] indicated, Medications that cannot be returned to the dispensing pharmacy .are disposed of in accordance with federal, state, and local regulations .non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications.

Based on interview and record review, the facility failed to follow FDA (U.S. Food and Drug Administration) Black Box Warnings (or BBW, the most stringent safety warning required by the FDA for prescription drugs) and manufacturer specification for dosing a fentanyl transdermal patch (a powerful synthetic opioid, 50 to 100 times more potent than morphine, that is absorbed through the skin for consistent pain relief) for one of three sampled patients, Resident 1 when:1. Resident 1's fentanyl patch initiation on 11/26/25 did not follow FDA Black Box Warnings and manufacturer specification on starting dose based on history of opioid use, old age, and Chronic Obstructive Pulmonary Disease (or COPD, a long-term lung inflammation and obstruction, making it hard to breathe without medication or supplemental oxygen).2. Resident 1's fentanyl dose increase, which doubled the dosage, on 1/30/26 also did not follow FDA and manufacturer dose escalation guidelines, soon after administration of Norco and anxiety medication called lorazepam (or Ativan, anti-anxiety drug) in span of 1.5 hours apart may have contributed to respiratory depression (unable to breath) and hospitalization.These failures resulted in Resident 1 becoming hypoxic (low oxygen levels in the blood) and being sent to the emergency department (ED) where she was diagnosed with an accidental opiate overdose (a potentially fatal medical emergency occurring when too many opioids (such as heroin, fentanyl, or prescription pain meds) suppress breathing). A review of the fentanyl patch drug information using DailyMed (U.S. government database providing up-to-date, FDA-approved manufacturer drug labeling information), last accessed on 4/6/26 via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2a2238e9-4b5d-c56d-8663-dd354ff9ae0c, the record under FDA Black Box Warning (BBW) indicated Fentanyl transdermal system should ONLY be used in patients who are already receiving opioid therapy, who have demonstrated opioid tolerance [a state where the body and brain adapt to regular opioid use, reducing the drug's effectiveness and requiring higher or more frequent doses to achieve the same pain relief], and who require a total daily dose at least equivalent to fentanyl trans dermal system 25 mcg/hr [microgram per hour, a rate at which the drug is released to the body]. Patients who are considered opioid-tolerant are those who have been taking, for a week or longer, at least 60 mg [milligrams] of morphine daily, . or an equianalgesic [the amount of one pain medication required to produce the same pain relief as another] dose of another opioid. (the Conversion factor from hydrocodone (an opioid) to morphine was 1:1 or 1.5:1 depending on the total dose 40mg hydrocodone per day). The FDA's fentanyl package inserts under Geriatric [the branch of medicine focusing on the treatment of elderly people] Use indicated Respiratory depression is the chief hazard in elderly or debilitated [in a very weakened state] patients, usually following large initial doses in non-tolerant patients or when opioids are given in conjunction with other agents that depress respiration. Fentanyl transdermal system should be used with caution in elderly . patients as they may have altered pharmacokinetics [how the body processes a drug, from the moment is taken until it is completely gone] due to poor fat stores, muscle wasting, or altered clearance [occurs when the body's ability to eliminate medication is compromised by disease (kidney/liver dysfunction), drug interactions, or physiological factors (age/genetics)]. The document under CONTRAINDICATIONS (significant harm to the patient or a warning signal that the potential risks of an intervention outweigh any expected benefits) indicated, Because serious or life-threatening hypoventilation [breathing is too slow or shallow to meet the body's needs] could occur, fentanyl transdermal system is contraindicated: in patients who are not opioid-tolerant . in the management of intermittent pain (e.g., use on an as needed basis [prn]), in situations of significant respiratory depression . and in patients who have acute [sudden] or severe bronchial asthma [airway constriction, swelling, and mucus production]. The document under Chronic Pulmonary Disease [long-term, often irreversible conditions that obstruct airflow and hinder breathing] indicated, Because potent opioids can cause serious or life-threatening hypoventilation, fentanyl transdermal system should be administered with caution to patients with pre-existing medical conditions predisposing them to hypoventilation. In such patients, normal analgesic doses of opioids may further decrease respiratory drive [the body's natural instinct to breathe in and out at a rate and depth that meets the body's needs] to the point of respiratory failure [the respiratory system cannot adequately supply oxygen to the blood or remove carbon dioxide]. 1. During a record review, Resident 1's face sheet, not dated, indicated an admission date of 2/5/21, age late 70s, and medical diagnoses including dementia (a decline in cognitive function severe enough to interfere with daily life), chronic pain, wedge compression fracture of T11 - T12 vertebra (occurs when the front part of the mid-back bones collapse, forming a wedge shape), bipolar disorder (a chronic mental health condition characterized by extreme mood swings that interfere with daily life), anxiety disorder, and COPD, among others. During a review of Resident 1's electronic medical record, titled Medication Administration Record or MAR, dated 11/2025, the record indicated Resident 1 was taking hydrocodone-acetaminophen (same as Norco; two pain medications in one: an opioid and a mild pain reliever/fever reducer) four times per day for pain as follows: HYDROcodone-Acetaminophen Oral Tablet 5-325 MG ( MG is milligram, a unit of dosage); Give 1 tablet by mouth every 6 hours for Pain Hold for sedation (drowsiness)-Order Date- 10/21/25 HYDROcodone-Acetaminophen Oral Tablet 5-325 MG ; Give 1 tablet by mouth at bedtime for pain Total of 2 tablet of 5/325 mg tablet only at 1800 [6 p.m.]-Order Date- 10/21/25The MAR record for the month of November 2026 indicated Resident 1 either refused or was too sedated to take scheduled Norco on seven occasions which was a total of five Norco tablets per day (equivalent of 25 mg of hydrocodone per day).During a review of Resident 1's electronic medical record, titled Medication Administration Record or MAR, dated 10/2025, the record indicated Resident 1 was taking Norco six times per day for 14 days from 10/1/25 to 10/14/25 during which the drug was not given or held 14 times. The MAR record further indicated when the Norco frequency of use changed to every six hours from 10/15/25 to 10/31/25, the drug was not given or held a total of seven times.Review of Resident 1's electronic medical record, titled Medication Administration Record, dated 11/2025, the record indicated Resident 1 was started on a fentanyl patch on 11/26/25 and Norco was changed to as needed basis (or PRN) as follows: Duragesic-25 Transdermal Patch 72 Hour 25 MCG/HR ( or fentanyl, a very potent pain drug that delivered drug through the skin; MCG/HR is microgram per hour, a rate at which drug released to body on hourly basis); Apply 1 patch transdermally (put on skin) one time a day every 3 day(s) for pain management related to OTHER CHRONIC PAIN . -Order Date- 11/26/25 HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (or Norco); Give 1 tablet by mouth every 6 hours as needed for pain -Order Date-11/28/25Review of Resident 1's medical record did not show any justification for switching from Norco to fentanyl patch and/or a risk assessment (a systematic process of identifying hazards, evaluating potential harm, and implementing control measures to manage risks) for an elderly resident with baseline COPD diagnosis and not meeting the FDA Black Box Warning and manufacturer dosing specification. Resident 1's hydrocodone use (Norco opioid) was 25 mg per day prior to fentanyl 25 mcg/hr patch start. The daily hydrocodone use was equivalent to 25-37.5 mg Morphine Equivalent (ME) per day (When a 1:1 to 1.5:1 ratio was used for conversion from hydrocodone to morphine).During a phone interview with facility's Consultant Pharmacist (Pharmacist C) and concurrent record review on 4/1/26 at 9:12 a.m., Pharmacist C verified she reviewed the medication regimen for Resident 1 last month. Pharmacist C verified Resident 1 was started on a fentanyl patch 25 mcg/hr on 11/26/25. Pharmacist C stated that according to the morphine equivalent (ME) calculator (a tool that converts various opioid pain medications into a standardized, equivalent daily dose of oral morphine. It identifies at-risk patients, aids in switching medications, and is essential for safety monitoring when assessing high-dose opioid therapy), based on Resident 1's daily use of hydrocodone, Resident 1 was taking 20 to 25 mg of morphine equivalent per day when the fentanyl patch was started on 11/27/25. Pharmacist C reviewed the Duragesic (brand name for fentanyl) patch dosing guidelines and verified the guidelines indicated that when starting the patch at 25 mcg/hr, the patient should have been taking at least 60 mg morphine equivalent per day for minimum of 7 days in a row. Pharmacist C verified Resident 1 was taking less than the minimum morphine equivalent per day when the patch was started according to the FDA Black Box Warning and manufacturer specification on use. 2. During a record review, Resident 1's face sheet indicated an admission date of 2/5/21, age late 70s, and medical diagnoses including dementia (a decline in cognitive function severe enough to interfere with daily life), chronic pain, wedge compression fracture of T11 - T12 vertebra (occurs when the front part of the mid-back bones collapse, forming a wedge shape), bipolar disorder (a chronic mental health condition characterized by extreme, often debilitating, mood swings), anxiety disorder, and cerebral infarction (a blockage of blood flow to the brain), among others. Review of Resident 1's November 2025 medication administration record (MAR) indicated a fentanyl patch 25 mcg/hr was ordered on 11/26/25 and administered on 11/27/25. Further review of Resident 1's November 2025 MAR indicated Resident 1 was administered hydrocodone-acetaminophen 5-325 mg 1 tablet every 6 hours, with an additional tablet at 6 p.m., for a total of five tablets a day, every day in November until 11/28/25. Review of Resident 1's January 2026 MAR indicated lorazepam (or Ativan, a benzodiazepine anxiety medication) 0.5 mg (milligrams) tablet was administered on 1/29/26 at 5:20 p.m., and one Norco tablet was administered on 1/29/26 at 4 p.m. The record further indicated the next day Resident 1's fentanyl patch dose was increased to 50 mcg/hr starting on 1/30/26 at 9 p.m. Further review of Resident 1's January MAR indicated Resident 1 had an order dated 11/28/25 for hydrocodone-acetaminophen 5-325 mg 1 tablet every 6 hours as needed for pain. Further review of Resident 1's January MAR indicated Resident 1 was administered hydrocodone-acetaminophen 5-325 mg one to three tablets per day, with nine days when no pain medication (Norco) tablets were administered. Review of Resident 1's pain score in January 2026 revealed scores varied between 0 and 9 (on a scale of 0 to 10 where 0 is no pain and 10 is worst pain imaginable).Review of Resident 1's MAR for January of 2026, the MAR indicated Resident 1's nurse removed the Fentanyl patch 25 mcg/hr from her skin on 1/26/26 at 9 a.m. The MAR record further indicated new fentanyl patch ordered was not available to replace the old patch on 1/26/26, 1/27/26,1/28/26, and 1/29/26.Review of Resident 1's nurse progress note dated 1/29/26 at 5:15 p.m. indicated Resident 1 was restless and unable to be consoled by the sitter. Further review of Resident 1's nurse progress note dated 1/29/26 at 5:15 p.m. indicated that the nurse obtained an order from the doctor for lorazepam 0.5 mg for anxiety.Review of Resident 1's nurse progress note dated 2/1/26 at 11 a.m. indicated, . Resident started screaming out 'Help Me'. [Licensed Nurse] went to assist resident with needs. Resident stated, 'I can't breathe, I can't talk, I can't swallow'. Further review of Resident 1's nurse progress note dated 2/1/26 at 11 a.m., indicated the nurse gave Resident 1 supplemental oxygen (oxygen delivered to the nostrils through plastic tubing), but Resident 1's oxygen level in her blood dropped to 77% (normal oxygen level is greater than 90%), her temperature was 100.1 degrees, and the nurse notified Medical Director who gave an order to send Resident 1 to the emergency department (ED).During an interview on 3/30/26 at 3:44 p.m., Medical Director stated that he followed the fentanyl patch dosing guidelines for Resident 1. Medical Director stated that if the guidelines were not followed Resident 1 could have uncontrolled pain if the dose was not enough, or somnolence (sleepiness) if the dose was too high. Medical Director stated that he ordered the dose increase for the fentanyl patch because Resident 1's pain was not controlled. When queried, Medical Director stated Resident 1's difficulty breathing on 2/1/26 could have been caused by any number of things, but he did not know what caused it.During a phone interview and concurrent record review on 4/1/26 at 9:12 a.m., Pharmacist C verified she reviewed the medication regimen for Resident 1 two weeks ago and she was able to review Resident 1's records on her computer. Pharmacist C verified Resident 1 was started on a fentanyl patch 25 mcg/hr on 11/27/25. Pharmacist C stated that according to the morphine equivalent calculator, based on Resident 1's daily use of hydrocodone, Resident 1 was taking 20 to 25 mg of morphine equivalent per day when the fentanyl patch was started. Pharmacist C verified Resident 1's fentanyl patch dose was increased to 50 mcg/hr on 1/30/26. Pharmacist C stated that according to the morphine equivalent calculator, based on Resident 1's daily use of hydrocodone, Resident 1 was taking 5 to 15 mg of supplementary morphine equivalent per day when the dose was increased. Pharmacist C reviewed the Duragesic (brand name for fentanyl) patch dosing guidelines and verified the guidelines indicated that when starting the patch at 25 mcg/hr, the patient should be taking at least 60 mg morphine equivalent per day, and at least 45 mg of supplementary morphine equivalent per day for a dose increase of 12.5 mcg/hr. Pharmacist C verified Resident 1 was taking less than the minimum morphine equivalent per day both when the patch was started and when the patch dose was increased according to the FDA and manufacturer guidelines. Pharmacist C verified Resident 1 was administered lorazepam 0.5 mg on 1/29/26 at 5:20 p.m. the day before the fentanyl patch was started. Pharmacist C stated respiratory depression was the potential outcome to Resident 1, when administering lorazepam and Norco the day before doubling the fentanyl patch dose on 1/30/26.Review of Resident 1's ED records, dated 2/1/26, indicated a triage note at 12:50 p.m., [Shortness of breath] reported by staff, [patient (pt)] had increased dose of fentanyl and still was administered [hydrocodone/acetaminophen], pt had slow, shallow respirations and pinpoint pupils [small, constricted pupils, a symptom of opiate overdose], had a positive response to [naloxone, medication that reverses opioid overdose] administered by [emergency medical services (EMS)]. Fentanyl patch removed by EMS, pt also possible [fever].Review of Resident 1's ED History and Physical, dated 2/1/26 at 12:58 p.m. indicated, Review of systems: Somnolence presumed due to opioid overdose, Shortness of breath. Review of Resident 1's ED physician's note dated 2/1/26 at 2:32 p.m., indicated Resident 1's arterial blood gas (measures the levels of oxygen, carbon dioxide, and the acid-base balance (pH) in blood taken from an artery) results indicated some hypoxia (low oxygen level), chest x-ray showed no aspiration (when something other than air gets into the airways), and this appears to be an iatrogenic event (adverse effect of treatment) that requires her pain management strategy to be re-evaluated. Review of Resident 1's ED diagnoses indicated accidental or unintentional opiate overdose and hypoxia.Review of facility policy, titled Pain - Clinical Protocol, last revised 10/2025, the policy under Treatment/Management section indicated 2a. Pain medications should be selected based on pertinent treatment guidelines. Generally, and to the extent possible, an analgesic [pain medication] regimen should utilize the simplest regimen and lowest risk medications before using more problematic or higher risk approaches. 4. If the physician determines that opioid medication is an appropriate option for managing acute (or in some cases chronic) pain in the resident, the lowest possible effective dose is prescribed for the shortest time possible with ongoing staff monitoring for effectiveness and adverse effects. 5. Combining opioids and benzodiazepines is avoided. If prescribed concomitantly, the resident will be carefully monitored for respiratory depression .A review of the fentanyl patch drug information using DailyMed (U.S. government database providing up-to-date, FDA-approved manufacturer drug labeling information), last accessed on 4/6/26 via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2a2238e9-4b5d-c56d-8663-dd354ff9ae0c, the record under Dose Titration [the process of adjusting a medication's dosage over time to find the lowest effective amount that provides maximum benefit with minimal side effects] indicated Appropriate dosage increments should be based on the daily dose of supplementary opioids, using the ratio of 45 mg/24 hours of oral morphine to a 12.5 mcg/hr increase in fentanyl transdermal system dose. The document under Important Dosage and Administration Instructions indicated Respiratory depression can occur at any time during opioid therapy, especially when initiating and following dosage increases with fentanyl transdermal system. Consider this risk when selecting an initial dose and when making dose adjustments.

Based on interview and record review, the facility failed to ensure that Resident 1, who had suffered a fall from bed on 3/17/20, was provided adequate supervision by direct care staff and had effective revisions and implementation of Resident 1's nursing care plan to prevent further falls to keep Resident 1 safe. As a result, Resident 1 suffered a fall from bed with major injury (broken hip) on 4/25/20, which required hospitalization and surgery for [REDACTED]. Findings: Resident 1, a [AGE] year-old female, was admitted to the facility on [DATE] with Medical [DIAGNOSES REDACTED]. Resident 1's MDS (Minimum Data Set-A clinical assessment), dated 8/5/20, indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition) score was 5, which indicated her cognition was severely impaired. Resident 1's MDS also indicated she required extensive assistance with bed mobility and total dependence on staff for toilet use. A nursing care plan for falls initiated on 10/08/19 included the following intervention, (Resident 1) has low bed with mat at side. A fall risk assessment dated [DATE] (day of facility admission), indicated Resident 1 was at high risk for falls. First Fall: An undated facility document titled, Facility-reported Event Follow-Up, indicated Resident 1 had an unwitnessed fall from bed on 3/17/20. The document indicated, It was reported at 1415 (2:15 p.m.), resident (Resident 1) was found on the floor next to her bed. Resident was screaming and crying for help and complaining of pain to her back .Intervention: d/c (Discontinue) air mattress, replace with regular foam mattress, fall mats at bedside and f/u (follow up) investigation. Resident 1's care plans for falls was updated after the fall on 3/17/20, but only one new intervention was added. The new intervention, initiated on 3/18/20 indicated, Place fall mat at bedside when (Resident 1) is in bed. This intervention had already been in place since 10/08/19 and had not been effective in reducing the incidence of falls. Replacing the air mattress with a regular foam mattress was not documented in the revised care plan. This was confirmed by the Director of Nursing (DON) during a phone interview on 9/15/20 at 2:30 p.m. The Nursing Care Plan did not mention increased supervision for Resident 1. The facility provided a delivery ticket dated 4/28/20 at 10:29 a.m., which indicated the facility received a foam mattress for Resident 1 on 4/28/20, 42 days after the fall on 3/17/20, and after Resident 1 had suffered a subsequent fall from bed that resulted in injury. During a phone interview with the DON on 9/15/20 at 2:30 p.m., she was asked how floor mats prevented incidents of bed falls. The DON confirmed floor mats did not reduce incidents of falls but could prevent injuries. A fall risk assessment dated [DATE] (performed 24 days after Resident 1's fall on 3/17/20) indicated Resident 1 was at high risk for falls. Second Fall: A facility's document titled, Resident Incident Report dated 4/25/20, indicated, Pt (patient (Resident 1)) heard yelling that she fell out of bed. Was found on floor mat c/o (complaint) L (left) Hip + (and) pelvic pain. According to this document, the incident occurred on 8/25/20 at 1:30 a.m. An undated facility document titled, Facility-reported Event Follow-Up, indicated, Resident (Resident 1) yelled out that she had fallen out of bed. CNA (Certified Nursing Assistant) found her on the floor on the left side fall mat next to her bed. Resident MD (Medical Doctor) and RP (Responsible party) notified. Resident sent to (Acute Care Facility) ER (emergency room ) per MD order for evaluation for possible [MEDICAL CONDITION]. Hospital report indicated resident sustained [REDACTED]. Resident 1's care plan for falls was revised after the fall on 4/25/20, but only one new intervention was added. The new intervention, initiated on 5/15/20 (20 days after Resident 1's fall) indicated, (Resident 1) has low bed with mat at side. This intervention had been in place since 10/20/19 and had not been effective in preventing falls for Resident 1. During a phone interview with the DON on 9/15/20 2:30 p.m., she was asked how low beds prevented incidents of bed falls. The DON stated low beds did not reduce incidents of falls. The DON was asked if supervision had been increased for Resident 1 after the falls. The DON stated she did not know if Resident 1 received increased supervision after the falls. During a phone interview on 9/14/20 at 8:45 a.m., Unlicensed Staff A (Nursing assistant who found Resident 1 on the floor on 4/25/20) stated she was not the assigned nursing assistant for Resident 1 the night of the fall, but heard Resident 1 yelling loudly and went to check on her. Unlicensed Staff A stated she found Resident 1 on the floor right next to her bed. Unlicensed Staff A stated Resident 1's bed was 3 to 4 feet high. During a phone interview on 9/14/20 at 1:49 p.m., Unlicensed Staff B (Resident 1's assigned nursing assistant the night of the fall) confirmed Resident 1's bed was a little high the night of her fall, and higher than previous shifts. When asked the reason for leaving the bed in that position, Unlicensed Staff B stated she did not think Resident 1 would fall that night, but confirmed Resident 1 could move slightly in bed and may have slid. Unlicensed Staff A stated being unaware Resident 1 had suffered a fall from bed on 3/17/20, or that Resident 1 was at high risk for falls. Unlicensed Staff B was asked if she remembered what time she checked Resident 1 prior to the fall on 4/25/20. Unlicensed Staff B stated she did not remember the last time she checked on her. Unlicensed Staff B was asked if she had access to the residents' nursing care plans. Unlicensed Staff B stated not knowing if she had access to residents' nursing care plans. During an interview on 9/15/20 at 2:30 p.m., the DON confirmed nursing assistants did not have access to nursing care plans, and indicated they could only see the interventions in the nursing care plans if those interventions were present in the Residents' Kardex (A medical-patient information system). The DON was asked if, based on her judgment, Resident 1's care plan for falls was appropriate, and had resident centered interventions to prevent further falls. The DON stated, No, it is not. Resident 1's Kardex, dated 10/7/19 and active on 4/25/20, the day of the second fall, did not indicate Resident 1's bed needed to be in low position; therefore, nursing assistants would not have access to that information, since they did not have access to Resident 1's Nursing Care Plans. The facility policy titled, Care Plans, Comprehensive Person-Centered, last revised in December of 2016 indicated, Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The facility policy titled, Falls-Clinical Protocol last revised in March of 2018, indicated, For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation.

Based on observation, dietary staff interview, and facility record review, the facility failed to ensure safe and sanitary food storage when mold was present at disease-causing levels in the walk-in cooler (refrigerator and freezer). The facility conducted two independent laboratory mold tests; both tests revealed the presence of mold and one test revealed Category 2-3 moisture damage in the walk-in cooler's wall, flooring and ceiling surfaces. Category 2 damage included contamination that could cause sickness or discomfort if consumed by humans. Category 3 damage was considered highly contaminated and could cause death or serious illness if consumed by humans. This failure to store food under sanitary conditions had the potential to cause residents receiving food from the kitchen to be exposed to contaminated food by Cladosporium (the disease-causing mold that was cultured from the walk-in cooler's wall, floor and ceiling surfaces). Food-borne illness may result in fever, gastrointestinal distress (nausea, vomiting and diarrhea) and weight loss, compromising residents' medical status. IMMEDIATE JEOPARDY (IJ) was identified on 4/22/15 at 5:20 p.m., under 483.35 Dietary Services for: F371 and 483.65 Infection Control: F441. Administrative Staff B, Administrative Staff C and Dietary Consultant G were present when the IJ was identified. The IMMEDIATE JEOPARDY was not abated at the time of the recertification exit conference on 4/30/1015 at 5:30 p.m. Administrative Staff A, Administrative Staff B, Administrative Staff C, Management Staff D, Management Staff E, and Management Staff F were present at the exit conference. The IMMEDIATE JEOPARDY was abated on 5/6/15 at 11:00 a.m., after the recertification exit conference. Findings: During an observation and concurrent interview on 4/22/15 at 10:10 a.m., the walk-in cooler had areas of dark discoloration on the left side of the ceiling. The freezer door, located inside the walk-in refrigerator, was constructed of wood and the wood door frame also had areas of black discoloration. One tray of uncovered baked potatoes was located in the refrigerator. The baked potatoes were cut in half and Management Staff F stated they were not covered because they needed to cool down. During an observation and concurrent interview on 4/22/15 at 10:20 a.m., Management Staff D stated the dark and black discolored areas looked like mold. Facility Staff H stated the freezer door defrosts every six hours which creates moisture. He said the wooden freezer door is wet most of the time. When queried if the wood door could be cleaned, Facility Staff H stated the wood was porous and hard to clean. During an interview 4/22/15 at 10:35 a.m., Dietary Consultant G stated the dark, discolored areas in the walk-in cooler had been present for a long time. During a later interview at 12:35 p.m., Dietary Consultant G stated Administrative Staff A had built the wooden freezer door himself. Dietary Consultant G stated she told staff to clean the black areas with bleach. When queried why she instructed dietary staff to use bleach, she responded that she thought it might be mold. During an observation and concurrent interview on 4/22/15 at 12:13 p.m., Consultant I took four samples from the walk-in cooler on which to run mold tests. He took three surface samples from the inside freezer door, the outside freezer door, and the ceiling. He took one air sample. When queried why he took a sample from the inside freezer door he stated, it looked suspect. He told Administrative Staff B and Dietary Consultant G that the refrigerator, was a concern and recommended they sample the ceiling as well. He said the lab results would be available in twenty four hours. During an interview on 4/22/15 at 1:05 p.m., Administrative Staff B was speaking with Consultant I in the Administrator's office. Administrative Staff B stated the mold testing could be rushed and the results obtained by 6:00 p.m. that evening. He stated the facility would not place a rush order on the test and would receive the results the following morning (4/23/15) because rushing the results would cost an additional $300. Dietary Consultant G's Monthly Reports were reviewed on 4/22/15 at 1:22 p.m. She documented on four monthly reports that vegetables were improperly covered or uncovered in the refrigerator. During an interview on 4/22/15 at 4:35 p.m., Administrative Staff B stated the facility had no policy and procedure for sanitizing porous material (like the freezer's wood door). During an interview on 4/22/15 at 4:40 p.m., Dietary Consultant G was queried how staff would sanitize porous material like the wood freezer door. She stated they would do so in the same way as non-porous surfaces; wash, clean, sanitize. When queried what type of sanitizer was utilized, Dietary Consultant G obtained the product. Review of the product label indicated it was only for use on non-porous surfaces, not wood surfaces. IMMEDIATE JEOPARDY (IJ) was identified on 4/22/15 at 5:20 p.m., under 483.35 Dietary Services for: F371 and 483.65 Infection Control: F441. Administrative Staff B and Administrative Staff C were present when Immediate Jeopardy was identified. Review of lab report from the mold sampling on 4/22/15 titled, Expanded Fungal Report (dated 4/23/15) indicated mold was present on the walk-in cooler's inside freezer door, the outside freezer door, and the ceiling. The report indicated that Cladosporium was present in, high levels on the ceiling. During an interview on 4/23/15 at 4:15 p.m., Consultant J (an industrial hygienist and environmental microbiologist) stated he performed a visual inspection of the walk-in cooler. He stated area had microscopic growth and the problem was visible. He stated bleach was not an effective cleaner. He stated he treats all mold the same since all microorganisms have the potential to be harmful to humans. He stated he would take samples and generate a report. The facility corrective actions to abate the Immediate Jeopardy included, 1. Nothing would go in or out of the refrigerator/freezer until area deemed safe. Safety of cooler/freezer would be based on Consultant J's preliminary and final reports, including instructions for any needed maintenance, 2) Facility would purchase an additional refrigerator and plug into the kitchen, 3) If the current unit was deemed unsafe, the facility would obtain a temporary refrigeration unit and receive approval from OSHPD (California Office of Statewide Health Planning and Development), 4) While waiting for this unit and approval, the Facility would clean/sanitize the existing employee refrigerator to store resident food. Only dietary staff would have access to employee refrigerator and temperatures would be monitored, 5) For breakfast on 4/23/15 and all subsequent meals, refrigerated foods would be purchased from a local grocery store before meal service and would be temporarily stored in the employee refrigerator. Food would be transported covered and on ice to the kitchen. Cooked, leftover food would be disposed. This process would continue until the kitchen walk-in cooler/freezer is deemed safe, 6) Facility consultant dietitian would modify menus for proper nutritional substitutions and menu substitutes must be approved by the Registered Dietician. An addendum to the Plan of Action (plans to abate the Immediate Jeopardy) was received on 4/27/15 at 9:00 a.m. regarding utility room refrigerator (employee refrigerator) and included, 1) Monitor temperature every hour and document on a log, 2) Increase, Staff Do Not Use This Fridge signs, 3) If refrigerator temperature is over 40° Fahrenheit, staff would move food into new refrigerator located in the kitchen. The action plan was not implemented prior to the Recertification Exit Conference on 4/30/15 at 5:30 p.m. Review of Consultant J's preliminary report (untitled, sent via email message) dated 4/24/15 at 9:00 a.m., indicated that based on the initial site assessment, yesterday, and the cursory airborne mold spore samples and surface mold growth sampling, mold growth was present on the surface of the walk-in cooler. Review of Consultant J's formal report (untitled, dated 4/26/15) on 4/27/15 at 9:00 a.m. revealed the limited visual observations indicated there was mold growth on kitchen's walk-in cooler walls, flooring and ceiling. The document further indicated the visible inspection and moisture mapping revealed Standard Category 2-3 moisture damage in the kitchen's walk-in cooler's wall, flooring and ceiling surfaces (Category 2 water damage could cause sickness or discomfort if consumed by humans; Category 3 water damage could included that which is highly contaminated and could cause death or serious illness if consumed by humans). The document further revealed Condition 3 mold damage (presence of actual mold growth and associated spores). The document indicated that based on the visual observations, moisture mapping and the IICRC S500 and S520 industry Standards, conduction of professional restoration was recommended. During an interview on 4/27/15 at 4:15 p.m., Physician K stated she had weekly meetings with Administrative Staff B but was not aware of any issues in the kitchen. During an interview on 4/28/15 at 10:10 a.m., Administrative Staff C stated she was not notified black discolored areas or mold were present in the kitchen. Review of facility policy and procedure titled, Food Service Management subtitled, Storage of Food and Non-food Supplies (dated 2014) indicated improper food storage is a potential cause of foodborne illness, refrigerators must be in good repair, and staff should check for situations of potential cross-contamination. The policy further indicated walk-in freezers and refrigerators are to be properly cleaned. The policy revealed all food items in the refrigerator are to be wrapped or contain a tight fitting lid. Review of facility policy and procedure titled, Infection Control subtitled, Preventing Food Borne Illnesses (dated 2014) indicated food will be protected from sources of possible contamination and food will be stored by methods that reduce risk of contamination. The document indicated the Consultant Dietitian promoted standards for safe and sanitary food handling and the Dietary Supervisor immediately intervenes to correct poor methods as they occur. The Immediate Jeopardy was not abated at the time of the Recertification Exit Conference on 4/30/15 at 5:30 p.m. Administrative Staff A, Administrative Staff B, Administrative Staff C, Management Staff D Management Staff E, Management Staff F, and Dietary Consultant G were present at the Exit Conference. The IMMEDIATE JEOPARDY was abated on 5/6/15 at 11:00 a.m., after the recertification exit conference. Administrative Staff C, Administrative Staff B, and Management Staff F were present when the IJ was abated. The facility provided adequate refrigeration as evidenced by a self-generated refrigeration truck that met OSHPD (Office of Statewide Healthplanning and Development) requirements.

Based on observation, interview, and facility record reviews, the facility failed to maintain an effective infection control program when mold was present at disease-causing levels in the walk-in cooler (refrigerator and freezer). The facility conducted two independent laboratory mold tests; both tests revealed the presence of mold and one test revealed Category 2-3 moisture damage in the walk-in cooler's wall, flooring and ceiling surfaces. Category 2 damage included contamination that could cause sickness or discomfort if consumed by humans. Category 3 damage was considered highly contaminated and could cause death or serious illness if consumed by humans. The facility failed to inform the infection control nurse or the medical director of the potential health hazard in the kitchen. This failure had the potential to lead to avoidable infectious diseases, which could slow rehabilitation, increase debility, or hasten a resident's decline. Residents were potentially exposed to food contaminated by Cladosporium (the disease-causing mold that was cultured from the walk-in cooler's wall, floor and ceiling surfaces). Food-borne illness may result in fever, gastrointestinal distress (nausea, vomiting and diarrhea) and weight loss, compromising residents' medical status. IMMEDIATE JEOPARDY (IJ) was identified on 4/22/15 at 5:20 p.m., under 483.35 Dietary Services for: F371 and 483.65 Infection Control: F441. Administrative Staff B, Administrative Staff C and Dietary Consultant G were present when the IJ was identified. The IMMEDIATE JEOPARDY was not abated at the time of the recertification exit conference on 4/30/1015 at 5:30 p.m. Administrative Staff A, Administrative Staff B, Administrative Staff C, Management Staff D, Management Staff E, and Management Staff F were present at the exit conference. The IMMEDIATE JEOPARDY was abated on 5/6/15 at 11:00 a.m., after the recertification exit conference. Findings: During an observation and concurrent interview on 4/22/15 at 10:10 a.m., the walk-in cooler had areas of dark discoloration on the left side of the ceiling. The freezer door, located inside the walk-in refrigerator, was constructed of wood and the wood door frame also had areas of black discoloration. One tray of uncovered baked potatoes was located in the refrigerator. The baked potatoes were cut in half and Management Staff F stated they were not covered because they needed to cool down. During an observation and concurrent interview on 4/22/15 at 10:20 a.m., Management Staff D stated the dark and black discolored areas looked like mold. Facility Staff H stated the freezer door defrosts every six hours which creates moisture. He said the wooden freezer door is wet most of the time. When queried if the wood door could be cleaned, Facility Staff H stated the wood was porous and hard to clean. During an interview 4/22/15 at 10:35 a.m., Dietary Consultant G stated the dark, discolored areas in the walk-in cooler had been present for a long time. During a later interview at 12:35 p.m., Dietary Consultant G stated Administrative Staff A had built the wooden freezer door himself. Dietary Consultant G stated she told staff to clean the black areas with bleach. When queried why she instructed dietary staff to use bleach, she responded that she thought it might be mold. During an observation and concurrent interview on 4/22/15 at 12:13 p.m., Consultant I took four samples from the walk-in cooler on which to run mold tests. He took three surface samples from the inside freezer door, the outside freezer door, and the ceiling. He took one air sample. When queried why he took a sample from the inside freezer door he stated, it looked suspect. He told Administrative Staff B and Dietary Consultant G that the refrigerator, was a concern and recommended they sample the ceiling as well. He said the lab results would be available in twenty four hours. During an interview on 4/22/15 at 1:05 p.m., Administrative Staff B was speaking with Consultant I in the Administrator's office. Administrative Staff B stated the mold testing could be rushed and the results obtained by 6:00 p.m. that evening. He stated the facility would not place a rush order on the test and would receive the results the following morning (4/23/15) because rushing the results would cost an additional $300. Dietary Consultant G's Monthly Reports were reviewed on 4/22/15 at 1:22 p.m. She documented on four monthly reports that vegetables were improperly covered or uncovered in the refrigerator. During an interview on 4/22/15 at 4:35 p.m., Administrative Staff B stated the facility had no policy and procedure for sanitizing porous material (like the freezer's wood door). During an interview on 4/22/15 at 4:40 p.m., Dietary Consultant G was queried how staff would sanitize porous material like the wood freezer door. She stated they would do so in the same way as non-porous surfaces; wash, clean, sanitize. When queried what type of sanitizer was utilized, Dietary Consultant G obtained the product. Review of the product label indicated it was only for use on non-porous surfaces, not wood surfaces. IMMEDIATE JEOPARDY (IJ) was identified on 4/22/15 at 5:20 p.m., under 483.35 Dietary Services for: F371 and 483.65 Infection Control: F441. Administrative Staff B and Administrative Staff C were present when Immediate Jeopardy was identified. Review of lab report from the mold sampling on 4/22/15 titled, Expanded Fungal Report (dated 4/23/15) indicated mold was present on the walk-in cooler's inside freezer door, the outside freezer door, and the ceiling. The report indicated that Cladosporium was present in, high levels on the ceiling. During an interview on 4/23/15 at 4:15 p.m., Consultant J (an industrial hygienist and environmental microbiologist) stated he performed a visual inspection of the walk-in cooler. He said area had microscopic growth and the problem was visible. He stated bleach was not an effective cleaner. He said he treats all mold the same since all microorganisms have the potential to be harmful to humans. He stated he would take samples and generate a report. The facility corrective actions to abate the Immediate Jeopardy included, 1. Nothing would go in or out of the refrigerator/freezer until area deemed safe. Safety of cooler/freezer would be based on Consultant J's preliminary and final reports, including instructions for any needed maintenance, 2) Facility would purchase an additional refrigerator and plug into the kitchen, 3) If the current unit was deemed unsafe, the facility would obtain a temporary refrigeration unit and receive approval from OSHPD (California Office of Statewide Health Planning and Development), 4) While waiting for this unit, the Facility would clean/sanitize the existing employee refrigerator to store resident food. Only dietary staff would have access to employee refrigerator and temperatures would be monitored, 5) For breakfast on 4/23/15 and all subsequent meals, refrigerated foods would be purchased from a local grocery store before meal service and would be temporarily stored in the employee refrigerator. Food would be transported covered and on ice to the kitchen. Cooked, leftover food would be disposed. This process would continue until the kitchen walk-in cooler/freezer is deemed safe, 6) Facility consultant dietitian would modify menus for proper nutritional substitutions and menu substitutes must be approved by the Registered Dietician. An addendum to the Plan of Action (plans to abate the Immediate Jeopardy) was received on 4/27/15 at 9:00 a.m. regarding utility room refrigerator (employee refrigerator) and included, 1) Monitor temperature every hour and document on a log, 2) Increase, Staff Do Not Use This Fridge signs, 3) If refrigerator temperature is over 40° Fahrenheit, staff would move food into new refrigerator located in the kitchen. The plan of action was not implemented prior to the Recertification Exit Conference on 4/30/15 at 5:30 p.m. Review of Consultant J's preliminary report (untitled, sent via email message) dated 4/24/15 at 9:00 a.m., indicated that based on the initial site assessment yesterday and the cursory airborne mold spore samples and surface mold growth sampling, mold growth was present on the surface of the walk-in cooler. Review of Consultant J's formal report (untitled, dated 4/26/15) on 4/27/15 at 9:00 a.m. revealed the limited visual observations indicated there was mold growth on kitchens walk-in cooler walls, flooring and ceiling. The document further indicated the visible inspection and moisture mapping revealed Standard Category 2-3 moisture damage in the kitchen's walk-in cooler's wall, flooring and ceiling surfaces (Category 2 water damage could cause sickness or discomfort if consumed by humans; Category 3 water damage could included that which is highly contaminated and could cause death or serious illness if consumed by humans). The document further revealed Condition 3 mold damage (presence of actual mold growth and associated spores). The document indicated that based on the visual observations, moisture mapping and the IICRC S500 and S520 industry Standards, conduction of professional restoration was recommended. During an interview on 4/27/15 at 4:15 p.m., Physician K stated she had weekly meetings with Administrative Staff B but was not aware of any issues in the kitchen. She stated she had been in her new role at the facility for two months. She stated infection control in the kitchen had not been addressed at the Quality Assessment Meetings she had attended. During an interview on 4/28/15 at 10:10 a.m., Administrative Staff C stated she was not notified black discolored areas or mold were present in the kitchen. During a later interview at 2:40 p.m., Administrative Staff C stated staff usually tell Management Staff D about infection control concerns. During an interview on 4/28/15 at 4:00 p.m., Management Staff D stated all staff need to report hazards. She further stated dietary staff should have notified nursing immediately of mold concerns in the kitchen so nursing could monitor and consult with the Medical Director as necessary. Review of facility employee handbook (revised April 2013) indicated all employees have the responsibility to report to their supervisor, or anyone in management, any hazard they detect. Review of facility policy and procedure titled, Infection Control subtitled, Preventing Food Borne Illnesses (dated 2014) indicated food will be protected from sources of possible contamination and food will be stored by methods that reduce risk of contamination. The document indicated the Consultant Dietitian promoted standards for safe and sanitary food handling and the Dietary Supervisor immediately intervenes to correct poor methods as they occur. Review of facility policy and procedure titled, Food Service Management subtitled, Storage of Food and Non-food Supplies (dated 2014) indicated improper food storage is a potential cause of foodborne illness, refrigerators must be in good repair, and staff should check for situations of potential cross-contamination. The policy further indicated walk-in freezers and refrigerators are to be properly cleaned. The policy revealed all food items in the refrigerator are to be wrapped or contain a tight fitting lid. The Immediate Jeopardy was not abated at the time of the Recertification Exit Conference on 4/30/15 at 5:30 p.m. Administrative Staff A, Administrative Staff B, Administrative Staff C, Management Staff D Management Staff E, Management Staff F, and Dietary Consultant G were present at the Exit Conference. The IMMEDIATE JEOPARDY was abated on 5/6/15 at 11:00 a.m., after the recertification exit conference. Administrative Staff C, Administrative Staff B, and Management Staff F were present when the IJ was abated. The facility provided adequate refrigeration as evidenced by a self-generated refrigeration truck that met OSHPD (Office of Statewide Healthplanning and Development) requirements.

Based on observation, interviews, and record review, the facility failed to notify the attending physician and obtain an order for [REDACTED]. Findings: Resident 2 was a [AGE] year old female admitted to the facility for rehabilitation. The MDS, dated [DATE], (minimum data set, an assessment tool) indicated Resident 2's cognitive skills ( person's ability to process thoughts, long term and short term memory) for daily living was severely impaired and Resident 2 needed assistance for activities of daily living. The Weekly Pressure Ulcer Record dated 3/15/15 indicated that Resident 2 had pressure ulcers on her left buttock and coccyx with an onset date of 3/15/15. During a wound treatment observation on 4/28/15 at 4:30 p.m., performed by a wound care specialist, Resident 2 moaned and grimaced in pain while the wound bed of the pressure ulcer on her left buttock was debrided (scraped). During an interview on 4/29/15 at 11:55 a.m., Management Staff C stated she would see if Resident 2 was being premedicated before wound care. Management Staff C stated Resident 2 did not complain of pain before. During an interview on 4/29/15 at 3:45 p.m., Licensed Staff M stated it was the first time she noticed Resident 2 moaned and grimaced in pain during wound treatment. Licensed Staff M stated there was no order for pain medication before wound treatment. Licensed Staff M stated she would notify the attending physician for pain medication to be given prior to wound treatment. Record review of the facility policy and procedure for pain management titled, Pain Assessment and Management (reviewed on 4/29/15) indicated . the purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and need and that address the underlying causes of pain. General guidelines for pain management program included assessing the potential for pain. Steps in the procedure further indicated. identifying the causes of pain and to recognize pain, possible behavioral signs of pain; a. verbal expressions such as groaning and b. facial expressions such as grimacing. review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including .b. Skin/Wound Conditions: (1) Pressure, venous or arterial ulcers (2) Surgical incision.

Based on observation, staff interview, record and policy review, the facility failed to protect residents from potential nosocomial (facility acquired) infections when a pattern of ineffective infection control practices and precautions were observed: 1) A glucometer was not cleaned after use; 2) Hand washing practices were not followed between residents; 3) An ice scoop, for distributing ice to facility residents, was in contact with ice and the hands of unlicensed staff who used the scoop, resulting in contaminated ice being distributed to facility residents. 4) The facility failed to ensure a shower chair used by residents was clean and sanitary; 5) [MEDICATION NAME] precautions were not followed for Resident 7 who had an infectious disease; 6) A food tray and dining card holder that was used for Resident 7, who was on isolation precautions, was placed in the shared food cart after use without being disinfected; 7) Sanitary practices were not followed when Resident 6 was instructed to wash his face with contaminated water and unlicensed staff did not change gloves. The failure to have an effective Infection Control Program had the potential for the development and transmission of diseases and epidemic infections in residents who possessed a range of functional disabilities and were weakened by other co-morbidities. On 4/9/13 at 4:50 p.m. the facility staff, Administrative Staff BB, Administrative Staff CC and Licensed Staff DD were informed that a situation of Immediate Jeopardy existed due to the failure of the Infection Control Program. The Immediate Jeopardy was abated on 4/10/13 at 4:10 p.m. Findings: 1) During a medication pass observation on 4/9/13 at 7:30 a.m., Licensed Staff D took a glucometer (a medical device used to check blood sugar) from the medication cart, went into non sampled Resident 13's room and placed the glucometer on the resident's bedside table before performing a finger stick to retrieve a drop of blood. After the procedure Licensed Staff D returned to the medication cart and placed the glucometer in a drawer without cleaning the device. During an interview on 4/9/13 at 10:05 a.m., Licensed Staff D, when asked about cleaning the glucometer, stated that she was not taught she had to wipe it clean after each use. A review of the facility policy, Cleaning and Disinfection of Resident Care Items and Equipment, April 2013, indicated medical equipment must be cleaned and disinfected before reuse. During an interview on 4/9/13 at 11:00 a.m., Administrative Staff C stated that she did not have a specific policy written up regarding the glucometer cleaning. Administrative Staff C acknowledged there were no products to sanitize the glucometer. The Center for Disease Control's recommended best practice for glucometer cleaning: If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. 2) During a medication pass observation on 4/9/13 at 10:00 a.m., Licensed Staff D took non sample Resident 14's blood pressure. Upon exiting the resident's room Licensed Staff D did not wash her hands and proceeded to the medication room. During an interview on 4/9/13 at 10:05 a.m. Licensed Staff D swhen asked, stated, she did not wash her hands when leaving the resident's room after taking Resident 14's blood pressure. During an observation on 4/8/13 at 12:10 p.m., Unlicensed Staff N was observed coughing into her hand, entering a resident room, and touching the handles of a resident's wheelchair to move the resident down the hall without washing her hands. During an observation on 4/9/13 at 9:35 a.m., Unlicensed Staff E distributed residents' fresh water without washing his hands. A container used to distribute ice to the residents for their water pitchers had the ice scoop and its handle resting on the ice. Unlicensed Staff E, with bare hands, filled a resident's pitcher with ice and went to the bathroom faucet to fill the pitcher with water. Unlicensed Staff E replaced the pitcher, then proceeded to grab the resident's roommate's water pitcher and repeated the same actions. Unlicensed Staff E was requested to assist another resident nearby and again, did not wash his hands between assisting residents. On 4/10/13 at 10:00 a.m., Administrative Staff K stated staff were supposed to wash their hands between patients. A review of the facility policy "Handwashing/Hand Hygiene," April 2013, indicated employees must wash their hands for at least fifteen seconds using antimicrobial gel or soap and water: before and after direct contact with a resident, before and after entering an isolation room, before and after assisting a resident with toileting, and before and after personal care such as bathing, after handling soiled linens, bedpans, catheters, and urinals or other soiled equipment or utensils, after blowing or wiping nose, among other situations. Before and after contact with a resident with an infectious disease, e.g. Clostridium difficile (characterized by frequent, profuse diarrhea and spread through contact with the organism's spores found in stool or on contaminated items and surfaces where spores are not destroyed by hand sanitizer) staff are required to wash their hand with soap and water. The policy indicated that the use of gloves did not replace hand washing/hand hygiene. 3) During an observation on 4/8/13 at 9:55 a.m., a covered container of ice was on a cart outside a resident room with a metal scoop lying horizontally on top of the ice, the handle in contact with the ice. On 4/8/13 at 4:25 p.m., Unlicensed Staff H was observed scooping crushed ice from a covered container into a resident's water pitcher and returning the scoop to the container of ice. Unlicensed Staff H was asked if the scoop was always in the ice and responded, "Yes." During an observation on 4/9/13 at 9:35 a.m. Unlicensed Staff E parked a three tier cart with a clear container of ice with lid (approximately 18 inches by 12 inches in diameter) outside of an unidentified resident's room. The ice scoop was inside the container on top of the ice. Unlicensed Staff E obtained the water pitcher from the resident's bedside stand in bed "A." Unlicensed Staff E returned to the cart and lifted the ice container's lid, placed the lid face down on the cart, grabbed the scoop that was in the container of ice, scooped ice into the resident's water pitcher, put the scoop back into the container of ice with the scoop's handle touching the ice, and replaced the lid onto the container. During an observation and interview on 4/8/13 at 4:25 p.m., Unlicensed Staff H gave ice to a resident and put the ice scoop on top of the ice in a container. There was no separate container for the ice scoop. When asked about the procedure, Unlicensed Staff H stated that the scoop is always put back on the ice. During an interview on 4/9/13 at 8:05 a.m., Unlicensed Staff E, when asked about the procedure on using the ice scoop, stated that the facility's normal set up was to put the scoop in the ice. Review of facility policy titled Ice Machine, dated 4/9/13, reflected: "To help prevent contamination of...ice storage chests/containers or ice...staff shall follow these precautions....(c) Ice scoop will be in a separate covered container when serving ice from room to room." 4) During an observation of resident shower room with Maintenance Staff O on 4/8/13 at 3:40 p.m., 1 of 4 shower chairs that had a light brown stain on the underside of the frame which supported the commode seat. Maintenance Staff O directed an unidentified unlicensed staff to wipe the area with a cloth to rule out a rust stain and subsequently acknowledged that it appeared to be fecal matter. A review of the facility policy "Cleaning and Disinfection of resident Care Items and Equipment" indicated reusable items and durable medical equipment would be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations. The policy indicated reusable equipment would be cleaned and disinfected before use by another resident. 5) During initial tour on 4/8/13 at 8:50 a.m., a sign posted adjacent to the door of Resident 7's room reflected [MEDICATION NAME] (related to the intestines) Precautions with instructions to wash hands upon entering and leaving the room, wear gloves when having direct contact with the resident or fecal contaminated articles, and wear a gown for direct contact with the resident. Record review on 4/8/13 at 4:00 p.m. indicated that Resident 7 had a positive test for Clostridium difficile, an infectious disease characterized by frequent, profuse diarrhea and spread through contact with the organism's spores found in stool or on contaminated items and surfaces. During observation on 4/8/13 at 3:45 p.m., unidentified unlicensed staff entered Resident 7's room wearing gloves, but no gown. Unlicensed staff picked up the call light cord from the floor and placed it on Resident 7's bed. Unlicensed staff exited the room, wearing the same gloves and without washing her hands. Unlicensed staff then went to a linen room, used the door knob to enter, retrieved a clean washcloth, and went to another part of the facility, wearing the same gloves and without washing her hands. During an observation on 4/9/13 at 7:20 a.m., Licensed Staff D administered medications to Resident 7 who was on [MEDICATION NAME] precautions. Licensed Staff D leaned over Resident 7 who was in bed, her clothing making contact with the resident's bed cover. Licensed Staff D did not have a disposable gown on during the medication pass. During an interview on 4/9/13 at 4:20 p.m., Unlicensed Staff P stated she did not always use a disposable gown when she went into Resident 7's room. Unlicensed Staff P stated there were gowns in the room in case she needed one. Unlicensed Staff P stated when providing care in changing the resident's adult diaper with a regular stool, she did not need to use a gown. Unlicensed Staff P stated if "it (was) really bad" she would use a gown. During an interview on 4/9/13 at 4:00 p.m., Unlicensed Staff H discussed hand washing procedures for Resident 7, who was on [MEDICATION NAME] precautions. Unlicensed Staff H stated that she did not need to wear gloves when she combed the resident's hair. The facility was informed on 4/9/13 at 4:50 p.m. that a situation of Immediate Jeopardy existed due to an ineffective Infection Control Program that included: 1) not cleaning a glucometer after patient use; 2) multiple observations of direct care staff not washing hands before and after resident care; 3) cross-contamination of an ice scoop and ice for residents; 4) a soiled shower chair; and 5) multiple observations staff were not following contact precautions for Resident 7 who was diagnosed with [REDACTED]. During an observation on 4/10/13 at 8:55 a.m., Unlicensed Staff E entered Resident 7's room wearing a gown and gloves. Unlicensed Staff E removed and discarded the gown, retrieved a dining tray from the resident's table, discarded the disposable items, exited the room without washing his hands, and placed the tray on a dining cart. Unlicensed Staff E entered an adjacent room without washing his hands. During an interview on 4/10/13 at 9:10 a.m., Unlicensed Staff E was asked whether he had washed his hands between exiting Resident 7's room and entering an adjacent room. Unlicensed Staff E stated he had used hand sanitizer. Unlicensed Staff E was asked if hand sanitizer was an acceptable alternative and responded, "Yes." Unlicensed Staff E was asked under what circumstances he used hand sanitizer versus washing with soap and water. Unlicensed Staff E stated, "Washing hands is preferable, but if I don't have time, I use hand sanitizer." Concurrent observation revealed that Resident 7 shared a bathroom with an adjacent room occupied by two other residents. The shared bathroom contained the only sink in the room at which staff caring for Resident 7 could wash their hands before exiting the room. This sink was unavailable for hand washing by staff caring for Resident 7 when occupied by other residents, periods observed to be as long as 15 minutes. Review of a facility document titled Isolation-Categories of Transmission-Based Precautions, dated 4/9/13 listed diarrhea associated with Clostridium difficile as an infection requiring Contact Precautions. Contact precaution instructions included wearing gloves (clean, non-sterile) when entering the room, removing gloves before leaving the room and performing hand hygiene, and wearing a disposable gown upon entering the room. Review of facility policy titled Clostridium Difficile, revised 4/10/13, revealed that "When caring for residents (with) [DIAGNOSES REDACTED]icile, staff will maintain vigilant hand washing with soap and water, rather than alcohol-based hand rubs, for the mechanical removal of [DIAGNOSES REDACTED]icile spores." 6) During observation on 4/10/13 at 8:55 a.m., Unlicensed Staff E entered Resident 7's room wearing a gown and gloves. Unlicensed Staff E removed and discarded the gown, retrieved a dining tray from the bedside table, discarded the disposable items, exited the room without washing his hands, and placed the tray on a dining cart for dirty trays in the hall. During an interview on 4/10/13 at 9:10 a.m., Unlicensed Staff E, was asked where he had put the tray removed from Resident 7's room, stated he had put it on the bottom of the dirty tray cart as "we usually do because we don't have disposable trays." Unlicensed Staff E stated the tray contained the dining card and card holder. During an observation in the kitchen on 4/10/13 at 10:10 a.m. the food tray from Resident 7's room was returned to the food cart container. During a concurrent interview, Dietary Consultant K acknowledged the tray, the dining card and card holder was placed in bottom of the food cart container and returned to the kitchen. During an interview on 4/10/13 at 10:40 a.m., Dietary Consultant K stated that for a resident on [MEDICATION NAME] precautions staff were not to put the food tray back into the food cart container. There was no facility procedure for handling food trays for residents on isolation precautions. On 4/10/13 at 9:26 a.m., the facility was informed of a infection control problem where staff did not have continuous access to a sink for washing hands with soap and water after providing care for a Resident 7 who was on contact precautions. The facility was informed of observations that staff were continuing to use hand sanitizer instead of soap and water for cleaning hands for Resident 7. A written plan of action was received that included staffing education on standard precautions and facility procedural changes for an effective infection control program demonstrated through observation, interview and document review. Multiple policy and procedures were revised, licensed staff were observed cleaning the glucometer before and after use, hand washing by staff between residents was observed, Resident 7 was moved to a private room where staff had continuous access to the bathroom sink for handwashing, [MEDICATION NAME] precautions were observed being practiced by staff which included gowning, gloving and washing hands with soap and water, the food tray and meal card holder for Resident 7 was disinfected before being returned the the kitchen, the ice scoop was placed in a separate container so as not to contaminate ice, shower chairs were cleaned after use. Based on the above mentioned actions the Immediate Jeopardy was abated on 4/10/13 at 4:10 p.m. and Administrative Staff BB, Administrative Staff C, and Administrative Staff K were informed. 7) During an observation on 4/12/13 at 10:00 a.m., Unlicensed Staff I, wearing gloves, was observed giving Resident 6 a bed bath, which involved handling multiple parts of Resident 6's body and handling the tubing and drainage bag of the urinary catheter (a device used to drain urine out of the body). Unlicensed Staff I, dried his gloves (and did not change his gloves) and continued to assist the resident, getting him dressed, which involved handling the urinary catheter tubing and the urinary drainage bag. Unlicensed Staff I, without changing gloves which were now contaminated, reached into the basin of soapy water for a washcloth and consequently contaminated the water and a washcloth. Unlicensed Staff I squeezed out the excess water and placed the cloth in resident's hand and instructed him to wash his face. A review of the facility's "Catheter Care Procedures," revised 12/15/13, after cleaning the catheter using soap and water, step 16 indicated to remove and discard the gloves, and step 25, was to wash hands.