Every finding on record at Ontario Healthcare Center

Based on observation, interview, and record review, the facility failed to identify and address early signs of pressure injury (localized damage to the skin and underlying soft tissue typically occurs over bony prominences like the tailbone, heels, and hips caused by prolonged or intense pressure) development for one (1) of three (3) sampled residents (Resident 1).This failure placed Resident 1 at risk for worsening skin breakdown, pain, infection, delayed treatment, and other complications related to pressure injury.Findings: A review of Resident 1's face sheet (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus type 1(a condition where the body can't make insulin anymore. Insulin is the hormone that helps move sugar from the blood into the body's cell of energy), difficulty in walking, and muscle weakness. A review of Resident 1's Braden Scale (evidence-based assessment tool used by healthcare professionals to evaluate a patient's risk of developing pressure injury) indicated a score of 11 (a total score of 12 or less represent HIGH RISK). A review of Resident 1's weekly skin/wound assessment dated [DATE], April 10, 2026, and April 17, 2026, indicated Resident 1 was identified with Moisture-Associated Skin Damage (MASD- skin irritation and breakdown caused by prolonged exposure to moisture, such as urine, stool, sweat, or wound drainage) on the sacral (inverted triangle-shaped bone located between your hip bones) and coccyx (tailbone) area. A review of Resident 1's clinical record indicated there was no weekly skin/wound assessment conducted on April 24, 2026. A review of Resident 1's weekly skin/wound assessment dated [DATE], indicated Resident 1's sacral/coccyx MASD has progressed to pressure injury Stage 3 (a deep, crater-like wound that goes completely through the top and middle layers of skin. The damage has reached the fatty layer beneath the skin) measuring 2.5 cm long x 3 cm wide x 0.3 cm deep. 80% granules (80% healthy red tissue) and 20% slough with moderate serosanguinous (20% medium amount of drainage from the wound that contained both clear fluid and small amount of blood). During a concurrent interview and record review on May 19, 2026, at 2:35 PM, with the Wound Care Nurse (WCN 1), the WCN 1 reviewed Resident 1's weekly wound assessments, stated there was no documentation showing the wound progressed from Stage 1 (the earliest clinical sign of tissue damage where the skin is not open or broken, but looks red or discolored, may feel warm and tern, and does not briefly turn white when you press on it) or Stage 2 (a shallow, open sore or a fluid filled blister) before it was identified as Stage 3. WCN 1 acknowledged she did not complete a wound assessment between April 17, 2026, and April 30, 2026, and stated this was unacceptable because the required assessment and progress note were not completed. WCN 1 further stated that if the pressure ulcer had been identified earlier, interventions could have been started to prevent the wound from progressing to Stage 3. During an interview on May 19, 2026, at 3:47 PM, with the Administrator (Admin), Admin acknowledged the early changes in Resident 1's skin condition were not identified which resulted in the resident's MASD progressing to pressure injury Stage 3. During concurrent telephone interview and record review on May 21, 2026, at 9:32 AM, with the Admin, the Admin reviewed and acknowledged the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, dated 2001, which indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 55 out of 55 residents when a live roach was observed in kitchen food preparation area.This failure had the potential to contaminate food, food preparing surfaces, and equipment which will place residents at risk for food borne illness and infections.During a concurrent observation and interview on February 17, 2026, at 12:28 PM, with Dietary Supervisor (DS- a person who oversees food services in the facility), in the kitchen, a live roach was observed crawling on the wall above the kitchen sink. The DS caught the roach with a piece of aluminum foil. The DS stated she was not sure how the roach came inside the kitchen. DS further stated, it is not acceptable to have roaches inside the kitchen as it is a concern for contamination and infection.During an interview on February 18, 2026, at 3:30 PM, with the Dietician, the Dietician stated, it is important to have a pest control program inside the kitchen as there is a high risk of food contamination that could affect the health of residents.During a concurrent interview and record review on February 19, 2026, at 2:55 PM, with the Infection Preventionist (IP- an individual who is responsible for preventing infection in the facility), the facility's policy and procedure (P&P) titled, Infection Control, dated April 2025, and Pest Control, dated May 2008, were reviewed. The Infection Control P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The IP stated, as there was a live roach in kitchen there is a high chance of contaminating and infecting the food. The Pest Control P&P indicated, The facility shall maintain an effective pest control program, the IP stated, policy was not followed as there was roach in the kitchen.During a concurrent interview and record review on February 20,2026, at 2:35 PM, with Director of Nursing (DON), the facility's P&P titled, Sanitation, dated November 2022, was reviewed. The P&P indicated, Policy statement. The food service area is maintained in a clean and sanitary manner. Policy interpretation and implementation . 1. All kitchen, kitchen areas and dining area are kept clean, free from garbage and debris and protected from rodents and insects. The DON stated roaches inside the kitchen are unacceptable and she said the facility should be free of pest. The DON further stated roaches inside the kitchen pose a high risk of food contamination of food and can cause infection for residents.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a screening assessment to ensure individuals who are identified to have a significant mental illness [SMI] or intellectual/developmental [I/DD] disability are appropriately placed in nursing homes for long term care) was completed accurately for one of two sampled residents (Resident 8) when PASRR screening assessment for Resident 8 did not include her diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities) and psychotic disorder not due to a substance or known physiological condition (severe mental illness). This failure had the potential to result in Resident 8's condition not being identified prior to admission and their needs for treatment and services not being accurately assessed, placing them at risk of inadequate care. During a review of Resident 8s admission Record (contains medical and demographic information), the admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included depression, anxiety disorder, and other psychotic disorder not due to a substance or known physiological condition.During a review of Resident 8's Preadmission Screening and Resident Review (PASRR) Level I screening (a level 1 screening includes assessment of the resident's medical diagnoses to determine if the resident has or is suspected of having a PASRR condition [i.e. SMI, or I/DD]), dated December 16, 2025, it indicated in section III for Serious Mental Illness . 9. Diagnosed Serious Mental Illness. Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of psychosis, delusions, and/or mood disturbance? The answer was marked NO. Further review of the PASRR indicated, Result of Level I Screening: Level I- Negative, resolution status LII (Level II -triggered when the initial Level 1 screening identifies a potential need for specialized care, meaning the individual being assessed is suspected of having SMI or I/DD) - not required.During an interview on February 19, 2026, at 2:24 PM, with Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 8's PASRR dated December 16, 2025, did not reflect Resident 8's diagnoses. The MDSC further stated the facility should have accurately screened the resident and corrected the PASRR to include the diagnoses on readmission to the facility.During a concurrent interview and record review on February 20, 2026, at 3:03 PM, with the Administrator, the facility's policy and procedure (P&P) titled, admission Criteria, revised March 2019, was reviewed. The P&P indicated, . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process.b. if the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred o the state PASARR representative for the Level II (evaluation and determination) screening process. The DON acknowledged that based on Resident 8's admission records, the PASRR was not accurate, and that the P&P was not being followed.

Based on observation, interview, and record review the facility failed to ensure staff followed safe infection control practices for 2 of 24 sampled residents (Residents 5 and 6) when:1. A Certified Nursing Assistant (CNA) did not use appropriate personal protective equipment (PPE- equipment used to minimize injuries and illness) while providing hygiene care to Resident 5, who was on Enhanced Barrier Precautions (EBP- health care staff wear gowns and gloves during high contact care (providing hygiene, dressing, bathing, wound care, changing linens and device care) to prevent the spread of resistant germs).2. A Certified Hospice Health Aid (CHHA) did not use appropriate PPE while changing linens for Resident 6 who was on EBP precautions.These failures had the potential to increase the risk of transmission of multidrug-resistant organisms (MDROs- germ or bacteria that are had to kill with common antibiotic) to the resident, other residents, and staff due to improper use of infection control precautions and potentially prolong resident's recovery caused my complications.1. During a Review of Resident 5's Face sheet (FS-Document containing resident demographics), the Face sheet indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), peripheral vascular disease (PVD- blood flow to the arms and legs is reduced because the vessels are narrow or blocked), and peripheral neuropathy (nerve damage in the hand or feet that can feel like burning, tingling, numbness).During a review of Resident 5's Orders dated April 10, 2024, the Orders indicated, May have Enhanced Barrier Precaution. Every shift for D/T [DUE TO] Diabetic Ulcer [ an open wound/sore the develops on the foot of someone with diabetes].During an observation on February 18, 2026, at 10:46 AM, in room [ROOM NUMBER], CNA 2 was brushing Resident 5's hair without a gown or gloves.During an interview on February 18, 2026, at 10:58 AM, CNA 2 stated, the residents with a blue dot next to their name are on EBP. CNA 2 further stated Resident 5 is on EBP and she should have worn a gown and gloves to protect the residents from the spread of infections.A review of Resident 5's care plan (a detailed guide outlining an individual's medical, personal and social needs, as well as the support required to meet them), dated August 21, 2025, indicated, use gown and gloves during high contract resident care activities (dressing, bathing, transfers, hygiene, toileting, brief changes, changing linens, device care, wound care).2. During a Review of Resident 6's Face sheet, it indicated Resident 6 was admitted to the facility on [DATE], with diagnoses that included of diabetes, hemiplegia (paralysis on one side of the body), gastrostomy (a surgically created opening into the stomach for feeding and medication), and is on hospice care (care is based on comfort for someone who is near the end of life).A review of Resident 6's Orders, dated November 16, 2025, the Orders indicated, Resident may be on Enhanced Barrier Precaution related to gastrotomy tube and colonization of MDRO VRE [VRE- vancomycin Resistant Enterococcus is a germ that has become resistant to the antibiotic [medication to heal bacterial infections] vancomycin] every shift.During an observation on February 17, 2026, at 8:50 AM, in room [ROOM NUMBER], CHHA was removing and changing linens without a gown for Resident 6. During an interview on February 17, 2026, at 8:54 AM, CHHA stated, she works for an outside hospice company and was changing Resident 6's Linens. CHHA further stated she was not sure if Resident 6 was on any type of precautions. During an interview on February 17, 2026, at 8:56 AM, with an Environment Staff Aid (EVS Aid) and CHHA, the EVS Aid 1 stated, any residents who have a blue dot next to their name are on EBP. CHHA confirmed that Resident 6 was on EBP and should have worn a gown when removing linens. CHHA stated it is important to use the proper PPE to not transmit [spread] infection from resident to resident.During a review of Resident 6's care plan dated January 27, 2026, indicated, use gown and gloves during high contract resident care activities (dressing, bathing, transfers, hygiene, toileting, brief changes, changing linens, device care, wound care).During a concurrent interview and record review on February 19, 2026, at 2:10 PM, with the Infection Preventionist (IP), Resident 5 and 6 orders were reviewed. Resident's 5 orders dated April 10, 2024, indicated Resident 5 was on EBP. Resident 6's ordersdated November 16, 2025, indicated Resident 6 was on EBP. The IP confirmed and verified both Resident 5 and Resident 6 were on EBP and stated, the expectation is that any staff who is providing high contact care, for a resident on EBP, should wear a gown and gloves. The IP added, it is important to wear appropriate PPE because it is an extra layer of precautions to protect the residents from us and to prevent the spread of MDRO.During a concurrent interview and record review on February 20, 2026, at 2:34 PM, with the Director of Nursing (DON), the facility's Policy and Procedures (P&P) titled Enhanced Barrier Precautions, dated April 2024 was reviewed. The P&P indicated, .a. gloves and gown are applied prior to performing the high contact resident care activity. The DON stated that the policy was not followed and should have been for Resident 5 and Resident 6. The DON stated it is important to follow the policy to prevent because the staff should not cross contamination and reduce the spread of infections from one resident to another.

Based on interview and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Medication Cart Station 2) reviewed for medication storage. This failure had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by an unauthorized person in a highly vulnerable population of 55 residents.During a concurrent interview and record review on February 18, 2026, at 4:15 PM, with the Administrator (Admin), the Narcotic Floor Release (NFR- narcotic records, a form used by the facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses) NFR- dated February 1, 2026, through February 18, 2026, was reviewed. The NFR indicated there were eight signatures missing as follows:-February 4, 2026, oncoming day shift (7 AM to 3:00 PM)-February 5, 2026, oncoming day shift (7 AM to 3:00 PM and off going evening shift (3:00 PM to 11:00 PM)-February 11, 2026, oncoming night shift (11:00 PM to 7:00 AM)-February 13, 2026, off going night shift (11:00 PM to 7:00 AM)-February 16, 2026, oncoming evening shift (3:00 PM to 11:00 PM)-February 17, 2026, off going night shift (11:00 PM to 7:00 AM)-February 17, 2026, off going evening shift (3:00 PM to 11:00 PM)The Admin confirmed there were missing signatures for reconciling the narcotic inventory in the NFR.During an interview on February 18, 2026, at 4:20 PM, with Licensed Vocational Nurse (LVN) and Admin, LVN 1 stated, the nursing staff are responsible for signing the NFR at the start of their shift and at the end of their shift. LVN 1 stated it is important for nursing staff to fill out the NFR to verify that the narcotic count is correct and that the cart is intact.During an interview on February 18, 2026, at 4:30 PM, with LVN 2, LVN 2 stated the expectation is to fill out the NFR at the start and end of shift because it is important to hold the staff accountable and to avoid drug diversion.During a concurrent interview and record review on February 20, 2026, at 2:40 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Controlled Substances, dated November 2022, was reviewed. The P&P indicated, dispensing and Reconciling Controlled Substances. 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up. 3. Nursing staff count controlled medication inventory at the end of each shift, using records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. The DON stated the policy was not followed and should have been because the nursing staff should ensure the narcotic count is correct for drug diverging.

Based on observation, interview, and record review, the facility failed to ensure 11 of 25 resident's rooms (1, 2, 3, 4, 6, 7, 8, 9, 11, 14, and 21) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident.This failure had the potential to negatively impact resident comfort, dignity, and safety by limiting adequate space for movement, equipment placement and staff assistance of 26 residents who reside in those 11 rooms.Findings:During an interview with the administrator (Admin) on February 17, 2026, at 10:59 AM the admin stated that the facility had 11 rooms (room [ROOM NUMBER], 2, 3, 4, 6, 7,8, 9, 11, 14, and 21) that were smaller than the required 80 Sq feet. The Admin stated the facility had previously submitted a room waiver for all 11 rooms and that there are not any issues with care in relation to the size of the rooms. During a concurrent observation and interview on February 17, 2026, at 4:00 PM with the Maintenance Supervisor (MS), during an environmental tour of rooms 1, 2, 3, 4, 6, 7,8, 9, 11, 14, and 21, The following measurements were noted as follows:- room [ROOM NUMBER] had two residents (Resident 22 and 34) and measured 77.91 square feet (Sq Ft. -unit of measurement) for each resident.- room [ROOM NUMBER] had two residents (Resident 58 and 25) and measured 78.14 Sq Ft. for each resident. - room [ROOM NUMBER] had two residents (Resident 8 and 10) and measured 76.59 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 7 and 53) and measured 76.73 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 14 and 45) and measured 77.78 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 37 and 40) and measured 78.37 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 21 and 52) and measured 77.91 Sq Ft. for each resident.- room [ROOM NUMBER] had four residents (Resident 17, 39, 54, and 55) and measured 70.95 Sq Ft. for each resident.- room [ROOM NUMBER] had three residents (Resident 3, 11 and 51) and measured 76.66 Sq Ft. for each resident.- room [ROOM NUMBER] had three residents (Resident 15, 28, and 64) and measured 77.54 Sq Ft. for each resident.- room [ROOM NUMBER] had two residents (Resident 12 and 33) and measured 70.06 Sq Ft. for each resident.The MS verified that all 11 rooms (room [ROOM NUMBER], 2, 3, 4, 6, 7, 8, 9, 11, 14 and 21) did not have the required 80 Sq Ft of space for each resident.During an interview on February 18, 2026, 2:57 PM with Certified Nurse Assistant (CNA) CNA 1, stated the size of all rooms in the facility are wheelchair accessible and have sufficient space to provide care.During an interview on February 20, 2026, at 2:50 PM with the Admin, the Admin stated there have been no issues with care in relation to the rooms that are less than 80 Sq Ft.

Based on observation, interview, and facility policy review, the facility failed to ensure all food items removed from its original container were dated and labeled. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: A facility policy titled, Labeling and Dating of Food, revised 01/03/2018, revealed, All food will be dated and labeled, and prepared for storage to prevent contamination, deterioration, and dehydration. During the initial tour of the kitchen on 10/21/2024 at 9:46 AM, the surveyor noted four, unlabeled and undated bags that contained corn tortillas in the dry storage. During an observation of the kitchen on 10/23/2024 at 11:04 AM, the surveyor noted a gallon size, undated bag of nine snickerdoodle cookies on a shelf in the dry storage. During an interview on 10/23/2024 at 2:36 PM, the Dietary Supervisor (DS) stated all food should be labeled with a use-by date to ensure the food was fresh. The DS acknowledged the food items should have been dated, and stated they must have gotten missed. During an interview on 10/24/2024 at 8:12 AM with the Administrator and the Director of Nursing, the Administrator stated all items should be dated when they were taken out of the box. Per the Administrator, all food should be dated to ensure it was fresh.

Based on interview, record review, and facility policy review, the facility failed to refer the resident to the appropriate state-designated authority for Level II preadmission screening and resident review (PASARR) evaluation after the resident was identified to have a newly evident mental illness diagnosis for 1 (Resident #26) of 2 sample residents reviewed for PASARR. Findings included: An Admission Record revealed the facility admitted Resident #26 on 07/16/2021. According to the Admission Record, the resident had a medical history that included diagnoses of disorder of muscle, neuromuscular dysfunction of bladder, and functional quadriplegia. Per the Admission Record, the resident received a diagnoses of anxiety disorder on 03/21/2023, post-traumatic stress disorder (PTSD) on 04/19/2023, and major depressive disorder on 08/31/2023. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/19/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) Score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include anxiety disorder, depression, and PTSD. Resident #26's care plan included a focus area initiated 02/27/2023 that indicated the resident was on an antidepressant due to a diagnosis of depression. Resident #26's care plan, indicated a focus area initiated 03/03/2023, that indicated the resident had PTSD. Resident #26's care plan included a focus area initiated 03/18/2024, that indicated the resident used anti-anxiety medication related to a diagnosis of anxiety disorder. Resident #26's medical record revealed no evidence to indicate the resident was referred to the appropriate state-designated authority for a Level II PASARR after the resident received a diagnosis of anxiety disorder on 03/21/2023, post-traumatic stress disorder (PTSD) on 04/19/2023, or major depressive disorder on 08/31/2023. During an interview on 10/23/2024 at 2:16 PM with the Administrator and the Director of Nursing (DON), the DON stated he was not working at the facility when Resident #26 admitted to the facility.

Based on observation, interview, record review, facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #150) of 5 sampled residents reviewed for infection control. Findings included: A facility policy titled, Enhanced Barrier Precautions, dated 04/2024, revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions are used an as infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity. b. Personal protective equipment is changed before caring for another resident. c. Face protections may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care. An Admission Record revealed the facility admitted Resident #150 on 10/07/2024. According to the Admission Record, the resident had a medical history that included diagnoses of encounter for attention to gastronomy dysphagia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11//2024, revealed Resident #150 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for eating and had a feeding tube. Resident #150's care plan included a focus area, initiated 10/22/2024, that indicated the resident required enhanced barrier precautions (EBP) related to gastrostomy tube (G-tube) placement. Interventions directed staff to use gown and gloves during high-contact resident care activities. Resident #150's Order Summary Report that contained active orders as of 10/23/2024, revealed an order dated 10/10/2024 for EBP related to G-tube every shift. During a concurrent observation and interview on 10/22/2024 at 8:19 AM, Licensed Vocational Nurse (LVN) #1 entered Resident #150's room to administer medications to the resident via enteral route. LVN #1 wore gloves and no other personal protective equipment (PPE). The surveyor noted a sign posted on the resident's door that specified the staff wear a gown and gloves during high-contact resident activities when a resident had a central line, urinary catheter, feeding tube, or tracheostomy. LVN #1 stated gowns were necessary only for direct care like showering or changing the resident. During an interview on 10/22/2024 at 11:41 AM, Registered Nurse #3 stated nurses must wear PPE for medication administration if a resident had G-tube. During an interview on 10/22/2024 at 12:17 PM, the Director of Staff Development (DSD) stated there was verbiage posted on residents' doors when on EBP should be implemented and this guided the staff on what PPE to wear. The DSD stated the purpose of EBP was to protect residents at higher risk for infection because of opened areas such as enteral feeding, wounds, intravenous port, and a dialysis catheter. The DSD stated nurses must wear a gown when they administered medications to a resident who had a G-tube as required on the post listed on the resident's door. During an interview on 10/22/2024 at 1:25 PM, the Infection Preventionist stated the staff was required to wear PPE during high contact activities such as changing of a resident's linens, showering a resident, resident transfers, wound care, G-tube feedings, and administration of medications for residents with indwelling medical devices such as a catheter, peripherally inserted central catheters lines, feeding tubes, and chronic wounds. During an interview on 10/23/2024 at 10:52 AM, the Director of Nursing stated the administration of medication through a G-tube was a closed contact activity, and LVN #1 should have worn a gown. During an interview on 10/24/2024 at 8:29 AM, the Administrator said LVN #1 should have worn a gown during the enteral medication administration for Resident #150. The Administrator stated the expectation was for the staff to follow the facility policy and procedure for the safety of the residents.

Based on interview and record review, the facility failed to ensure the preadmission screening and resident review (PASARR) was accurate at the time of admission for 1 (Resident #15) of 2 sampled residents reviewed for PASARR. Findings included: An Admission Record revealed the facility admitted Resident #15 on 12/01/2022. According to the Admission Record, the resident had a medical history that included a diagnose of anxiety disorder. Resident #15's Preadmission Screening and Resident Review Level I Screening, dated 12/02/2022, revealed the resident did not have a serious diagnosed mental disorder such as depression disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusion, and/or mood disturbance. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/2024, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) Score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an active diagnosis to include anxiety disorder. During an interview on 10/23/2024 at 2:16 PM with the Administrator and the Director of Nursing (DON), the DON he was not working at the facility when Resident #15 admitted to the facility, but added the PASARR should be accurate.

Based on observation, document review, and interview, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 11 (Rooms 1 - 4, Rooms 6 - 9, room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]) of 24 resident rooms in the facility. Findings included: The Client Accommodations Analysis, signed by the Administrator and dated 10/23/2024, revealed: - In room [ROOM NUMBER], there was 77.9 sq ft for each resident. - In room [ROOM NUMBER], there was 77.5 sq f for each resident. - In room [ROOM NUMBER], there was 77 sq ft for each resident. - In room [ROOM NUMBER], there was 76.2 sq ft for each resident. - In room [ROOM NUMBER], there was 76.78 sq ft for each resident. - In room [ROOM NUMBER], there was 78.65 sq ft for each resident. - In room [ROOM NUMBER], there was 78.75 sq ft for each resident. - In room [ROOM NUMBER], there was 72 sq ft for each resident. - In room [ROOM NUMBER], there was 77.7 sq ft for each resident. - In room [ROOM NUMBER], there was 78.39 sq ft for each resident. - In room [ROOM NUMBER], there was 69.35 sq ft for each resident. During an interview with on 10/23/2024 at 1:14 PM, Certified Nursing Aide #7 stated the size of the rooms had not prevented her from providing proper care. During an interview on 10/23/2024 at 2:42 PM with the Administrator and the Director of Nursing, the Administrator stated there had been no issues with care in relation to the size of some resident rooms.

Based on interview and record review, the facility failed to report an allegation of abuse within regulatory requirement time-frame and in accordance with the facility's policy and procedure for one of two sampled residents (Resident 1). This failure had the potential to compromise safety and delay measures to be in place to ensure the well-being of Resident 1. Findings: During a record review of Resident 1's face sheet (a document that contains resident demographics and diagnoses) indicated Resident 1 was admitted on [DATE], with primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review of Resident 1's Minimum Data Set (MDS- a tool for implementing standardized assessment and for facilitating care management in nursing homes), dated March 28, 2022, the care area for functional status indicated Resident 1 was totally dependent on staff for transfers to and from bed and bathing. During an interview with Resident 1's Wife, on June 21, 2022, at 5:07 PM, Resident 1's Wife stated that on June 18, 2022, between 3:30 PM and 4:00 PM, she requested Certified Nurse Assistant 1 (CNA 1) to give her husband [Resident 1] a shower. She further stated CNA 1 then asked assistance from CNA 2 and after the shower, Resident 1 notified his wife that he was handled roughly during the shower, and that CNA 1 and CNA 2 referred to his genital part as [NAME], which the wife clarified means small in Spanish. During an interview on June 21, 2022, at 5:37 PM, a Licensed Vocational Nurse 1 (LVN 1) assigned to Resident 1 at the time of incident, stated Resident 1's Wife reported to her the allegation of rough handling and the alleged remarks made by CNA 1 and CNA 2. LVN 1 stated there was no Registered Nurse Supervisor at the time it was reported, and that she reported the allegation of abuse to her Director of Nursing (DON) on June 20, 2022, two days after the incident was initially reported. LVN 1 further stated she did not report the incident immediately, because there was no distress to Resident 1. During a record review of a letter faxed by the facility to the California Department of Public Health (CDPH), dated June 20, 2022, signed by the DON, notifying the CDPH of an allegation of abuse for Resident 1, which had been reported on June 18, 2022. Further review of the letter indicated the Police Department and the Ombudsman were also notified on June 20, 2022, two days after the allegation was reported to LVN 1. During a concurrent interview and record review with the DON, on June 21, 2022, at 6:39 PM, the DOn reviewed the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised July 2017, whch indicated, .Reporting .2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury . The DON stated the incident was reported on June 20, 2022, 2 days after the incident. The DON further stated the facility was not in compliance with their policy for reporting abuse.

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage and refuse when one of two lids on garbage receptacles, was not closed and there was trash on the ground. This failure had the potential to attracts pests. Findings: During a concurrent observation and interview on February 9, 2022, at 1:11 PM, with the Supervisor of Maintenance Service (SMS), in the garbage storage area, located outside the facility, one of two garbage containers was not closed, and there was trash on the ground between the containers. The SMS stated the garbage container lid should be closed to avoid pest infestation and trash must be inside the containers. During an interview on February 10, 2022, at 9:42 AM, with the Registered Dietician (RD), the RD verbalized the garbage containers should be closed always, because of the potential to attract pests. The RD also stated the trash should not be on the ground. During a concurrent interview and record review on February 10, 2022, at 9:45 AM, with the RD, the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised October 2017, was reviewed. The P&P indicated, .7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. The RD stated that facility did not follow the policy. During a review of the Food and Drug Administration (FDA) Federal Food Code 2017, 5-501.113, indicated, Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the food establishment.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when: 1. One table mounted can opener was observed with rust (a reddish-brown brittle coating form on iron when is exposed to air and moisture) in the slide bar (used to adjust different can sizes) near the knife, and in the washer inside the slide bar. 2. The ice machine had a hard deposit of white-greenish-black buildup inside the ice machine. These failures had the potential to contaminate residents' food and cause foodborne illnesses to a population 49 of 51 medically compromised residents who received food from the kitchen. Findings: 1.During a concurrent observation and interview on February 7, 2022, at 10:01 AM, with the Dietary Services Supervisor (DSS), inside the kitchen, one table mounted can opener had rust in the slide bar near the knife, and in the washer inside the slide bar. The DSS stated that the can opener was considered a utensil and it had rust and was not clean. During an interview on February 9, 2022, at 8:14 AM, with the Dietary Aid 1 (DA 1), she verbalized the can opener was cleaned in the dishwasher and left to air dry after each use. During a concurrent interview and record review on February 10, 2022, at 9:23 AM, with the DSS, the facility's policy and procedure (P&P) titled, Sanitation, revised October 2008, was reviewed. The P&P indicated, .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . The DSS stated that facility did not follow the policy and rust can contaminate the food. During a concurrent interview and record review on February 10, 2022, at 9:40 AM, with the Registered Dietitian (RD), the facility's policy and procedure (P&P) titled, Sanitation, revised October 2008, was reviewed. The P&P indicated, .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning ., The RD stated that the policy was not followed. During a review of the Food and Drug Administration (FDA) Federal Food Code 2017, 4-602.13, indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2. During a concurrent observation and interview on February 7, 2022, at 10:25 AM, of the ice machine with the Supervisor of Maintenance Services (SMS), inside the kitchen, the ice machine had hard deposits of a white-greenish-black buildup on top of a metal nut (a thick metal ring used to hold pieces of machinery together) attached to a clear plastic device located at the left front side inside the ice machine. The SMS stated that he sanitized the ice machine once a month and the last time he did was on January 21, 2022. The SMS further stated that he did not remember seeing that buildup in the machine when he sanitized it, and the machine was cleaned in August 2021 by a vendor company, per manufacturer's instructions. During a concurrent observation and interview on February 7, 2022, at 11:25 AM, of the ice machine with the SMS, inside the kitchen, the SMS removed the ice chute. The surveyor used a white paper napkin to wipe the tray and no residue was visible on the napkin. Afterward, the surveyor used a paper napkin to wipe on top of the metal nut and the clear plastic device located at the left front side of the ice machine and no residue was visible in the napkin. The SMS stated that he uses a solution of one ounce (oz- unit of volume) of bleach and diluted in a gallon of water to sanitize inside the ice machine, including the plastic and metal parts with a clean cloth and let air dry, according to the ice machine sanitation log. During an interview on February 7, 2022, at 12:30 PM, with the Dietary Services Supervisor (DSS), the DSS verbalized that a vendor cleans the ice machine every six months, and the SMS was responsible for sanitizing it every month and signing in the log. The DSS further stated that the part of the ice machine that contains the white-greenish-black buildup must be completely clean and without any stains. During a telephone interview on February 10, 2022, at 8:19 AM, with the [name of company] Ice Machine Technician (IMT), the IMT verbalized that no chlorine-based solution such as bleach shall be used to disinfect inside the ice machine, because it can cause rust when in contact with metal parts. The IMT further stated that it was recommended a nickel-safe sanitizer solution (cleaner solution formulated for remove scale deposits in ice machine) to be used. During a concurrent interview and record review with the SMS, on February 10, 2022, at 8:49 AM, Ice Machine Sanitation Log (Log), dated August 2008, was reviewed. The Log indicated that ice machine was sanitized on January 21, 2022. The Log indicated Procedure to Clean Ice Machine .5. After cleaning, rinse inside the bin with fresh water. Rinse again using a solution of 1 oz of bleach to 1 gallon of tepid water. The SMS stated that he follows the facility Log when cleaning the ice machine. During a review of the manufacture's guidelines titled [name of the company] Cleaning and Sanitizing an [name of the company] commercial Ice Machine, revised June 2015. The manufacture's guidelines indicated .it is important to use solutions that do not harm the ice machine. Never use cleaning or sanitizing solutions that contain Nitric Acid, Sulfuric Acid or any chlorine-base solution such as bleach, chlorine [MEDICATION(S)] or any type of salts such as potassium chloride or sodium chloride These chemicals can attack the surface of the evaporator as well as other metal components causing corrosion and flaking. During a review of facility invoice [name of the company] number , dated August 18, 2021, indicated that ice machine was cleaned and sanitized with a nickel safe cleaner. During a concurrent interview and record review on February 10, 2022, at 8:55 AM, with the SMS, the facility's policy and procedure (P&P) titled, Sanitation, revised October 2008, was reviewed. The P&P indicated, .12. Ice machine and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy . The SMS stated the facility did not follow the policy. During a concurrent interview and record review on February 10, 2022, at 9:40 AM, with the RD, the facility's policy and procedure (P&P) titled, Sanitation, revised October 2008, was reviewed. The P&P indicated, .12. Ice machine and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy . The RD stated that the policy was not follow and the ice machine must be clean and free of any residue inside and out. During a review of the FDA Federal Food Code 2017, 4-202.11, indicated, Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.

Based on observation, interview, and record review, the facility failed to ensure staff followed safe infection control practice as evidenced by staff did not perform hand hygiene (cleaning hand) after touching contaminated (dirty) areas and before handling a resident's meal tray for one of 20 sampled residents (Resident 9). This failure had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to a vulnerable resident whose health conditions are already compromised. Findings: During a review of Resident 9's Admission Record (Patient demographic), not dated, the Admission Record indicated, Resident 9 was admitted into the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on February 8, 2022, at 5:50 PM, in the hallway, there were alcohol-based hand rub (ABHR) located by the entrance and outside Resident 19's room. Certified Nursing Assistant (CNA) 1 was observed to open the door push bar with bare hands, carried residents' drink tray and coffee inside, and used bare hands to turn off the alarm panel by the door. Licensed Vocational Nurse (LVN) 2 made a statement out loud, wash your hands. CNA 1 did not perform hand hygiene. CNA 1 picked up a cup of water from the resident's drink tray and placed a cup on Resident 19's dinner tray. A follow-up interview on February 8, 2022, at 5:55 PM, with CNA 1, in front of room [ROOM NUMBER], CNA 1 stated, he knew he had to wash his hands after touching dirty areas. CNA 1 further stated, he did not hear LVN 2's statement about hand washing. CNA 1 confirmed, he did not clean his hands with ABHR after touching the door push bar and the alarm panel before handling a resident's food tray, CNA 1 stated, I'm sorry. A follow-up interview on February 8, 2022, at 6:02 PM, with LVN 2, LVN 2 stated, she is a registry staff and new to this facility. LVN 2 stated, she tried to tell CNA 1 to wash his hands after she saw CNA 1 touched the door push bar and the alarm panel. LVN 2 further stated, she did not know CNA 1's name yet so he might not know when she tried to tell him to wash his hands. LVN 2 confirmed, CNA 1 should have washed his hands with ABHR after touching the door push bar and the alarm panel before handling residents' meal trays. During an interview on February 14, 2022, at 11:50 AM, with the Infection Prevention Nurse (IPN), the IPN stated, appropriate hand hygiene practices should be implemented and followed throughout all areas within the facility to prevent the spread of infection. The IPN stated, she was informed of the incident. The IPN further stated, staff should most definitely wash hands after touching the potential contaminated areas and before handling food. The IPN confirmed, staff did not follow the facility's policy and procedure (P&P) for hand hygiene. A review of the facility's P&P titled, Handwashing/Hand Hygiene, revised August 2015, indicated the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; o. Before and after eating or handling food .

Based on observation, interview, and record review, the facility failed to ensure nursing staff followed the physician's order as evidenced by the blood sugar testing and insulin (medication to control blood sugar) administration record were not completed for one of 20 sample residents (Resident 252). These failures resulted in poor coordination of care and had the potential to cause diabetes complications that can negatively affect Resident 252's health such as high or low blood sugar, and diabetic [CONDITION(S)] (a common and serious complication of diabetes that damage nerves). Findings: During a review of Resident 252's Admission Record (Patient demographic), not dated, the Admission Record indicated, Resident 252 was admitted into the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on February 8, 2022, at 9:30 AM, in room [ROOM NUMBER], Resident 252 was lying in bed. Resident 252 stated, he did not know all his medications. During a review of the Resident 252's Order Summary Report, dated February 2, 2022, through February 28, 2022, the Order Summary Report indicated, a finger blood sugar check was ordered to be performed three times a day (TID) before meals and to give insulin based on a blood sugar result. During a concurrent interview and record review on February 14, 2022, at 9:45 AM, with a Licensed Vocational Nurse (LVN) 1, in the nursing station, Resident 252's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 stated, Resident 252 had an order to check the blood sugar TID before meals and insulin administration based on the blood sugar result. LVN 1 confirmed, he did not see the blood sugar check and insulin administration record, on February 7, 2022, at 11:30 AM. LVN 1 stated, he wanted to go through the chart and see documentation to explain about the tasks not completed. A follow-up interview on February 14, 2022, at 10:45 AM, with LVN 1, LVN 1 stated, he was unable to provide documentation to indicate the reason of missing blood sugar check and insulin administration record, on February 7, 2022, at 11:30 AM, as ordered. LVN 1 confirmed, staff did not follow the physician's order to check the blood sugar and document on the insulin administration record. During a concurrent interview and record review on February 14, 2022, at 2:55 PM, with the Director of Nursing (DON), in the DON's office, the DON stated, staff had to document on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed, staff did not follow the facility's policy and procedure (P&P) for medication holds. A review of the facility's P&P titled, Administering Medication, revised December 2012, indicated the following: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . A review of the facility's P&P titled, Medication Holds, revised April 2007, indicated the following: Policy Statement: Temporary medication holds may be ordered by the resident's Attending Physician. Policy Interpretation and Implementation: 1. A hold order for a medication must be accompanied by a restart date or time. Hold orders without a restart date or time will be considered discontinued. 2. When medications are held, they must be stored in a separate location in the medication room or returned to the issuing pharmacy. 3. The nursing staff must document in the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for two of 20 sampled residents (Resident 13 and 19) when: 1. Resident 13's RAI-MDS submitted by the facility on November 8, 2021, did not indicate the resident had weight gain, but instead had listed weight loss. 2. Resident 19's RAI-MDS submitted by the facility on December 1, 2021, inaccurately indicated the resident did not use tobacco products. These failures in MDS coding had the potential to result in unmet care needs for Residents 13 and 19, which can potentially jeopardize their health and safety. Findings: 1. During a review of Resident 13's Admission Record (clinical record with demographic information), the Admission Record indicated, Resident 13 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on February 8, 2022, at 5:39 PM, Resident 13 resident was sitting at the edge of the bed, eating dinner. Resident 13 stated that he had good appetite and had not lost weight. During a review of Resident 13's IDT ( Interdisciplinary team- a group of clinical staff) Weight Management Assessment, dated November 4, 2021, indicated that Resident 13 gained twenty-one pounds (16%) in six months and there was no significant weight changes for thirty and ninety days. During a review of Resident 13's RAI-MDS Assessment, dated November 8, 2021, section K0300 Weight Loss, indicated Resident 13 had a weight loss of 5% or more in the last month or 10% or more in the last six months. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on February 10, 2022, at 2:50 PM, she reviewed Resident 13's clinical record and the RAI-MDS assessment dated [DATE]. The MDSC stated Resident 13's clinical record had no documentation indicating the resident had lost weight and the MDS section K0300 was incorrect, and facility used the current RAI manual to complete RAI-MDS assessments. During a concurrent interview and record review with the Director of Nursing (DON), on February 10, 2022, at 2:59 PM, she reviewed Resident 13's clinical record and the RAI-MDS assessment dated [DATE]. The DON stated the MDS section K0300 was incorrect, and the correct section should be MDS K0310, which indicated Resident 13's weight gain. A review of the MDS 3.0 RAI Manual titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1, dated October 2019, section K0300: Nutritional Approaches, indicated Steps for Assessment - This item compares the resident's weight in the current observation period with his or her weight at two snapshots in time: At a point closest to 30-days preceding the current weight and at a point closest to 180-days preceding the current weight. 2) A review of Resident 19's Admission Record, indicated, Resident 19 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on February 8, 2022, at 11:00 AM, with Resident 19, Resident 19 stated she smoked daily and had been a smoker the entire time she lived at the facility. During a review of the facility document titled, List of Patients Who Smoke, undated, the document indicated Resident 19 was a smoker at the facility. During a review of Resident 19's smoking assessment (an assessment to determine safety risk for residents who smoke), dated November 26, 2021, the smoking assessment indicated Resident 19 could light her own cigarette, needed a smoking apron (a fire-retardant apron used to prevent any hot ash from burning resident's clothes), and supervision. During a review of Resident 19's care plan, dated November 26, 2021, the care plan indicated, .is a smoker resident is non-compliant with smoking apron . During a review of Resident 19's RAI-MDS assessment, dated December 1, 2021, the MDS section J1300 (current tobacco use) indicated no which indicated the resident did not use tobacco. During a concurrent interview and record review on February 10, 2022, at 3:37 PM, with the Director of Nursing (DON), Resident 19's RAI-MDS assessment, dated December 1, 2021, was reviewed. The DON stated section J1300 was incorrectly coded by the Minimum Data Set Coordinator (MDSC). The DON further stated the section should have indicated Resident 19 used tobacco. During a concurrent interview and record review on February 10, 2022, at 3:43 PM, with the MDSC, Resident 19's RAI-MDS assessment, dated December 1, 2021, was reviewed. The MDSC stated she was the one who completed the RAI-MDS for Resident 19 and confirmed section J1300 indicated no for the resident's use of tobacco. The MDSC stated she incorrectly completed the section and should have looked more closely at the resident's records. The MDSC further stated she used the current version of the RAI manual for instructions regarding how to complete each section of the RAI-MDS assessment. A review of the MDS 3.0 RAI Manual titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1, dated October 2019, section J1300: Current Tobacco Use, indicated, 1. Ask the resident if he or she used tobacco in any form during the 7-day look-back period. 2. If the resident states that he or she used tobacco in some form during the 7-day look-back period, code 1, yes.

Based on interview, and record review, the facility failed to provide one of three sampled residents (Resident 154) with beneficiary liability protection notifications (notification letter/s which explain resident rights regarding financial liability and the right to appeal) when the resident was discharged from Medicare Part A services (services covered by insurance payer) on August 12, 2021. This failure had the potential for Resident 154 to be uninformed regarding his specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal. Findings: A review of Resident 154's Admission Record, (contains demographic and medical information), the Admission Record indicated Resident 154 was initially admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facility document titled, [Name of facility] - Beneficiary Notice, undated, the document indicated Resident 154 was discharged from Medicare Part A services on August 12, 2021, with 17 benefit days left in the facility. The document also indicated the resident remained in the facility. During a review of the facility document titled, [Name of facility] Census List, Dated February 14, 2022, the census list indicated Resident 154 remained in the facility from August 13, 2021, through December 13, 2021. During a review of the facility document untitled and undated, in Resident 154's Electronic Health Record (EHR), the document indicated Resident 154 had Medicare A as the Primary Payer on July 30, 2021. Further review of the document indicated the Primary Payer changed to IEHP-CCI-LTSS-MCal (name of new insurance payer) on August 13, 2021. The document further indicated, Level of Care from July 30, 2021, through August 12, 2021, the services provided were Y [yes] under the question, skilled? and the level of Care, from August 13, 2021, through December 12, 2021, the services provided were N [no] under the question Skilled? During an interview on February 14, 2022, at 11:24 AM, with the Business Office Manager (BOM), the BOM, reviewed Resident 154's records. The BOM stated Resident 154 had his last covered day for Medicare Part A services on August 12, 2021. The BOM stated on August 12, 2021, Resident 154 should have been given the beneficiary notifications, but she was unable to find documented evidence that they were provided to him. The BOM stated the two beneficiary notifications which should have been provided to Resident 154 were the Skilled Nursing Facility Advance Beneficiary of Non-coverage (SNF ABN) CMS and the Notice of Medicare Non-coverage (Form CMS -NOMNC) forms. The BOM stated the business office was the department which oversaw the beneficiary notifications and ensured they were provided to the residents when indicated. During an interview on February 14, 2022, at 11:38 AM, with the BOM, the BOM stated resident 154 remained in the facility as a custodial resident from August 13, 2021, through December 12, 2021. During an interview on February 14, 2022, at 12:14 PM, with the Director of Nursing (DON), when asked about the process for providing beneficiary notifications to residents, the DON stated she deferred all questions regarding beneficiary notifications to the business management office because they were the ones who managed the process. During an interview on February 14, 2022, at 11:36 AM with the BOM, the BOM stated the facility did not have a policy and procedure regarding beneficiary notifications.

Based on interview, and record review, the facility failed to ensure the medical record for four residents (Residents 13, 19, 23, and 49) clearly indicated if the residents had advanced directives (advance directive is a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions). All four residents had incomplete documentation on their Physicians Orders for Life Sustaining Treatment (POLST - written medical orders that addresses a limited number of critical medical decisions) when: 1) For Resident 13, section D (section which includes information regarding advanced directives) of the POLST, was not completed. 2) For Resident 19, section D of the POLST was not completed. 3) For Resident 23, section D of the POLST was not completed. 4) For Resident 49, section D of the POLST was not completed. This failure had the potential to result in a delay of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1) During a review of Resident 13's Admission Record (clinical record with demographic information), the Admission Record indicated, Resident 13 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 13's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review with the Social Services Director (SSD), on February 10, 2022, at 4:50 PM, Resident 13's POLST, signed April 5, 2021, was reviewed. The POLST indicated Section D had not been answered. The SSD stated Section D must be completed and she missed it. SSD stated she had not inquired about Advance Directives to Resident 13 or family members. 2) A review of Resident 19's Admission Record, indicated, Resident 19 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 19's POLST, dated November 29, 2021, section D did not have information documented to indicate whether or not an advanced directive existed for the resident. There were three checkboxes in section D which related to advanced directives. The three checkbox options were, Advance directive dated [space left blank to insert date], available and reviewed . or Advance directive not available or No advance directive. None of the checkboxes were marked. During further review of Resident 19's Electronic Health Record (EHR) and physical paper chart, no documented evidence was found regarding whether or not the resident had an advance directive. During an interview on February 10, 2022, at 4:52 PM, with the Social Services Director (SSD), the SSD stated the POLST document in section D should have a checkbox marked by either advance directive dated and available, advance directive not available, or no advance directive. During a review of the facility's policy and procedure titled, Advance Directives, revised April 2013, the policy indicated, Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . 3) During a review of Resident 23's Admission Record, the Admission Record indicated, Resident 23 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 23's POLST, signed November 17, 2021, Section D - Information and Signatures regarding Advance Directives, was not answered. During a concurrent interview and record review with the SSD, on February 10, 2022, at 5:00 PM, the POLST, signed November 17, 2021, was reviewed. The POLST indicated Section D was left unanswered. The SSD stated that Section D was not complete, and she had not inquired about advance directives to Resident 23 or family members. 4) During a review of Resident 49's Admission Record, the Admission Record indicated, Resident 49 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 49's POLST, signed July 6, 2021, Section D - Information and Signatures regarding Advance Directives, was unanswered. During a concurrent interview and record review with the SSD, on February 10, 2022, at 4:55 PM, the POLST, signed July 6, 2021, was reviewed. The POLST indicated Section D was left unanswered. The SSD stated that Section D was not complete, and she had not inquired about Advance Directives to Resident 49 or family members. During a concurrent interview and record review on February 14, 2022, at 8:35 AM, with the SSD, the facility's policy and procedure (P&P) titled, Advance Directives, revised April 2013, was reviewed. The P&P indicated, 3. Prior to, or upon Admission of a resident, the Social Services Director or designee will inquire of the resident and/or his/her family members, about the existence of any written advance directives., and 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The SSD stated that the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 29) had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) next to his bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident). This failure had the potential for the resident to sustain an injury during a fall in which the severity of the injury may have been lessened had the fall mat been in place. Findings: 1. During a review of Resident 29's Admission Record (clinical record with demographic information), the Admission Record indicated, Resident 29 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 29's fall risk assessment (a document used to determine if a resident was at risk for falls), dated September 3, 2021, indicated Resident 29 was at risk for falls. During a review of Resident 29's care plan, dated September 3, 2021, the care plan titled, The resident is at risk for falls r/t [related to] right sided weakness, dx [diagnosis] of [CONDITION(S)], use of meds [medications] . Interventions for this care plan included, follow facility fall protocol. During a review of Resident 29's care plan, dated January 4, 2022, the care plan indicated, Unwitnessed fall on 1/3/22 [January 3, 2022]: Resident found on the floor next to bed .fall mat on one side of bed . During a concurrent observation and interview on February 9, 2022, at 3:07 PM, with Certified Nursing Assistant 3 (CNA 3), in room [ROOM NUMBER] bed B, Resident 29 was observed to be lying in his bed. There was no floor mat on either side of his bed. CNA 3 confirmed Resident 29 did not have any floor mats next to his bed. CNA 3 further stated she was familiar with Resident 29's care and Resident 29 was brought into room [ROOM NUMBER] about two weeks ago and she (CNA 3) did not see a fall mat next to Resident 29's bed for the entire two weeks. When asked if Resident 29 was at risk for falls, CNA 3 stated she did not think so, because if the resident was a fall risk, he would have had a fall mat next to his bed. During a review of the facility document titled, Falls in the last 4 months, dated October 8, 2021, through February 8, 2022, the Falls in the last 4 months indicated Resident 29 had a fall on December 3, 2021, and January 4, 2022. During a review of Resident 29's progress notes, dated January 6, 2022, the progress note indicated, .Resident had unwitnessed fall on 1/3/22 [January 3, 2022] resident was found on the floor on a sitting position. Resident unable to state cause of the incident. Call light was not activated and is within reach . During an interview on February 9, 2022, at 3:25 PM, with the Director of Nursing (DON), the DON reviewed Resident 29s electronic health record. The DON stated Resident 29 had a care plan for falls and was supposed to have a fall mat next to his bed. The DON further stated Resident 29 had a room change on January 3, 2022 (37 days prior to observation of resident without floor mat) and stated she thought maybe the resident's floor mat was not implemented with the room change. During a review of the facility's policy and procedure titled, Falls - Clinical Protocol, revised September 2012, the policy indicated, Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .Monitoring and follow-up .2.b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.

Based on observation, interview, and record review, the facility failed to ensure the glucometer (device used to check blood sugar) was disinfected, before and after residents' use, according to the facility policy and procedure and manufacturer's maintenance guidelines for five out of 17 sampled residents (Residents 4, 15, 18, 25, and 49) in the universe of 19 residents, when; A. Registered Nurse 1 (RN 1) did not disinfect the glucometer used between Residents 4,15, and 49. B. Licensed Vocational Nurse 1 (LVN 1) did not disinfect the glucometer used between Residents 18 and 25. These failures created an overall danger of transmission of blood borne infection (disease that can be spread through contaminated blood and other body fluids) to all residents who shared potentially contaminated glucometer. Findings: A. During a medication pass observation on (MONTH) 27, 2019 at 5:41 AM, Registered Nurse (RN 1) was preparing to perform a blood glucose test to Resident 4. RN 1 did not disinfect the glucometer before and after testing Resident 4's blood sugar. A review of Resident 4's admission record indicated Resident 4 was admitted to the facility on (MONTH) 12, (YEAR) with a [DIAGNOSES REDACTED]. During an interview with RN 1 on (MONTH) 27, 2019 at 5:56 AM, RN 1 stated he was going to do the blood sugar test of Resident 15. RN 1 went to Resident 15's room and proceeded to use the glucometer machine. RN 1 did not disinfect the glucometer device before and after use. RN 1 stated there was only one glucometer device on the medication care he was using. A review of Resident 15's admission record indicated Resident 15 was admitted to the facility on (MONTH) 10, 2019 with a [DIAGNOSES REDACTED]. RN 1 then proceeded to go to Resident 49's room. RN 1 used the same glucometer device to test the blood sugar. RN 1 did not disinfect the glucometer device before and after use. A review of Resident 49's admission record indicated Resident 49 was admitted on (MONTH) 8, (YEAR) with a [DIAGNOSES REDACTED]. During an interview with RN 1, on (MONTH) 27, 2019, at 7:00 AM, he stated that upon start of his work shift he cleaned the glucometer machine with Super Sani cloth Wipes (EPA Environmental Protection Agency) approved disinfectant/anti-microbial agent (a chemical that destroys bacteria). RN 1 stated that the glucometer machine will be cleaned before the end of the shift. RN 1 confirmed he did not disinfect the glucometer machine before and after in between resident uses. B. During a medication pass observation with Licensed Vocational Nurse (LVN 1) on (MONTH) 27, 2019 at 6:06 AM, LVN 1 proceeded to do blood sugar test of Resident 18. LVN 1 did not disinfect before and after use of the glucometer. After use, LVN 1 placed the glucometer device on top of the medication cart. A review of Resident 18's admission record indicated Resident 18 was admitted to the facility on (MONTH) 15, 2019 with a [DIAGNOSES REDACTED]. During an observation on (MONTH) 27, 2019 at 6:16 AM, LVN 1 proceeded to Resident 25's room. LVN 1 used the same glucometer machine that was used for Resident 18, to check Resident 25's blood sugar. LVN 1 did not disinfect the machine before and after use. A review of Resident 25's admission record indicated Resident 25 was admitted to the facility on (MONTH) 5, (YEAR) with a [DIAGNOSES REDACTED]. During an interview with LVN 1, on (MONTH) 27, 2019 at 7:03 AM, she stated she used Super Sani Cloth to sanitize the glucometer machine. LVN 1 further stated that she never sanitized the glucometer device in between residents use because she only had two residents that use glucometer device. During an interview with Director of Nursing on (MONTH) 27, 2019 at 7:29 AM, she stated the staff were required to disinfect the glucometer machine before and after use and between residents with disinfectant wipes. A review of the facility's policy and procedure titled, Obtaining a Finger stick Glucose Level, revised (MONTH) 2011 indicated, Procedure: . 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. A review of the Manufacturer's Guidelines of (Brand Name) Machine Monitoring System under Section Maintenance/Cleaning, dated (MONTH) 2009 indicated, Healthcare professionals should wear gloves when cleaning the (Brand Name) Pro Meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. Suggest cleaning the meter between patients. These failures to follow and implement the policies and procedures and manufacturer's guideline resulted in an Immediate Jeopardy (IJ immediate danger of harm) situation. An IJ was identified and called on (MONTH) 27, 2019 at 11:10 AM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and the DON were informed of the observations, interviews, and record reviews with the facility staff. The facility submitted an acceptable corrective action plan on (MONTH) 27, 2019 at 2:30 PM as follows: The facility's corrective action plan included in service training of all staff in proper cleaning and disinfecting of the glucometer machine before and after use between resident, use of appropriate disinfectant to clean glucometer, replaced with new glucometers in all medication carts, reassessed all identified residents on blood glucose monitoring for any complication or possible infection and notification of physician of any change in condition, revised the policy and procedure in obtaining finger stick glucose level. The DON and Pharmacy Nurse Consultant will conduct medication pass observation with emphasis of proper technique and proper cleaning and disinfecting of the glucometer machine based on manufacturer guideline. The skills check will be conducted monthly 3 times and quarterly thereafter. The DON and Designee will conduct random daily observation on proper technique in obtaining the finger stick glucose. The DON will report in the QAPI meeting any negative finding and /or concerns related to Licensed Nurse skills and competency related to blood glucose monitoring technique, cleaning, and disinfecting. The IJ was lifted on (MONTH) 28, 2019 at 2:32 PM in the presence of the ADMIN and the DON after submission of an acceptable corrective action plan. Observation, staff interviews, and record reviews were conducted to ensure the corrective action plan was implemented.