Every finding on record at Plymouth Village

Based on observation, interview, and record review the facility failed to maintain a sanitary kitchen when:There was white build up on the top inside of the ice bin around the ice chute and there was slime that was wipeable with a paper towel.The grill grates of the grill on the cooking line had black grime build-up, there was also black grime build-up on the metal around the grates. The ovens of two ranges not being used had food crumbs inside and under the ovens there was a metal ledge that had food and grease build-up, the wheels of the ranges had grease and grime build-up. A metal shelf storing the toaster had a build-up of grime and grease.The outside of the fryer had a build-up of grease and grime. One oven had food crumbs and build-up inside, the handles of the 3 ovens had build-up, and the front of the ovens had food splash.These failures had the potential to contaminate food and cause food-borne illness to the 41 of 41 residents who received food from the kitchen.During an observation on August 3, 2026, at 1:51 p.m. in the dining area, inside the ice bin of the ice machine on the upper ceiling where ice exits the machine into the bin, the ceiling had a build-up of a white substance. The area was wiped with a paper towel, and a slimy yellow substance was observed.During an observation on August 4, 2026, at 8:20 a.m. in the main kitchen of the cooking line the grates and the metal around the grates of the grill had a black grime build-up. The grill range and griddle range had bottom ovens that were not being used, the inside of the ovens had old food crumbs, there was also grease build-up on a metal ledge under the ovens, and the wheels of the oven ranges and a metal cart storing the toaster had grease and grime build-up.During a subsequent observation and interview on August 4, 2026, at 8:25 a.m. with the Executive Chef, the outside of the fryer had a build-up of grease. The Executive Chef stated that the fryer was used last evening for dinner, and they planned to clean it later today. Around the corner there were 3 ovens, the handles of the ovens had a build-up of food grime and food splash, the inside of one of the ovens had a build-up of food crumbs on the bottom shelf.During an interview on August 5, 2026, at 1:31 p.m. with the Director of Dining Services (DDS) the DDS stated the fryer should be cleaned up after each use, and those areas identified should be kept clean and free of build-up. The DDS stated she expects the ice machine bin ceiling to be clean and free of discoloration.During a review of the facility policy and procedure (P&P) titled, Sanitation and Infection Prevention/Control: Cleaning of Food and Nonfood contact surfaces, dated January 2025, the P&P indicated, .the food -contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. nonfood contact surfaces of equipment, such as handles on reach-in units, sides of sinks, gaskets on cooler and freezer doors, tracks of sliding doors on equipment, and the exterior of ice machines, shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris.During a review of the facility P&P titled, Ice Machines and Ice Storage Chests, dated 2001, the P&P indicated .Ice machines ice storage/distribution containers will be used and maintained to assure safe and sanitary supply of ice .During a review of the FDA Federal Food Code 4-602.11, dated 2022, indicated, .(E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment:(a) At a frequency specified by the manufacturer, or(b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.In addition, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

Based on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs when four of 18 residents (Resident #12, 14, 19 and 28) on an easy to chew diet received chips for lunch on Monday, August 3, 2026.This failure had the potential for Resident 12, 14, 19, and 38 to potentially choke.During an observation on August 3, 2026, at 12:16 p.m. in the dining room, Resident 14 was eating a peanut butter and jelly sandwich and chips.During a review of the Resident 14's admission Record (contains demographic and medical information), the admission Record indicated resident was admitted on [DATE], with a diagnosis of Dementia (a decline in memory, language, problem-solving, and other thinking skills that interferes with daily life).During a review of the Resident 14's Order Details (contains medical doctors orders), dated February 27, 2026, the Order Details indicated resident is on an easy to chew, level 7 texture (soft foods), regular/thin consistency, for cut up meals; finger foods.During a review of the Resident 14's Care Plan Report (care plan includes interventions by the facility to address resident care), dated April 20, 2026, the Care Plan indicated, provide and serve diet as ordered: CCD (Controlled carbohydrate diet) easy to chew, thin liquids, cut-up meat and finger foods as desired, likes peanut butter and jelly sandwich, quesadillas, likes bananas, soup, fruit and sweets.During an observation, on August 3, 2026, at 12:30 p.m. in the dining room, Resident 12 was eating a peanut butter and jelly sandwich and chips.During a review of the Resident 12's admission Record, the admission Record indicated resident was admitted on [DATE], with a diagnosis of Dementia (a decline in memory, language, problem-solving, and other thinking skills that interferes with daily life) and hypertension.During a review of the Resident 12's Order Details, dated March 8, 2025, the Order Details indicated resident is on an easy to chew texture, regular/thin consistency, provide 8-ounce milk with all meals as tolerated.During a review of the Resident 12's Care Plan Report, dated June 4, 2024, the Care Plan indicated, regular easy to chew, thin liquids. 8-ounce milk with all meals. Resident prefers soft foods.During an observation in the dining room, on August 3, 2026, at 11:58 am, Resident 19 was sitting in a wheelchair at a table in the dining room. Resident 19's lunch included potato chips and a peanut butter and jelly sandwich.During a review of the Resident 19's admission Record, the admission Record indicated resident was admitted on [DATE], with a diagnosis of senile degeneration of brain (severe, age-related cognitive decline and brain tissue loss), and hypertension.During a review of the Resident 19's Order Details, dated July 11, 2025, the Order Details indicated resident is on an easy to chew texture, regular/thin consistency.During a review of the Resident 19's Care Plan Report, dated May 28, 2024, the Care Plan Report indicated, diet-regular easy to chew, thin liquids d/t (due to) advancing age, h/o (history of) dentures. Does well with finger foods such as sandwiches, likes soups.During an observation in the dining room, on August 3, 2026, at 12:04 pm, Resident 28 sitting at a table in the dining room, lunch included peanut butter and jelly sandwich and potato chips.During a review of the Resident 28's admission Record, the admission Record indicated, resident was admitted on [DATE], with a diagnosis of Dementia (a decline in memory, language, problem-solving, and other thinking skills that interferes with daily life) and history of falling.During a review of the Resident 28's Order Details, dated November 19, 2025, the Order Details indicated, Easy to chew texture, regular/thin-level 0 consistency, may provide lactose products upon request.During a review of the Resident 28's Care Plan Report, dated November 20, 2025, the Care Plan Report indicated, Provide, serve diet as ordered. Easy to chew diet /thin liquids family requested easy to chew diet. No rice, no spaghetti, lactose intolerance. Likes sandwiches and soup at lunch.During an interview with the Director of Dining Services (DDS) on August 5, 2026, at 1:31 p.m., DDS stated staff serving the food to the residents should be checking that the food is compliant with their diet. DDS stated the residents on an easy to chew diet should not receive chips.During a record review of the facility document titled, Easy to Chew Level 7, dated May 2026, indicated, Foods are nearly normal in texture, but exclude hard, tough, chewy, fibrous, stringy, crunchy.

Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration was provided in accordance with the physician's order for two (2) of 18 sampled residents (Resident 21 and 1) when: 1. Resident 21 was receiving oxygen at four (4) L (liters- unit of measurement) per minute via nasal cannula (NC- plastic tubing used to deliver oxygen) instead of the ordered two (2) L per minute.2. Resident 1 was receiving oxygen at two (2) L per minute via nasal cannula, but the physician's order indicated three (3) L per minute via nasal cannula.These failures had the potential to placed Resident 21 and 1's health at risk for inadequate or unsafe oxygen delivery.1. During a review of Resident 21's admission Record (contains demographic and medical information), the admission Record indicated Resident 21 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- lung condition that makes breathing difficult due to damaged airways), Chronic Kidney Disease stage 4 (CKD- a condition when the kidneys are damaged and cannot filter blood as they should), and anemia (a condition when the body does not have enough red blood cells to carry oxygen) in CKD, and Phobic Anxiety Disorder (intense, overwhelming fear). During a concurrent observation and interview on August 3, 2026, at 9:17 AM, in Resident 21's room, Resident 21 was on oxygen at 4L per minute via NC. Resident 21 stated, she was recently hospitalized , but she was unsure of the reason. Resident 21 stated she received a blood transfusion while hospitalized and now requires oxygen. During a review of Resident 21's Physician Order, dated August 5, 2026, the Physician Order- indicated, Resident 21 had an order for Intermittent (PRN [as needed]) Oxygen at 2L/minute per nasal cannula for O2 saturation (the amount of oxygen the blood is carrying) less than 90% or for shortness of breath. During a concurrent observation and interview on August 4, 2026, at 2:44 PM, with a Licensed Vocational Nurse (LVN 1), in Resident 21's room, Resident 21 was receiving oxygen at 4L/ minute via NC. LVN 1 checked Resident 21's order for oxygen and stated Resident 21 should be on oxygen at 2L/ minute NC. LVN 1 stated, oxygen is a medication, and it was the responsibility of the nurse to ensure oxygen was administered per the physician's orders. LVN 1 stated, he did not check the oxygen flow rate today and did not know how long Resident 21's oxygen had been set to 4L/ minute. LVN 1 further stated, too much oxygen can be bad for Resident 21 because she has COPD. During a concurrent interview and record review, on August 5, 2026, at 1:10 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration dated 2001, was reviewed. The P&P indicated, . Verify there is a physician's order. The DON stated, oxygen is a medication and Resident 21 receiving Oxygen at a higher flow than prescribed was a problem. 2. During a review of 1's admission Record (clinical record with demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included, acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the body tissues or remove enough carbon dioxide from it), pneumonia(an infection/inflammation in the lungs), and asthma (a long-term lung disease that makes breathing hard). During a review of Resident 1's Physician Order, dated May 29, 2026, the Physician Order indicated, Continuous oxygen at three L per minute via nasal canula every shift. During a concurrent observation and interview on August 4, 2026, at 4:05 PM, with Resident 1, in Resident 1's room, Resident 1 was observed receiving two L of oxygen via nasal cannula. Resident 1 stated he/she receives oxygen because he/she has difficulty breathing. Resident 1 further stated he/she experiences increased coughing in the evening and has more difficulty breathing when the coughing occurs. During a concurrent observation and interview on August 4, 2026, at 4:07 PM, with Licensed Vocational Nurse 4 (LVN 4), in Resident 1's room. Resident 1 was observed receiving oxygen at two L per minute via nasal cannula. LVN 4 acknowledged Resident 1 was receiving oxygen at two liters per minute. During a concurrent interview and record review on August 4, 2026, at 4:12 PM, with LVN 4, LVN 4 reviewed Resident 1's Order Summary, dated May 29, 2026, which indicated, Continuous oxygen at three L per minute via nasal canula every shift. LVN 4 acknowledged Resident 1 was receiving oxygen at a rate that was less than ordered and this could put Resident 1 at increased risk for respiratory distress. During a concurrent interview and record review on August 6, 2026, at 11:19 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration dated 2001, was reviewed. The P&P indicated, . Verify there is a physician's order. The DON stated Resident 1's oxygen should have been administered according to the physician's order and the nurses are expected to check the order, and document the oxygen rate every shift. DON acknowledged the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. There were two medication errors observed out of 29 opportunities for errors, affecting one of 10 observed residents (Resident 11). This resulted in an overall medication error rate of 6.9 percent when:Resident 11 was given two multivitamin (a supplement with various vitamins and minerals) tablets but was prescribed only one multivitamin tablet.This failure had the potential to lead to vitamin mineral toxicity (buildup of excess vitamins and minerals in the body that can be harmful) and digestive discomfort.Resident 11 received Vitamin D3 (a vitamin that helps with strong bones, muscles, and immune health) 10 mcg (micrograms- unit of measurement) instead of Vitamin D3 50 mcg, as prescribed by the physician.This failure had the potential to be an inadequate dose of Vitamin D3 to produce a therapeutic benefit (desired outcome).1. During a review of Resident 11's admission Record (contains demographic and medical information), the admission Record indicated, Resident 11 was admitted to the facility on [DATE], with diagnoses which included Waldenstrom Macroglobulinemia (a rare, slow growing blood cancer), B-cell Lymphoma (a type of blood cancer), and Gastro-Esophageal Reflux Disease (digestive condition often causing heartburn).During a review of Resident 11's Minimum Data Set (MDS- a standardized assessment tool) section C, for Cognitive Patterns (the way the brain understands and responds to information) the Brief Interview for Mental Status (BIMS- tool to assess how the brain processes information) score was 15. The BIMS score indicated no impairment.During a review of Resident 11's Physician Order, dated August 5, 2026, the Physician Order indicated, Resident 11 had an order for Multiple Vitamins-Minerals Tablet give 1 tablet by mouth one time a day for supplement.During a medication observation on August 5, 2026, at 8:03 AM, in Resident 11's room, with Licensed Vocational Nurse (LVN 2), LVN 2 gave Resident 11 a medication cup containing two Multi-Vitamin with Minerals tablets. Resident 11 looked at the medications in the cup and stated, Why are there 2 pink pills?. LVN 2 inspected the medication cup and verified Resident 11's orders and she said, I accidently gave you 2 multi-vitamins. Then LVN 2 removed one multi-vitamin from the cup.During a concurrent interview and record review, on August 5, 2026, at 1:15 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, was reviewed. The P&P indicated, .medications are administered in accordance with prescriber orders. The DON stated the policy was not followed. 2. During a review of Resident 11's admission Record (contains demographic and medical information), the admission Record indicated, Resident 11 was admitted to the facility on [DATE], with diagnoses which included Waldenstrom Macroglobulinemia (a rare, slow growing blood cancer), B-cell Lymphoma (a type of blood cancer), and Gastro-Esophageal Reflux Disease (digestive condition often causing heartburn).During a review of Resident 11's Physician Order, dated August 5, 2026, the Physician Order indicated, Resident 11 had an order for Vitamin D3 Oral Tablet (Cholecalciferol) give 50 mcg by mouth one time a day for supplement.During a medication observation on August 5, 2026, at 8:04 AM, in Resident 11's room, LVN 2 administered Vitamin D3 10 mcg orally to Resident 11, not the prescribed dose of Vitamin D3 50 mcg.During a concurrent interview and record review, on August 5, 2026, at 9:00 AM with LVN 2, Resident 11's Physician Order, was reviewed. The Physician's Order indicated, Vitamin D3 50 mcg by mouth one time a day for supplement. LVN 2 confirmed and verified the order and then opened the medication cart and confirmed the Vitamin D3 10 mcg medication bottle that was used during Resident 11's medication administration. LVN 2 stated, the wrong dose was given. LVN 2 further stated, the physician order was not followed correctly. During a concurrent interview and record review, on August 5, 2026, at 1:17 PM, with the DON, the facility's P&P titled, Administering Medications dated April 2019, was reviewed. The P&P indicated, .medications are administered in accordance with prescriber orders. The DON stated the policy was not followed because the wrong dose was given.

Based on observation, interview, and record review, the facility failed to ensure storage of medications were properly secured for one of two (2) medication carts (Medication Cart 1) when one Licensed Vocational Nurse (LVN 3) left Medication Cart 1 unlocked and unattended while LVN3 was giving medication inside Resident 5's room.This failure had the potential to result in medications being accessible, diverted, or used inappropriately by unauthorized individuals. During a concurrent observation and interview on August 5, 2026, at 5:54 AM, with LVN 3, LVN 3 was in the hallway outside room [ROOM NUMBER] preparing medication. LVN 3 then walked inside room [ROOM NUMBER] and approached Resident 5 to discuss the medication. The Medication Cart 1 was left unlocked and unattended. LVN 3 verified the medication cart was left unlocked and stated it should not be left unattended for residents safety.During a concurrent interview and record review on August 5, 2026, at 9:38AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, was reviewed. The P&P indicated, .7. Controlled substances (listed as a schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug Distribution systems in which the quantity stored in minimal and a missing dose can be readily detected. The DON stated the policy was not followed. The DON further stated it was important for staff to lock the medication cart to prevent unassigned personnel and residents from gaining access to the medications.

Based on observation, interview, and record review the facility did not have staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service when:Staff did not use the appropriate temperature measuring device to check the surface temperature of a dish to ensure appropriate sanitation.Staff did not monitor the temperature of room temperature prepared foods to ensure bacteria was not allowed to grow.These findings had the potential to cause food-borne illness in 41 of 41 medically compromised residents who received food from the kitchen.During a concurrent observation and interview on August 5, 2026, at 8:57 a.m. with the Executive Chef in the kitchen, the Executive Chef used a food thermometer to check the temperature of the high temperature dish machine (dish washing machine that uses high heat to sanitize the dishes). She reached into the machine quickly to pull out the thermometer and read the temperature before it began to change, the temperature was 152 degrees Fahrenheit (unit of measurement). She stated she was taught that it was ok to use that thermometer because it was waterproof. During an interview on August 5, 2026, at 1:31 p.m. with the Director of Dining Services (DDS), the DDS stated the Executive Chef should be using the dish machine puck thermometer (Digital device shaped like a small disk or plate. It rides through a commercial dishwasher cycle to accurately measure and record the peak surface temperature of dishware) to check the surface temperature of a dish. During a record review of the facility policy and procedure (P&P) titled, Sanitation and Infection Prevention/Control, Dish Machine Temperature, dated January 2026, the P&P indicated, Supervisor/Food and Nutrition Associate as assigned: Once a day, run a dish machine puck through the dish machine to verify the surface temperature of a dish. (The machine readings are the temperatures at the manifold of the machine, and not on the surface of the plate). The dish machine puck must verify that the surface temperature of the plate reached 160 degrees Fahrenheit. Alternative: use an irreversible maximum registering thermometer. During an observation on August 4, 2026, at 8:11 a.m., there was a large container of tuna salad in the refrigerator with a prepared date of August 2. In another reach-in refrigerator there was a container of egg salad with a prepared date of August 4, and potato salad with a prepared date of August 3. During a concurrent interview and record review on August 5, 2026, at , at 8:57 a.m. with the Executive Chef, the facility document titled, Cooling Log, dated August 2026 was reviewed. The Cooling Log indicated the tuna salad, egg salad and potato salad were not logged on the cooling log. The Executive Chef stated they do not log the cool down of tuna, egg or potato salad. During an interview with the DDS on August 5, 2026, at 1:31p.m., the DDS stated the staff should be logging the room temperature prepared foods on the cooling log. During a review of the facility's P&P titled, Production, Purchasing, Storage: Food Handling Guidelines (HACCP), dated January 2026, the P&P indicated, Cooling of potentially hazardous foods prepared from room temperature ingredients: Food shall be cooled within 4 hours to 41 degrees Fahrenheit if prepared from ingredients at room temperature. Use the cooling log form at the end of this policy to document the temperature of the food at the following times: at the end of the food preparation and at 4 hours after the end of the food preparation. During a review of the FDA Federal Food Code 3-501.14, dated 2022, indicated, (B) time/temperature control for safety food shall be cooled within 4 hours to 5 degrees Celsius (unit of measurement- 41 degrees Fahrenheit) or less if prepared from ingredients at ambient (room temperature) temperature, such as reconstituted foods and canned tuna . Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms.

Based on observation, interview, and record review, the facility failed to ensure proper handling, cleaning, and storage of resident care equipment for one of 41 sampled residents (Resident 8) when, Resident 8's nebulizer machine ( a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing( a thin, hollow plastic hose that connects to nebulizer) was observed not in use, lying on Resident 8's nightstand and not stored in a protective plastic bag.This deficient practice had the potential to result in cross-contamination (when germs are spread from one open, surface or object to another, making it easier for infections to spread), placing Resident 8 at risk for infection and harm.Finding:During a review of 8's admission Record (clinical record with demographic information), the admission Record indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses which included, pneumonia (an infection/inflammation in the lungs), pleural effusion (water on the lungs) and cardiomyopathy ( a disease that weakens the heart muscle).During a review of Resident 8's Physician Order, dated July 22, 2026, the Physician Order- indicated, Albuterol Solution (a liquid medicine used to relax tight muscles in the airways making it much easier to breathe) 2.5 mg/3ml (milligram/milliliter - unit of measurement), one vial inhale orally every six hours for shortness of breath/wheezing.During an observation and interview on August 3, 2026, at 9:49 AM, in Resident 8's room, Resident 8's nebulizer machine tubing was observed lying on Resident 8's nightstand, not in use and was uncovered. Resident 8 stated the last treatment he received was earlier in the morning.During a current observation and interview on August 3, 2026, at 10:05 AM, with the Licensed Vocational Nurse (LVN 5), in Resident 8's room, the nebulizer machine tubing was observed not in use and not stored in a protective plastic bag. The LVN acknowledged the tubing was not properly stored and stated this increases the risk of contamination and potential infection to the resident.During a concurrent interview and record review on August 4, 2026, at 3:46 PM, with the Director of Nursing (DON), the facility's policy and procedure(P&P) titled, Respiratory Therapy-Prevention of Infection, dated November 2011, was reviewed. The P&P indicated, . Purpose: the purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment including ventilators, among residents and staff.Infection Control Considerations related to Medication Nebulizers/Continuous Aerosol.5. Take care not to contaminate internal nebulizer tubes.3. Store the circuit in plastic bag, marked with date and resident's name between uses. The DON confirmed the P&P was not followed and stated this increase Resident 8's risk for infections related to cross contamination.

Based on observation, interview, and record review, the facility failed to ensure the clinical record contained accurate documentation of fall history for one of three residents (Resident 1) reviewed for falls.This failure had the potential to result in an inaccurate assessment of fall risk and inappropriate fall prevention interventions, placing Resident 1 at increased risk for subsequent falls.During a review of Resident 1's clinical record, the admission Record (contains demographic and clinical data), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia (memory loss beyond expected age and difficulty with thinking), history of falling, and unspecified fracture (break of the bone) of the lower end of the left radius (lower forearm) and left ulna (broken left wrist).During a review of Resident 1's Change in Condition Note, dated April 4, 2026, the Change in Condition Note indicated Resident 1 sustained a fall on April 4, 2026.During a review of Resident 1's Fall Risk Evaluation (a fall risk assessment is used to find out if you have a low, moderate, or high risk of falling), dated April 4, 2026, the Fall Risk Evaluation indicated Resident 1 had 3 or more falls in the past 3 months.During a record review of Resident 1's subsequent Fall Risk Evaluation, dated May 6, 2025, the Fall Risk Evaluation indicated, .no falls in the past 3 month., despite the documented fall on April 4, 2026, fall (32 days prior) and a fall on May 6, 2026.During an observation on May 18, 2026, at 2:53 PM in Resident 1's room, Resident 1 was sitting upright in bed, with the bed in the lowest position. A cast was on her left upper extremity and was wearing a fall bracelet on the wrist.During a concurrent telephone interview and record review on May 26, 2026, at 12:39 PM with the Director of Nursing (DON), Resident 1's Fall Risk Evaluation, dated May 6, 2026, and Resident 1's Change in Condition Note, dated April 4, 2026, was reviewed. The DON verified Resident 1 sustained a fall on April 4, 2026, but the Fall Risk Evaluation, dated May 6, 2026, was documented as having no falls in the past 3 months. The DON stated this was not accurately documented.During a concurrent telephone interview and record review on May 26, 2026, at 12:41 PM with the DON, the facility's policy and procedure (P&P) titled, Falls-Clinical Protocol, dated March 2018 was reviewed. The P &P indicated, .The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days) . The facility's P&P titled, Charting and Documentation, dated July 2017 was also reviewed. The P &P indicated, .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The DON stated both policies were not followed.

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation, and storage practices in the kitchen when: 1. The main kitchen floors had accumulation of food crumbs, black stains, and dirt; the walk-in freezer had food crumbs on the floor, and the walk-in refrigerator floors had multiple cilantro leaves, cauliflower pieces, and multiple moist black and brown residue under the shelf. 2. Food equipment such as the toaster had black grime, white residue, and food crumbs; the mixer was found with multiple reddish-orange splashes on the handle. 3. The edge of the wall under the three-compartment sink had black build up and multiple white residues. These failures had the potential to cause foodborne illnesses (caused by the ingestion of contaminated food or beverages) in a highly susceptible population of 44 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on June 16, 2025, at 07:48 AM, with the Sous Chef (SC) in the main kitchen, the floors had an accumulation of food crumbs, black stains, and dirt. The walk-in freezer had food crumbs on the floor, and the walk-in refrigerator floors had multiple cilantro leaves, cauliflower pieces, and multiple moist black and brown residue under the shelf. The SC stated the floors are to be cleaned daily. During an interview on June 16, 2025, at 03:25 PM, with the Director of Dining Services (DDS), the DDS stated the expectation was for kitchen floors and walk in freezers/refrigerators to be maintained clean after each shift. During a review of the FDA Federal Food Code, dated 2022, under 4-601.11, it indicated, .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris [scattered pieces of waste or remains] . The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 2. During a concurrent observation and interview on June 16, 2025, at 7:53 AM, with the SC in the main kitchen, the toaster had black grime, white residue and food crumbs inside and out. The mixer was found with multiple reddish-orange splashes on the handle. The SC stated that equipment should have been cleaned. During a concurrent interview and record review on June 16, 2025, at 3:10 PM, with the DDS, the facility's policy and procedure (P&P) titled Sanitation and Infection Prevention/Control, revised January 2024, was reviewed. The P&P indicated Written procedures are available, detailing daily and weekly (as needed) cleaning for all areas and equipment in the department . The DDS stated the policy and procedure was not followed. During a concurrent interview and record review on June 16, 2025, at 3:27PM, with the DDS, the kitchen cleaning checklist titled, Station Cleaning Checklist Dishwasher (19), undated, was reviewed. The cleaning checklist indicated, Fri (Friday) - Deck brush kitchen, pull all equipment and clean under and behind . The DDS stated the checklist should have been followed. 3. During a concurrent observation and interview on June 16, 2025, at 7:57 AM, with the SC, the edge of the wall under the three-compartment sink had black build up and multiple white residues. The SC stated it should be cleaned daily after use. During an interview on June 16, 2025, at 3:25 PM, with the DDS, the DDS stated the expectation was for the wall to be cleaned and free of buildup. During a review of the FDA Federal Food Code, dated 2022, under 4-601.11, it indicated, .Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris [scattered pieces of waste or remains] .in addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained when a Laundry Staff used a dirty laundry basket (a basket for holding clothes and linen that have been washed) to transfer washed linens into the dryer machine. This failure had the potential to cause harm to the 44 residents residing within the facility by increasing the risk of exposure and spread of infection (the process by which an infectious agent (like a virus or bacteria) moves from one source to another, causing illness). Findings: During a concurrent observation and interview on June 18, 2025, at 12:10 PM, in the laundry room with the Infection Preventionist (IP), Laundry Supervisor (LS) and Laundry Staff (LS 1) observed a large rectangular blue plastic laundry basket with a lid covered with stained dirty white sheet located near the dryer. LS 1 stated the laundry basket is used to transfer washed linens from the washing machine to the dryer. The LS stated the white sheet on top of the laundry basket are changed every day. LS1 stated the white sheet on the laundry basket are changed once a week. LS1 proceeded to remove the white sheet from the top of the laundry basket to replace it with a clean sheet. Once LS 1 removed the dirty white sheet, the lid was observed dirty and appeared to had items inside the laundry basket. There was a black trash bag, a white trash bag, dirty socks, one individual packet of coffee creamer, a dirty mop, a blue blanket, a few dirty tissue papers and spray bottle, inside the laundry basket. The LS stated, I did not know about this. The IP stated, she had not seen this laundry basket when she was making rounds before. During an interview on June 18, 2025, at 12:30 PM, with the Director of Buildings and Grounds, the director of Buildings and Grounds stated he expected laundry staff to use a clean laundry basket. During a concurrent interview and record review on June 18, 2025, at 12:50 PM, with the Director of Nursing (DON) and IP, the facility policy and procedures (P&P) titled, Laundry and Bedding, Soiled, dated September 2022, was reviewed. The P&P indicated, Transport . 4. Linen carts are cleaned and disinfected whenever visibly soiled and according to the established schedule . 6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. The IP stated, Laundry staff had received education in handling and transporting linens and she was not sure why a dirty laundry basket was used. The DON acknowledged the policy and stated, the dirty laundry basket should not had been used at all. The DON stated her expectation for staff is to use clean laundry carts all the time.

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of seven residents (Residents 4) reviewed for dining observation when a Licensed Vocational Nurse (LVN 2) was standing over Resident 4 while feeding him lunch on June 16, 2025. This failure resulted in staff not maintaining Resident 4's individuality and dignity. Findings: During a review of Resident 4's admission Record (contains demographic and medical information), undated, the admission Record indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses of Hemiplegia, unspecified affecting right dominant side (weakness on one side of the body), Dysphasia (condition affecting speech) and dysphagia (difficulty swallowing). During an observation on June 16, 2025, at 12:24 PM, in the second dining room, LVN 2 was standing over Resident 4 while feeding him lunch. During an interview on June 16, 2025, at 1:00 PM, LVN 2 stated staff are expected to be seated while feeding residents. During a concurrent interview and record review, on June 16, 2025, at 3:14 PM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Assistance with Meals, revised March 2022, it indicated Dining Room Residents: . 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals . The DON stated staff should be engaging and sitting next to residents for a full meal.

Based on observation, interview, and record review, the facility failed to ensure safe oxygen administration were provided in accordance with the physician's orders and facility policies and procedures for one of three sampled residents (Resident 12) reviewed for respiratory care when Resident 12's oxygen tubing (a device which delivers oxygen) was not labeled to indicate the date that it was changed. This failure had the potential for Resident 12 to be at risk of developing a respiratory infection (caused by bacteria, viruses, fungi, or parasite). Findings: During a review of Resident 12's clinical record, the admission Record (patient demographics), indicated, Resident 12 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that makes it hard to breathe), diastolic (congestive) heart failure (a condition where the heart muscle is too stiff to relax properly, preventing the heart from filling with enough blood between beats), and atrial fibrillation (heart rhythm disorder). During a review of Resident 12's Physician Order, dated February 10, 2025, the Physician Order indicated, Resident 12's had an order for Oxygen Tubing and Humidifier Change when in use every night shift, every Wednesday. The Physician Order also indicated Resident 12 had an order dated March 30, 2025, for Oxygen at 2 LPM (Liters Per Minute) continuously to maintain O2 (Oxygen) sats (saturation- levels) > (greater than) 90% (percent) every shift for COPD. During a concurrent observation and interview on June 16, 2025, at 10:10 AM, with the Director of Staff Development (DSD), in Resident 12's room, a nasal cannula (device used to deliver supplemental oxygen to a patient through the nose) attached to an oxygen concentrator through the oxygen tubing, was found undated. The DSD stated she was not aware when the tubing was last changed. The DSD further acknowledged the oxygen tubing should have been labeled to know when to change every week. During a concurrent interview and record review on June 17, 2025, at 3:09 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy)-Prevention of Infection, dated 2001, was reviewed. The P&P indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff . Infection Copntrol Considerations Related to Oxygen Administration . 7. Change the oxygen cannula and tubing every seven (7) days, or as needed. The DON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure medication error rate was less than five percent. There were two medication errors identified out of 27 opportunities for errors, affecting one of 13 residents (Resident 14), resulting in an overall medication error rate of 7.4 percent when Resident 14's Levothyroxine (replacement hormone for people whose thyroid gland is not working properly) and Hydrocodone-Acetaminophen (medication used to relieve severe pain) were crushed together during medication administration. These failures had the potential for Resident 14 to have negative health consequences and effectiveness of the medications. Findings: During a review of Resident 14's clinical records, the admission Record (contains demographic and medical information) indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included, gastro esophageal reflux (a condition where stomach acid flows back up into the esophagus), hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone) and pain in thoracic spine (middle section of the spine, situated between the neck and the lower back). During a review of Resident 14's physician's orders, dated June 6, 2025, it indicated Resident 14 had an order for Levothyroxine Sodium Oral Tablet 25 mcg (micrograms- unit of measurement) Give 1 tablet by mouth in the morning for hypothyroidism. During further review of Resident 14's physician's order, dated June 6, 2025, it indicated, May Crush or pull apart medication unless contraindicated- separate meds [medications]. Evaluate each medication for indications/contraindication for crushing - each must be prepared individually if more than one is to be administered. During review of Resident 14's physician's order, dated June 9, 2025, indicated Resident 14 had an order for Hydrocodone - Acetaminophen Tablet 5 -325mg (milligrams- unit of measurement). Give 1 tablet by mouth every 8 hours for pain management. During medication administration observation on June 18, 2025, at 5:48 AM, at the medication cart in front of Resident 14's room, one Licensed Vocational Nurse (LVN 3) verified the information of Resident 14 and then proceeded to take out one tablet of Levothyroxine Sodium 25 mcg and one tablet of Hydrocodone-Acetaminophen 5-325 mg. LVN 3 then combined both medications in one plastic pouch and crush both medications together. LVN 3 placed the crushed medication in a plastic medication cup and mix it with apple sauce and proceeded to give it to Resident 14 to swallow it. During concurrent interview and record review on June 18, 2025, at 5:51 AM, with the LVN 3, LVN 3 stated mixing all medications is okay if there is an order. During a concurrent interview and record review, on June 18, 2025, at 7:00 AM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Administering Medications, revised April 2019. The P&P indicated, . 4. Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame. The DON stated facility did not follow the policy.

Based on observation, interview, and record review the facility failed to ensure the privacy of patient health records for one of six sampled residents (Resident 14) was maintained when a Licensed Vocation Nurse (LVN 3) left Resident 14's health information on the computer screen, unattended in the hallway, visible for anyone to see. This failure had the potential for Resident 14's private information to be disclosed without authorization which could lead to Health Insurance Portability and Accountability Act (to protect medical records and other personal information) violations. Findings: During a review of Resident 14's clinical records, the admission Record (contains demographic and medical information) indicated, Resident 14 was admitted to the facility on [DATE], with diagnoses which included, gastro esophageal reflux (a condition where stomach acid flows back up into the esophagus), hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone) and pain in thoracic spine (middle section of the spine, situated between the neck and the lower back. During a concurrent observation and interview on June 18, 2025, at 5:48 AM, with a LVN 3 at the medication cart in front of Resident 14's room, LVN 3 logged into Resident 14's electronic health records in the computer. LVN 3 proceeded to go inside the room to administer Resident 14's medication leaving the computer screen up and unattended. LVN 3 stated he realized he left Resident 14's information open on the computer when he was inside the room. LVN 3 further stated he was not supposed to keep the computer on with Resident 14's information unattended. During a concurrent interview and record review on June 18, 2025, at 7:00 AM, with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, HIPAA Privacy Policy, dated January 1, 2021, was reviewed. The P&P indicated, 1. Administrative, Technical and Physical Safeguards . [Name of Provider] ensures that appropriate administrative, technical , and physical safeguards are in place to (a) reasonably safeguard PHI from any intentional and unintentional use or disclosure that is in violation of the Privacy Rule; (b) ensure the confidentiality , integrity and availability of e-PHI it creates, receives, maintains or transmits; (c) protect against reasonably anticipated uses or disclosure that violate the Rules; and (d) limit incidental uses and disclosures resulting from otherwise permitted or required uses or disclosures. The DON stated the policy was not followed.

Based on interview and record review, the facility failed to implement a process to routinely evaluate contracted nursing staff on their skill levels (range of tasks and duties to be performed) and develop individualized competency-based training (a process to acquire skills and knowledge to be able to perform a task to a specified standard) for 10 of 10 contracted staff (one Licensed Vocational Nurse [LVN 1], and nine Certified Nursing Assistants [CNA 1, 2, 3, 4, 5, 6, 7, 8 and 9]). This failure had the potential to compromise the services and types of care necessary to safely meet the resident's needs. Findings: During an interview and record review on April 25, 2024, at 2:30 PM, with the Director of Nursing (DON), the DON reviewed the document titled, Orientation Checklist dated March 20, 2020, the checklist indicated, Skills-C.N.A . Ambulation . Bed making .Body Mechanics . Position in Bed .Charting and Reporting .Bladder Training . Foley Catheter Cares . Vital Signs . The DON stated the facility used the checklist for contracted nursing staff. DON was not able to provide documented evidence of the Orientation Checklist for LVN 1, CNA 1 and 2 to demonstrate that each of the contracted nursing staff have been validated for their skills. The DON stated she is not able to provide a documented competency checklist for any contracted staff that have been assigned to the facility today. During a concurrent interview and record review on April 25, 2024, at 2:49 PM, with the Director of Staffing Development (DSD), in the presence of the DON, the electronic files from Clipboard Health (staffing record) were reviewed. The DSD stated there were three (3) contracted nursing staff currently working at the facility (LVN 1, CNA 1 and 2). The DSD stated, the ,facility uses a buddy system for the contracted CNA's to validate their competencies and skills. The DSD further stated, the contracted RN's (Registered Nurses) and LVN's are assigned to a core staff member to be supervised throughout their shift. Both, the DON and DSD were not able to provide documented evidence of the competencies or skills set checklist for the contracted nursing staff were completed and reviewed. During a review of the staffing assignment for the month of April 2024, contracted nursing staff worked in the facility for the following dates, shifts, and assignments: 1. LVN 1 - April 25, 2024, 7:00 AM - 3:00 PM Shift, as a treatment nurse 2. CNA 1 - April 25, 2024, 7:00 AM - 3:00 PM Shift, Rooms 31A - 34A 3. CNA 2 - April 25, 2024, 7:00 AM - 3:00 PM Shift, Rooms 40A - 43B 4. CNA 3 - April 22, 2024, 3:00 PM - 11:00 PM Shift, Rooms 44A - 47B, 40A & 40B 5. CNA 4 - April 21, 2024, 11:00 PM - 7:00 AM Shift, Rooms 30 - 37B 6. CNA 5 - April 21, 2024, 11:00 PM - 7:00 AM Shift, Rooms 40 - 47B 7. CNA 6 - April 19, 2024, 3:00 AM - 11:00 PM Shift, Rooms 20A - 22B, 30A & 30B 8. CNA 7 - April 15, 2024, 7:00 AM - 3:00 PM Shift, Rooms 44A - 47B 9. CNA 8 - April 7, 2024, 11:00 PM - 7:00 AM Shift, Rooms 30A - 37 10. CNA 8 - April 5, 2024, 11:00 PM - 7:00 AM Shift, Rooms 30A - 37B 11. CNA 9 - April 1, 2024, 7:00 AM - 3:00 PM Shift, Rooms 40A - 43A During a concurrent interview and record review on April 26, 2024, at 8:26 AM, with the DSD, the DSD reviewed the electronic files from Clipboard Health, for CNA 3, 4, 5, 6, 7, 8 and 9. The DSD stated , there was no documented Orientation Checklist on file for CNA 3, 4, 5, 6, 7, 8 and 9. During an interview on April 26, 2024, at 10:02 AM with CNA 2, CNA 2 stated, during her first day of work, she was oriented to fire exits, rooms and resident assignments. CNA 2 further stated, she does not recall any checklist that was signed or given to her during her orientation. When asked ,if the facility provided any written documentation on completing competency training, she stated she does not recall any checklist that was signed or given to her during her orientation. During an interview with the DON on April 25, 2024, at 4:40 PM, the DON was not able to provide a policy and procedure regarding contracted nursing staff to validate their competencies and skills. The DON stated, We do not have any policy and procedure for contracted staff.

Based on observation, interview and record review, the facility failed to store food by methods that conserve nutritive value, flavor, and appearance, when four bags of raw chicken had freezer burn (frozen foods are exposed to cold, dry air, which causes them to dehydrate as the outer layers lose moisture. One of the most commonly recognized signs of freezer burn is the formation of ice crystals on the outside of food, making it appear frost bitten). This had the potential for the chicken to not be palatable when cooked and served to 40 of 41 medically compromised residents who received food from the kitchen. Findings: During an observation on April 22, 2024 at 9:00 a.m., inside the walk-in freezer, there were four bags of frozen chicken that had ice build-up and the bags had a lot of air that was keeping the bags expanded. During an interview with the Food Service Director on April 24, 2024, at 12:03 p.m., She stated that no food in the freezer should have any ice build-up or freezer burn. During a review of the facility policy titled Production, Purchasing, Storage, dated January 2023, indicated, All food, non-food items and supplies use in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption.

Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen when: 1. Floors under equipment in multiple areas of the kitchen had a build up of black grime, old food, crumbs, and trash, this had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. 2. Two convection (fans to circulate air around food to create an evenly heated environment) ovens, two ranges, a grill top, a food warmer box (appliance that holds already cooked foods at ideal temperatures until they are ready to be served) and 4 waffle irons, had a buildup of black grime, and yellow crusted grime. This had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. 3. Two buckets used as funnels to drain cooking liquid from a large steam kettle (used to cook large quantities of liquid-based foods) were crusted with old food. This had the potential for microorganism growth that could be inadvertently transferred to food and for pests to be attracted. These failures had the potential to cause food borne illness to 40 of 41 medically compromised residents who received food from the kitchen. Findings: 1. During an observation on April 22, 2024, at 8:41 a.m. in the kitchen, there was a build-up of crumbs under the stainless-steel counter-top and behind and under the industrial mixer. under the reach-in refrigerator and freezer there was a build-up of trash and crumbs. During an observation in the dry storage area on April 22, 2024, at 8:45 a.m., there was food crumbs, liquid spills and a tomato that had fallen on the floor and turned moldy (type of fungus that causes food spoilage) under the shelves on the floor. During an observation in the walk-in refrigerator on April 22, 2024, at 8:55 a.m., there was food and trash and spills under the shelves on the floor. During an observation in the walk-in freezer on April 22, 2024, at 9:00 a.m., there was old food and trash on the floor under the shelves. During an observation in the mop closet on April 22, 2024, at 9:04 a.m., there was crumbs and trash on the floor. During an observation and concurrent interview with the Executive Chef, on April 22, 2024, at 9:09 a.m., at the front cooking line the floors under the equipment and under the stainless-steel countertop had a build-up of old food and trash. The Executive chef stated that the floor under the equipment should be clean. During an interview with the Food Service Director on April 24, 2024, at 12:03 p.m., She stated that the floor underneath equipment should be kept clean and there shouldn't be any old food on the floor. She stated that they would need to add those areas that were identified to their cleaning list. During a review of the facility policy titled Sanitation and Infection Prevention/Control, dated January 2024, indicated Nonfood contact surfaces of equipment .shall be cleaned as often as is necessary. Kitchen floors will be swept and mopped at a minimum daily or as needed. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated C) Nonfood- contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. Section 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 2. During an observation in the kitchen on April 22, 2024, at 8:41 a.m., the convection oven near the handwashing sink had black grime build-up and the inside of the doors had yellow crusted build-up. During an observation in the kitchen on April 22, 2024, at 9:09 a.m., the convection oven near the steam kettle was crusted with black grime and had yellow build-up on the inside of the doors. During an observation in the kitchen on April 22, 2024, at 9:12 a.m., two range ovens had black grime build-up and food crumbs inside the ovens. Next to the ovens was a rack with storing waffle irons that had food crumbs, grease, and a white powdery substance. The grill next to the rack, used to grill hamburgers, was crusted with black grime and the stainless steel was crusted with black grime. During an interview with the Food Service Director, on April 24, 24, at 12:03 p.m., she stated the equipment should be kept clean and should be added to their cleaning list for deep cleaning. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 3. During an observation in the kitchen on April 22, 2024, at 9:06 a.m., under the grill top near the steam kettle there were two white buckets that were being used as funnels to drain water from the steam kettle into the floor drain so that water does not go all over the floor. The buckets were crusted with old food. During an interview with the Food Service Director, on April 24, 24, at 12:03 p.m., she stated the buckets being used as funnels should be kept clean, should have no food in them. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.

Based on observation, interview and record review the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube, a tube inserted through abdomen that delivers enteral feeding formula and hydration directly to the stomach) was implemented for one of two sampled residents with G-tube (Resident 37), when: 1) The G-tube pump (a machine which helps to deliver the enteral formula to the resident), was off and 1500 cc (cc - unit of volume) of Glucerna (enteral feeding formula) 1.2 cal [calories] was left in the bottle. This failure resulted in Resident 37 not receiving the calculated amount of enteral feeding formula for the day, as per physician's orders. 2) The order for Glucerna 1.2 cal was not transcribed (written) accurately onto the physician's orders (It was ordered via oral route of administration on April 1, 2024, instead of via G-tube). This failure has the potential for Resident 37 to receive the enteral feeding formula via the wrong administration route. Findings: 1) During a review of Resident 37's Face sheet (demographic data sheet), Resident 37 was admitted to the facility on [DATE], with the diagnoses of hemiplegia (paralysis of one side of the body), aphasia (a language disorder that affect a person's ability to communicate) and dysphagia (difficulty swallowing). During a review of Resident 37's physician orders, dated April 1, 2024, Physician order indicated, Glucerna 1.2 Cal 0.06 gram (gram- unit of weight measurement)1.2 kcal (Kilocalories) /mL(mL - milliliter, unit of measurement) oral liquid ,70 mL /hr (hour) . Notes: 70 ml/hr x (times) 22hrs to provide 1848 calories and 92 gram protein, to equal 1540cc. Off @1000 on@1200. During an observation on April 25, 2024, at 9:45 AM in Resident 37's room, Resident 37 was lying in bed with the head of the bed elevated. Resident 37's G-tube was connected to the pump. The G-tube pump was turned off. A bottle of Glucerna 1.2 cal was hanging from the pole, the bottle was dated April 25, 2024, the bottle label indicated Start time 2:00AM . Rate 70ml/hr. During an observation and interview on April 25, 2024, at 9:55 AM with Licensed Vocational Nurse 2 (LVN 2) in Resident 37's room, LVN 2 stated, I never calculate the feeding formula. I just do only visual checks if the bottle has enough. LVN 2 further stated, the formula was supposed to be stopped at 10:00 AM according to doctor's order, but I turned it off at 8:00 AM for his morning routine. During a concurrent observation and interview on April 25, 2024, at 10:50 AM with the Director of Nursing (DON), the DON inspected the G-tube bottle of Glucerna 1.2 cal on hanging in the pole. The DON stated the bottle has a remaining amount of 1500mL. The DON further stated, I agree that there is a discrepancy of more than 300 ml of formula which was supposed to be infused to the resident (Resident 37) by this time. During a concurrent interview and record review on April 26, 2024, at 10:30 AM with the DON, the facility's policy and procedure (P&P) titled, Enteral Nutrition, dated January 2024, was reviewed. The P&P indicated, . Nursing . Administer and document enteral nutrition per community protocol. The DON stated, The policy was not followed as there was a discrepancy in formula amount delivered. 2) During a concurrent Interview and record review on April 25, 2024, at 9:50 AM with LVN 2, LVN 2 reviewed Resident 37's physician orders, dated April 1, 2024, it indicated, Glucerna 1.2 Cal 0.06 gram-1.2 kcal/mL oral liquid, 70 cc/hr Oral. LVN 2 stated, it was the first time she noticed the order was written incorrectly (via oral route administration). During a concurrent interview and record review on April 25, 2024, at 11:00 AM with the DON, the DON reviewed Resident 37's physician's orders dated April 1, 2024. The order indicated Resident 37 to receive Glucerna 1.2 Cal 0.06 gram-1.2 kcal/ml oral liquid, 70 cc/hr via oral route. The DON stated, it was a mistake, the correct route should be via G-tube (enteral). During a concurrent interview and record review on April 26, 2024, at 10:33 AM with the DON, the facility's policy and procedure (P&P) titled, Enteral tube feeding via Continuous pump, dated November 2018, was reviewed. The P&P indicated, General Guidelines . 3. Check the enteral nutrition label against the order before administration . Check the following information: d. Route of delivery . The DON stated, the policy was not followed as the Route was wrong.

Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) for one of two medication carts (Front Hall medication cart), with seven missing signatures for narcotics count. This failure had the potential for drug diversion (Illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff. Findings: During concurrent interview and record review on April 24, 2024, at 6:30 AM, with the Director of Nursing (DON), the DON reviewed the Front Hall medication cart's narcotics shift count verification signature log (a form used by facility to verify counting of controlled drugs at the change of shift by oncoming and off going licensed nurses), dated March 2024 and April 2024. The log indicated the following: a. On March 20, 2024, missing signatures on the night shift (NOC) from Signature 1 (incoming nurse) and Signature 2 (outgoing nurse). b. On March 26, 2024, missing signature on NOC shift from Signature 1. c. On April 21, 2024, missing signatures on day shift from Signature 1 and Signature 2. d. On April 23, 2024, missing signatures on NOC from Signature 1 and Signature 2. The DON acknowledged the missing signatures for the above dates. The DON further stated her expectation is for licensed nurses to count at the beginning and end of shift and sign the sheet. I am not sure what happened. During interview on April 26, 2024, at 8:39, AM with Licensed Vocational Nurse (LVN 2), LVN 2 stated, We count narcotics together with incoming and outgoing nurse and we sign the sheet. LVN 2 further stated, I forgot to sign the narcotics sheet count verification signature log. It is simply a mistake. LVN 2 stated, We are responsible to count and sign at the beginning and end of each shift. During concurrent interview and record review on April 26, 2024 at 11:05 AM, with the DON, the facility's provided policy and procedure (P&P), titled Controlled Substances, revised November 2022, was reviewed. The P&P indicated, Dispensing and Reconciling Controlled Substances 3, Nursing staff count controlled medication inventory at the end of each shift, using these 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 . The DON stated, the licensed nurses have been educated to sign the shift confirmation for narcotics counts and it is expected that all licensed nurses count and verify at each shift.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles for one of one resident (Resident 247) when a bubble pack (a card that packages doses of medications within plastic bubbles organized by day and time of the day) containing morphine (medication used to treat pain) had no expiration date ( a date that indicates when medicine is no longer effective) written in the label. This failure had the potential to result in staff administering an expired medication to Resident 247 which can alter the efficacy (ability to produce desired effects) of the medications and reduce its therapeutic effectiveness. Findings: During a concurrent observation and interview on [DATE], at 6:15 AM, with the Director of Nursing (DON), the medication storage Cart 1 located at the front hallway, was inspected. A bubble pack containing Resident 247's Rx# (prescription number) 159536, Morphine Sulfate (MS), 15 milligrams (mg -a unit of measure), tablet (TAB) #10, dated [DATE], was inspected. The bubble pack contained 15 half tablets of morphine; the label did not have an expiration date. The DON stated, it is received by Registered Nurse (RN), RN verifies the medication with label and gets recorded on the narcotic log. The DON further stated, I know this one does not have an expiration date, but we can use all medications within one year of the order date. During a further interview on [DATE], at 7:54 AM with the DON, the DON stated, Unfortunately, we don't have the one-year use policy. I am going to check with our pharmacy consultant. During a telephone interview on [DATE], at 9:35 AM with the Pharmacy Consultant (PC), the PC stated he was not aware of Resident 247's Rx# 159536, MS 15 mg, TAB #10, order date [DATE]), had no expiration date. The PC further indicated, the standard for pharmacy is, for medications to have a label with an expiration date either written by hands or generated by computer. A review of the facility's policy and procedures (P&P) by [name of the pharmacy] policies and procedures titled, Medication Storage and Labeling,[ Undated], indicated, . All prescription medications used in the facility must have a pharmacy label that includes the following information: Expiration date of the effectiveness of the drug dispensed, . State of California Business & Professions Code, Chapter 9, Division 2, 4076 # 9, it indicated, the expiration date of the effectiveness of the drug dispensed.

Based on observation, interview, and record review, the facility failed to protect one of 40 residents (Resident 1), from abuse by licensed vocational nurses (LVN 1 and LVN 2) when: LVN 1 removed Resident 1 from bed and took Resident 1 from her room in a wheelchair neglecting Resident 1's request to use the restroom. LVN 1 and LVN 2 involuntarily secluded Resident 1 from other residents in the charting office by having Resident 1 remain in her wheelchair despite requesting to return to bed, and LVN 1 verbally abused Resident 1 for using her call light repeatedly. This failure resulted in psychosocial harm as evidenced by Resident 1's statement she urinated in her pants, and verbalizing nursing staff denied Resident 1's request to go back to her room and go to bed when Resident 1 desired to do so. Findings: During a phone interview with the DON, on September 9, 2015 at 2:00 PM, the DON stated, A licensed vocational nurse (LVN 1) made Resident 1 sit in a wheelchair at the nursing station because Resident 1 kept using the call light requesting help to get up. The DON stated, Resident 1 is alert, oriented, and sweet, can be needy, can make her needs known, and has occasional incontinence but can request to go to the restroom. The DON stated the incident occurred between 10:00 to 11:30 PM on September 7, 2015. The DON also stated CNA 1 and Resident 1 had been consistent (in their statements) about what happened to Resident 1 from both LVNs (LVN 1 and LVN 2). During an initial tour of the facility on September 9, 2015 at 4:45 PM, Resident 1 was observed sitting in a wheelchair in the facility's chapel. Resident 1 was well groomed. Resident 1's room was located on a hallway four doors down from the nurses' station. The nurses' station and the charting room were located on another hallway near the main entrance, adjacent to the Director of Staff Development (DSD) office. A record review of the facility's document titled, Admission Record, dated August 27, 2015, indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) fracture (broken bone) of the hip. A review of the Resident 1's history and physical dated, October 27, 2014, indicated Resident 1 was alert and oriented but had fluctuating capacity to participate in making care decisions. A review of the facility's document untitled and dated September 8, 2015, indicated a certified nursing assistant (CNA 1) reported an alleged incident of abuse to the Social Services Designee (SSD) and the Director of Nursing (DON). CNA 1 wrote in a written declaration she witnessed Resident 1 being yelled at and treated badly by two registry Charge Nurses (licensed vocational nurses, LVN 1 and LVN 2). During an interview with Resident 1, on September 9, 2015 at 4:45 PM, Resident 1 stated, I had used my call light and the nurse did not ask what I needed but put me in my wheelchair. I had to use the restroom and I ended up peeing in my pants. I asked a number of people to take me back to my room to go to bed but no one would. Resident 1 stated, They all said they could not take me until the half hour was up and I had to guess (it was) about six people. Resident 1 stated, I had not been treated this way before and LVN 1, the one who got me up, and then put me back in bed was the more aggressive of the two. During an interview with CNA 2 on September 9, 2015 at 5:05 PM, CNA 2 stated, I heard Resident 1 say she was hurting. I went into Resident 1's room to see if I could help. LVN 1 was in the room and told me she would take care of it. I checked on her in about fifteen minutes by the nurses' station and I said I could take her back to bed and was told, 'No,' by LVN 1. LVN 1 stated to Resident 1, 'You are going to learn today that you can't be on the call light like that today. During an interview with CNA 1, on September 24, 2015 at 8:15 AM, CNA 1 stated, I observed LVN 1 pushing Resident 1 'really fast' down the hallway and Resident 1 was in her pajamas. LVN 1 parked Resident 1 right in front of the nurses' station facing us. LVN 1 was talking very loud as she was pushing Resident 1 stating, 'I am not taking this tonight, I'm not dealing with this.' Resident 1 stated, 'I don't know what I did.' LVN stated, 'You know what you did - don't play stupid with me.' Resident 1 asked to go back to bed and LVN 1 stated, 'Oh no, you're staying out here. You just keep hitting your call light.' LVN 1's behavior was very threatening. Resident 1 started crying and LVN 1 put Resident 1 into the small (charting) office. During an interview with CNA 3, on November 14, 2015 at 4:30 PM, CNA 3 stated, I was walking by the nurses' station and saw Resident 1 in the office with two nurses (LVN 1 and LVN 2). And after I walked by the nurses' station, I sat down to chart at the nurses' station, one of the nurse's (LVN 1) pushed out a desk (from the office) and Resident 1 said she needed help. I asked her what she needed. Resident 1 said she wanted to go to bed. The Charge Nurse (LVN 1) said not to put her to bed right now. LVN 1 said Resident 1 kept pushing her call light and LVN 1 got her up out of bed. I wanted to help put Resident 1 to bed. I told her CNA that I would help her but her CNA said no because she was intimidated by LVN 1. A record review of the nurse's notes, dated September 7, 2015 at 9:17 PM, indicated Resident 1 was alert, with forgetfulness. No complaints of pain or discomfort noted at this time. Resident in bed at this time kept clean and dry and turned every two hours. A record review of the nurses' notes in the electronic health care record on January 13, 2016, indicated there are no nurses notes entered for Resident 1 after 9:17 PM on September 7, 2015. The next nurses' note entered was on September 8, 2015 at 7:57 AM for medication administration of insulin (medication for diabetes). A record review of the care plan on January 13, 2016, indicated Resident 1 had High risk for falls related to (r/t) unaware of safety needs, legally blind/history (hx) of fall, gait/balance problems, and listed as a nursing intervention, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. A review of two facility's documents titled, Interview Record, dated September 8, 2015, indicated CNA 1 and CNA 2 recorded in two written declarations Resident 1 stated to LVN 1, What did I do. LVN 1 stated to Resident 1, You know what you did. Resident 1 stated, No, I don't know. LVN 1 said, Don't play stupid, don't play that game with me as LVN 1 walked to the physician's office yelling at the same time. CNA 2 asked Resident 1 what was wrong and Resident 1 stated, Can I just please go to bed. CNA 2 told Resident 1 just a minute and then LVN 1 yelled, Don't take her back! LVN 1 yelled at Resident 1 and grabbed the wheelchair pushing Resident 1 into the (charting)office. Resident 1 asked again and both Charge Nurses (LVN 1 and LVN 2) told Resident 1, You can go back to bed in twenty minutes. LVN 1 stated to Resident 1, You are up because you continue to push the call light. A review of the facility's document titled, Interview Record, dated, September 8, 2015 noted LVN 2 wrote in a written declaration, We, no (LVN 1) got Resident 1 up. Resident 1 had her blanket/everything. (LVN 1) got her up because Resident 1's on the light so much. A review of the facility's document titled, Interview Record, dated September 8, 2015, indicated Resident 2, the roommate to Resident 1 stated, I just heard them tell her to shut up. A review of the facility's document titled, Nursing Staffing Assignment and Sign-In Sheet, dated September 7, 2015, indicated LVN 1 signed in for a twelve-hour shift from 7:00 PM to 7:00 AM and was assigned Rooms 34-47. LVN 1 was assigned Rooms 20-47 from 11:00 PM to 7:30 AM. LVN 2 signed in for a seventeen-hour shift from 7:00 AM to 12:00 PM midnight for Rooms 20 to 33. A review of the facility's document titled, Committee Review, dated September 9, 2015 at 2:22 PM, indicated CNA 1 observed LVN 1 roughly rolled Resident 1 again into the physician's office. CNA 1 observed LVN 1 loudly telling Resident 1 she had to stay up in wheelchair for twenty minutes because she pushes the call light too much. Resident 1 began to cry. After twenty to thirty minutes, LVN 1 assisted Resident 1 to her bed. A review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, dated 2005, indicated under 3a, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. A review of the facility's policy titled, Reporting Abuse to Facility Management, dated 2005, indicated under 2b, Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend, or disability. In the same policy under 2e, Mental abuse is defined as but not limited to humiliation, harassment, threats of punishment or withholding or treatment or services. A review of the facility's policy titled, Preventing Resident Abuse, dated 2005, indicated under 2i, Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g. using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.).

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from theft and loss when the resident's wallet with $120 and two major credit cards, checks, an insurance card and California Identification card were stolen from her purse. This failure resulted in emotional distress and verbalized mistrust of the facility for this resident. Finding: On October 2, 2014 at 4:20 PM, an unannounced visit was made to the facility to investigate an entity reported incident of a missing wallet. Review of the clinical record for Resident 1 indicated on the face sheet (contains resident demographics) Resident 1 was admitted to the facility on [DATE]. Review of the resident's inventory did not reflect a purse, wallet, money or credit cards had been brought to the facility at the time of admission or after the admission. During an interview with the facility Director of Nursing (DON) on October 2, 2014 at 4:22 PM, the DON stated Resident 1's wallet had not been recovered. During an interview with the facility Social Service Designee (SSD) on October 2, 2014 at 4:25 PM, the SSD was asked about Resident 1's missing wallet and money. The SSD stated the resident's family member had taken the purse home but had brought it back and given the resident's purse to a licensed nurse to keep in the medication room while the family member was on vacation. The SSD further stated the purse had been stored in the medication room because the facility did not have a safe to place it in. The SSD stated when the family member came back from vacation she retrieved the purse from the licensed nursing staff and left. The daughter returned a few minutes later and informed the licensed nurse that the client's wallet was missing. The SSD reported there had been other items which belonged to the facility, such as facility IPADs, which had been in the medication room at the same time as the purse, which had also come up missing. During a concurrent interview with the SSD and DON, they stated that the missing items were still being investigated but verbalized it must have been an employee that stole the wallet as they were the ones who had access to the purse. A continued interview with the DON was conducted. When asked who had keys to access the medication room, the DON stated that he was not aware of who else besides nursing may have had keys to the medication room. He stated the locks should have been changed after a new DON started working in the facility so the keys could be accounted for. During a brief tour of the facility conducted with the DON on October 2, 2014 at 4:50 PM, the medication room was observed. The medication room was a small room which would allow only one or two people at a time to use it. The medication room was located across from the nurses' station. The door to access the medication room contained a lock which required a key to open the door and enter. Once inside, several cabinets also required the same key to unlock them and access the contents. During an interview with Resident 1 on October 2, 2014 at 4:45 PM, Resident 1 was asked about her missing wallet. The resident appeared calm and pleasant. She stated her family member had the facility lock up her purse for her. When her family member had received the purse again, her wallet and everything in it were missing. She stated that she had not been reimbursed for the $120.00 that was in her wallet, or for the wallet itself. Resident 1 stated money had been charged on some of her credit cards but she had been reimbursed after her daughter had called and notified the credit card companies. She feels this is unacceptable and is upset by it. Resident 1 stated she was concerned it would happen again. During an interview with the facility Director of Staff Development (DSD) on October 15, 2014 at 3:33 PM, the DSD was asked what the protocol was for doing inventory of a resident's items. The DSD stated on admission to the facility the certified nurses aides (CNA) do an inventory of all items brought with the resident. If there were any other items brought after admission, the families were asked to check them in with the staff to be added to the facility inventory list. The DSD stated during a new protocol had been implemented, instead of items being kept in the medication room, the nurses were to have placed any items of value in the medication carts and were to count the items with a second nurse daily. This procedure had not been followed. When asked about Resident 1's missing wallet, the DSD further stated Resident 1's purse was not supposed to be in the medication room. The DSD stated the facility still does not know what happened to the resident's wallet and were continuing their investigation of the theft. The DSD explained that when staff sign an item out to family members they were supposed to inventory it first and then inventory it again when it was signed back in. Resident 1's family member had signed out the purse and taken it home after the resident was admitted to the facility. When the family member was going to go on vacation she brought the purse back in case Resident 1 needed it. The contents were not inventoried by staff when the daughter left the purse with them. The staff failed to follow protocol and did not inventory the contents of the purse when the family left it with the licensed nurse to lock in the medication room or before returning the purse to the daughter. During an additional interview with the SSD on October 15, 2014 at 4:15 PM, the SSD stated Resident 1 had not been reimbursed for her missing money or wallet yet. The SSD stated the resident had not yet asked for reimbursement. The credit card companies had already reimbursed any money that had been stolen on the cards. During an interview with a licensed vocational nurse (LVN 1) on October 15, 2014 at 4:44 PM, LVN 1 was asked about the policy for valuable items when the resident or family would ask for them to be locked up for safety by the facility. She stated that the staff would inventory everything with another nurse when it was given to them. LVN 1 stated that the items were then stored in the medication room and kept locked up. When the resident would ask for the item, they just gave it to them, they did not inventory it. The resident was trusted with their items. When the resident would give the item back to them they locked it back in the medication room without making sure that everything had been returned that was on the initial inventory. LVN 1 stated the licensed nurses had not been counting valuables entrusted into their care on a daily basis. A review of the report of the investigation provided by the facility, indicated Resident 1's family member had discovered that the resident's wallet was missing on September 15, 2014. The report indicated that there had been three charges attempted on Resident 1's major credit card. There was no documentation found to indicate an inventory of the contents of the resident's wallet had been taken when the wallet was given to LVN by the daughter for safe keeping for Resident 1. A message received from the facility DSD on October 17, 2014, indicated that the resident had requested to have a bill paid in lieu of being reimbursed for the wallet. The bill, totaling $150.00, was paid for Resident 1. During a review of the facility policy and procedure titled, "Personal Property," undated, the policy indicated the following: "5. The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. 6. The facility will promptly investigate any complaints of misappropriation or mistreatment of [REDACTED]. The facility policy and procedure titled, "(Name of the Corporation facility belongs to), Safeguards for Cash Resources, Personal Property and Valuables of Residents,"undated, indicated the following: "1. Every facility shall account for any cash resources, personal property and valuables entrusted to the care or control of the licensee or facility staff. Money and valuables of residents shall not be commingled with those of another RCFE in compliance with ." The policy further indicated that no employee shall make expenditures from residents' resources and the staff "shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, "... "Records of residents' cash resources and other valuables entrusted to the licensee for safekeeping shall include a copy of the receipt."

Based on observation, interview, and record review, the facility failed to implement the care plan and supervise one of three residents (Resident 1). This failure caused Resident 1 to be left alone in her room, where she subsequently fell from her wheelchair and sustained a hematoma (a collection of blood outside of a blood vessel) and a laceration (cut in skin) to her nose. Findings: Resident 1 was admitted to the facility on [DATE], with the following diagnoses, muscle weakness, Alzheimer's disease (an irreversible, progressive brain disease that slowly destroys memory and thinking skills), and dementia (loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior). During a review on October 22, 2013, of the clinical record for Resident 1, an entry by Registered Nurse 1 (RN 1) in the progress notes on October 19, 2013, at 10:37 AM, noted the following: Res (resident) found lying on floor with wheelchair next to her with blood on floor and under res head. Chair alarm was attached, but did not go off when res fell . Res has laceration to right upper side of nose. Also bleeding from b/l (bilateral) nares (nostrils). Res breathing on own. No other obvious s/s (signs and symptoms) of injury. Res drowsy. Family notified at 0950 (9:50 AM). 911 called and Resident 1 transferred out to GACH (General acute care hospital) by paramedics at 10:15 AM. Record review on October 22, 2013 noted an entry in Resident 1's progress notes by RN 2, dated October 19, 2013, at 1600 (4:00 PM) which noted that, "Res came back from ER (emergency room ). Has 2 x 2 laceration sutured on her rt. (right) periorbital (around the eye) area. 4.5 x 3.5 of discoloration on RT. Periorbital area, 4 x 3.5 of discoloration on lt. (left) periorbital area, and 3 x 3 of discoloration on lt. hand observed. Hematoma on her forehead is 8 x 5." Record review on October 22, 2013, noted a care plan for Resident 1 initiated February 21, 2013, and revised September 18, 2013. Documentation on the care plan showed, " At risk for falls, res is unaware of safety needs, confusion, poor communication/comprehension..." Documented interventions included, "The resident...will not stay in her room alone." Further review of the clinical record for Resident A showed a "Fall Risk Assessment," dated September 10, 2013, and which indicated that Resident 1 had a fall risk score of 10. The assessment indicated that a "total score of 10 or above represents high risk." A review of the facility policies was conducted on October 31, 2013. A policy titled, "Care Plans-Comprehensive" revised 10/2010, noted the following, "An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident." A second policy titled, "Using the Care Plan," revised 8/2006, noted, "The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident." During an interview with the Director of Staff Development (DSD) conducted on October 22, 2013, at 3:30 PM, she stated that there was a problem with the "at risk for falls" care plan, for Resident 1, with the date initiated February 21, 2013, and revision date of September 18, 2013. The DSD acknowledged that when this information was entered into the computer system, it was done in a way that did not trigger for the CNAs to see that Resident 1 "will not stay in her room alone." The DSD acknowledged that a change was made on October 19, 2013, to the computerized care plan to trigger the CNAs to not leave Resident 1 alone, after Resident 1 had fallen and sustained a serious injury. During an observation on October 22, 2013, at 1:15 PM, Resident 1 was observed lying in her bed, with her eyes closed. Both eyes were noted to be discolored with purple bruising. Bed was low to the ground and fall mats were noted to be next to both sides of the bed. Resident 1 was nonverbal during this observation. During an interview on October 22, 2013, at 1:20 PM, with Certified Nurse Assistant (CNA 1), she stated that Resident 1 does not stand or walk, and that she is a two person (needs two people) transfer (moving from wheelchair to bed). CNA 1 further stated that Resident 1 was assigned to her for care on October 19, 2013. On that day, another CNA (CNA 2) transported Resident 1 from the dining room after breakfast and placed her in her room alone. CNA 1 stated, "I did not know that CNA 2 left her alone in her room until the housekeeper came up and said the Resident 1 was on the floor." CNA 1 further stated that Resident 1 has been sliding from her chair these past couple of weeks. During further interview CNA 1 stated, "The Tab alarm (a device that alarms when the cord that is attached to a part of the resident's clothing is disconnected from the alarm box used to alert staff to resident movement) must have slipped off her. It was intact, but not attached to her." "No, it was not alarming when we found her on the floor." An interview was conducted with RN 1 on October 22, 2013, at 3:00 PM. RN 1 stated, "After breakfast CNA 2, who usually does not take care of Resident 1, transported her after breakfast, from the dining room to Resident 1's room. CNA 2 left Resident 1 in her wheelchair alone in her room. She should have been placed in bed." RN 1 stated that Resident 1 is usually in her wheelchair in the hallway next to the nurses' station, "where we can watch her," or she is in her bed. I knew something was wrong when the housekeeper came running down the hallway saying, "resident is on the floor." During an interview on October 29, 2013, at 1:40 PM, with CNA 2, she stated that she was assigned to care for Resident 1 "lots of times." CNA 2 stated that Resident 1 could shout out, but could not answer questions and that she did not think that she could press a call light (to make her needs known). CNA 2 further stated, "Yes, I took her to her room after breakfast on October 19, 2013, but she was not assigned to me that day. I pulled her up in the wheelchair because she would slide forward. I turned her television (TV) on and I left the room. I was never told not to leave her alone. No, I have never seen it written to not leave her alone." CNA 2 stated, "We used to allow the dementia residents to stay by the nurse's station while the dining room is being cleaned after breakfast. But, now we have to take those residents and leave them alone in their room while the cleaning occurs. The Director of Nurses (DON) told us to do this." CNA 2 acknowledged that breakfast in the dining room usually ends between 8:45 AM to 9 AM. An interview was conducted with the Facility Housekeeper on October 29, 2013, at 2:15 PM. The housekeeper stated that on October 19, 2013, at 9:45 AM, he noticed Resident 1 on the floor of her room. Resident 1 had blood by her head. He stated, "I ran down the hallway and told the nurse right away." The facility policy titled, "Safety and Supervision of Residents", revised 12/2007, was reviewed on November 14, 2013. Under the heading, "Resident-Oriented Approach to Safety," the following noted; 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff. b. assigning responsibility for carrying out interventions. d. ensuring that interventions are implemented. Under the heading "Systems Approach to Safety," the following is noted, 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident assessed needs and identified hazards in the environment. During an interview with CNA 3, on October 29, 2013, at 2:20 PM, CNA 3 stated, She would take Resident 1 to her room after meals and would leave her in her wheelchair and turn her TV on. CNA further stated, the previous DON (Director of Nursing) had a rule to leave residents who were at risk for falls lined up in the hallway after meals, so they could be watched closer. Now, with the new DON, those residents are taken to their rooms, we turn on their TV or radio and they are left alone. CNA 3 stated, "I guess it did not look good with the residents all lined up in the hallway." During an interview with the DON on October 31, 2013, at 11:00 AM, he stated, "I do not like residents clogging the intersection (area where four hallways meet adjacent to the nurse's station)." The DON called this area "Time Square." The DON acknowledged that he expects staff to take all, including dementia residents to their rooms after meals, while they are waiting for activities to start. When asked about residents who should not be left alone (Resident 1) the DON stated, "Someone should have been there with her or they should bring the resident to where someone could watch them." Record review conducted on October 31, 2013, noted a minimum data set (MDS, a tool used by long-term care facilities for assessing and planning care for residents) dated September 10, 2013. The MDS noted under section C0700, "Staff Assessment for Mental Status," that Resident 1 had both short term and long term memory problems. Under section C1000, "Cognitive Skills for Daily Decision Making," that Resident 1 was severely impaired. During a second interview, via telephone, with CNA 1, on November 1, 2013, at 12:20 PM, CNA 1 stated, "I usually would leave Resident 1 in her wheelchair by the nurses' station. I did this because she is a fall risk and we could keep an eye on her better. CNA 1 stated, "No, I never saw it anywhere written down to not leave Resident 1 alone." CNA 1 stated that the new DON does not like residents lined up in the hallway. She stated that the nurses would ask the CNA's to leave Resident 1 at the nurses' station to watch her because her room was so far down the hallway. CNA 1 stated that she did not know on October 19, 2013 that Resident 1 was alone in her room and that Resident 1, "potentially could have been alone in her room for one hour, between breakfast ending and the housekeeper finding her on the floor."

Based on observation, record review and interview, the facility failed to ensure that a resident who had a deep tissue injury (DTI- a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on readmission to the facility, received the necessary treatment and services to promote healing and to prevent the development of pressure ulcers (injuries to the skin and underlying tissues that result from prolonged pressure on the skin) for 1 of 11 sampled residents (Resident 6). This failure resulted in the resident 's left heel DTI to progress to an unstageable pressure ulcer. Findings: A wound treatment observation of Resident 6's left heel unstageable pressure ulcer was conducted on 4/3/12 at 10:00 AM. RN 1 was observed to remove the old dressing from the resident's left heel. Observation revealed that three quarters of the pressure ulcer was covered with eschar (thick, leathery, dead tissue, usually black in color), the pressure ulcer was odorous with reddened tissue surrounding the pressure ulcer. RN 1 measured the pressure ulcer as: 8 cm (centimeters) length by 5 cm in width. RN 1 stated that the pressure ulcer had "just grown to that size over the last 2 weeks." A record review for Resident 6 was conducted on 4/3/12. Resident 6 was originally admitted to the facility on [DATE]with [DIAGNOSES REDACTED]. Resident 6 was admitted to the acute hospital on [DATE] for treatment of [REDACTED]. Further review of Resident 6's record showed that there was no documentation to indicate that Resident 6 had a pressure ulcer or deep tissue injury (DTI) at the time of his transfer to the acute hospital on [DATE]. During the hospital stay, review of the hospital documentation located in the facility record showed a photograph taken while Resident 6 was at the acute hospital of the resident ' s left heel with documentation below the photograph as follows: " DTI or unstageable, date 1/20/12, 5 cm x 3 cm, first observed: 1/20/12 ". Continued record review revealed the hospital ' s readmission orders [REDACTED]. The only orders documented under the treatment section were for an air mattress. Further record review showed an initial assessment of the resident's readmission to the facility dated 1/24/12 at 9:30 PM and documented by LVN 1. On page 12 of the admission initial assessment form, under section #4 titled " Skin Risk Assessment ", LVN 1 documented the resident ' s total score for being at risk for developing pressure ulcers was 18. The instructions for the total score were as follows: "Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers. (15 or 16 = Low Risk, 13 or 14 = Moderate risk, 12 or less = High risk) ". On page 14 of the initial assessment form, LVN 1 documented the following regarding the resident ' s left heel: Type of wound: suspected deep tissue injury 6 cm (centimeters) in length x 4.1 cm. in width. There was no other description of the pressure ulcer. There was no other documentation that indicated that the physician had been notified of the suspected deep tissue injury nor that a treatment order had been obtained. Continued record review revealed 2 care plans, one for pressure ulcer and one for diabetes mellitus dated 1/25/12. Under the interventions section of the pressure ulcer care plan, two of the interventions were documented as follows: "Assess/record/monitor wound healing at least weekly ... Report improvements and declines to MD. The resident requires air mattress on bed, keep heels elevated off of bed on pillows, to wear heel protectors when in bed. " Interventions listed on the diabetes mellitus care plan were documented as follows: "Inspect feet daily for open areas, sores, pressure areas, blisters, [MEDICAL CONDITION] or redness. Record review showed the facility's "history and physical examination [REDACTED]. There was no documentation on the H & P that made reference to the resident ' s left heel DTI. Review of the " Weekly Skin/Wound Notes " documented by the licensed nursing staff for the dates beginning 2/1/12 through 4/4/12 revealed the status of the resident ' s left heel DTI as follows: The weekly wound assessment documented by the licensed nurse dated 2/1/12, revealed that the suspected left heel DTI measured 6 cm x 5.7 cm. The left heel DTI measurements indicated that from 1/24/12 to 2/1/12 showed the width of the DTI had increased in size by 1.6 cm. from the previous measurement of 6 x 4.1 cm on 1/24/12 at the time of admission. The weekly wound assessment documented by the licensed nurse dated 2/15/12, revealed the suspected left heel DTI measured 7cm x 6.5 cm. with serosanginous (blood and serous fluid) drainage present. The licensed nurse documented that compared to the previous assessment, the "wound is deteriorated." Record review from 1/24/12 through 2/20/12 showed that the licensed nursing staff did not inform the physician that the resident ' s left heel DTI had deteriorated. The weekly wound assessment documented by RN 1 dated 2/20/12 revealed that the suspected left heel DTI measured 7.4 cm x 4 cm. RN 1 did not document whether the wound had any drainage or if the wound had deteriorated compared to the previous assessment on 2/15/12. There were no " Weekly Skin/Wound Notes " with measurements of the wounds documented between the dates of 2/21/12 through 3/19/12, and no documentation in the licensed progress notes of any referenced wound treatment or the progress or decline of the left heel DTI. The weekly wound assessment documented by licensed nurse dated 3/21/12, revealed that left heel unstageable pressure ulcer measured 7cm x 5 cm. The licensed nurse now identified the suspected left heel DTI as an unstageable pressure ulcer that had odorous drainage and that pain was present at the unstageable pressure ulcer site. The licensed nurse also documented that compared to the previous assessment, the "wound is deteriorated." The weekly wound assessment documented by licensed nurse dated 3/29/12, revealed that left heel unstageable pressure ulcer measured 2.2 cm x 9 cm. The licensed nurse documented that compared to the previous assessment, the "wound is deteriorated." The weekly wound assessment documented by licensed nurse dated 4/4/12, revealed that left heel unstageable pressure ulcer measured 9 cm x 6 cm. The licensed nurse documented that compared to the previous assessment, the "wound is deteriorated." Record review of the " Licensed Nurses Progress Notes " documented by the licensed nursing staff for the dates beginning 2/20/12 through 4/4/12, revealed the communication between the licensed nursing staff and the physician as follows: 2/20/12 - Faxed communication to the physician documented by RN 1 showed, " ...also pressure with L-shaped at the rear of heel 7.4cm x 4 cm. MD notified by fax. ... " 2/20/12-" Physician ' s Non-Emergency Fax Communication" documented by RN 1 revealed: "Res on left leg dry scaling weepy [MEDICAL CONDITION] (again) with a scar/skin tear 3.8 x 3.5 cm oval shape at the back side of the calf and 7.4 x 4 cm L/oval at the rear heel." " Do Tx (treatment) with cleanse with Normal Saline (NS - a solution of sodium chloride or salt and sterile water), and apply triple antibiotic ointment, apply Vaseline gauze (a fine mesh absorbant gauze with white petroleum) and wrap it. Change daily and PRN (as needed) for soiling. " " Is this Tx ok with you. " The faxed communication was signed by the physician on 2/23/12, however, RN 1 had failed to accurately describe the left heel DTI, which could lead the physician to believe that the left heel wound was a skin tear and not the more serious DTI. 3/21/12: Licensed Nurses Progress Note - LVN 2 documented that, "Called Dr. (name of physician) to report pressure ulcer to heel is getting worse is 7 x 5 cm black in color with drainage. Requesting referral to wound clinic." 3/21/12 : Licensed Nurses Progress Note - LVN 2 documented that, "Called (Name of physician) to report pressure ulcer to heel is getting worse, is 7 x 5 cm black in color with drainage....Will call back with orders." The physician called back on 3/21/12 with orders documented by LVN 2 that showed, " May be evaluated and treated at (name of wound clinic). " 3/29/12: Licensed Nurses Progress Note - LVN 3 documented that, "F/U (follow-up) call to wound clinic placed 3/28/12. Initial call made 3/21/12. I (LVN 3) was told awaiting supervisor review. Physician notified." Review of the physician's order [REDACTED]. Beginning on 2/23/12, physician's order [REDACTED]. A review of a form titled, " Physician ' s Non-Emergency Fax Communication" dated 2/20/12 revealed " Res on left leg dry scaling weepy [MEDICAL CONDITION] (again) with a scar/skin tear 3.8 x 3.5 cm oval shape at the back side of the calf and 7.4 x 4 cm L/oval at the rear heel. " " Do Tx (treatment) with cleanse with Normal Saline (NS - a solution of sodium chloride or salt and sterile water), and apply triple antibiotic ointment, apply Vaseline gauze (a fine mesh absorbant gauze with white petroleum) and wrap it. Change daily and PRN (as needed) for soiling. " " Is this Tx ok with you." Further review of the faxed communication showed that it was signed by the physician on 2/23/12, 3 days after it was sent to the physician. Review of the document showed that RN 1 had failed to accurately describe the left heel wound, which could lead the physician to believe that the left heel wound was a skin tear and not the more serious DTI. There were no physician's order [REDACTED]. 3/20/12: " Physician ' s Non-Emergency Fax Communication " RN 1 documented that: " Res have wound at the left heal getting worse 7x5 cm black, with drainage small amount, and toe has open sore 1.5 x 0.5 cm and calf also open wound 2 x 1.5 cm. " ... " Are you considering him to refer to wound clinic for eval and tx? " The physician faxed the communication back to facility on 3/21/12. The physician's response was " yes. " 3/21/12: physician's order [REDACTED]." 3/29/12: "Physician's Non-Emergency Fax Communication " - LVN 3 documented that, " (Name of Physician) FYI (For Your Information)-Still awaiting for appt with wound clinic (name of wound clinic). Initial call 3/21/12. F/U (Follow up) call made 3/28/12 was told paperwork awaiting Supervisor review. Left heel wound deteriorating. " The physician signed the order on 3/30/12 with no additional orders written. Review of Licensed Nurses Treatment Records from 2/23/12 through 4/2/12 revealed that the wound care recorded for the left heel DTI which was initiated on 2/23/12, was not the wound care ordered by the physician on the fax communication dated 2/20/12. The wound care documented on the treatment record was as follows: "Cleanse left heel with NS and apply [MEDICATION NAME] (a sterile, adhesive foam dressing used to handle moderate to heavily draining wounds), change daily and PRN of soiling." According to the treatment records, the fore-mentioned wound care was performed by the licensed nurses until 4/2/12. An interview was conducted with CNA 1 on 4/4/12 at 11:00 AM. CNA 1 was asked if she had seen the residents left heel DTI. CNA 1 stated yes, she had noticed the left heel wound, further stating that the CNA's remove all dressings before the residents are showered or bathed and that Resident 6 received a shower two times a week. CNA 1 stated that she did not notice much of a change in the wound during the month of March 2012. An interview with the admission LVN 1 was conducted on 4/4/12 at 12:00 PM. LVN 1 confirmed she had documented the left heel DTI. LVN 1 was asked what the process was for when wounds were identified at the time of the admission assessment. LVN 1 stated, "You would notify the doctor." LVN 1 stated that she could not remember if she had called the physician regarding the resident's left heel DTI. She was then asked if she had obtained wound care orders from the doctor for the left heel DTI. LVN 1 stated, "I don't remember but I don't think I did." LVN 1 stated that she should have called the physician and obtained an order for [REDACTED]. An interview with DON was conducted on 4/4/12 at 12:15 PM. The DON was asked if there were wound treatment nurses at the facility. The DON responded, "There are no wound treatment nurses, if it's yours (Resident), it's yours." The DON confirmed that weekly wound summaries included a head to toe assessment and that if the licensed nurse had identified a wound, the licensed nurse should call the physician and obtain an order and then implemented the order. When asked about Resident 6's left heel DTI, the DON stated that the resident did not come from the hospital with wound care orders, further stating that " because Resident 6 has diabetes mellitus, " he ' s gonna lose that foot. " The DON further stated that, "they (the physicians) were thinking that the antibiotics would take care of the DTI to the left heel. The DON confirmed that the licensed nurses failed notify the physician and obtain wound care orders for the left heel DTI until 2/20/12, approximately one month after the resident had been readmitted to the facility. An interview with RN 1 was conducted on 4/4/12 at 3:30 PM. RN 1 was shown the physicians supplemental order dated 2/20/12 (the initial contact with the physician regarding the left heel DTI) she was asked if she had identified the left heel wound as a DTI. RN 1 confirmed that she had not described the left heel wound as a DTI. RN 1 further stated that the resident already had the wound to the left heel; she was notifying the physician of the skin tear to the left leg. RN 1 was asked if the physician had known about the left heel DTI, why was there no wound care ordered. RN 1 did not respond.