Every finding on record at Rancho Mesa Care Center

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours for 15 sampled days during the fiscal year Quarter 4 of 2024 (July 1 - September 30) and Quarter 3 of 2025 (April 1 - June 30).This failure had the potential for all residents living in the facility to not receive services and advanced care activities specifically performed by a registered nurse including resident assessments, administration of intravenous medications, and general oversight of the residents' clinical needs either directly by the RN or indirectly by the Licensed Vocational Nurses or Certified Nursing Assistants for whom the RN was responsible for overseeing resident care.During a review of the facility's report titled, Payroll-Based Journal Staffing Data Report (PBJ report- a reporting system for staffing data), dated Fiscal Year (FY) Quarter 4, 2024 (July 1 - September 30), the PBJ report indicated the facility had no RN coverage for eight consecutive hours on six days (August 4, 10, 11, 31 of 2024; September 21, and 22 of 2024).During a review of the facility's report titled Payroll-Based Journal Staffing Data Report, dated FY Quarter 3, 2025 (April 1 - June 30), the PBJ report indicated the facility had no RN coverage for eight consecutive hours on nine days (April 20, 27 of 2025; May 11, 18 of 2025; June 16, 17, 18, 19, 20 of 2025) .During an interview on September 18, 2025, at 10:54 AM with the Director of Staff Development (DSD), the DSD stated he was the individual who calculated the Direct Hours Per Patient Day (DHPPD - Direct Care Service Hours Per Patient Day - a staffing standard for skilled nursing facilities in California that specifies the minimum number of direct care hours performed by direct caregivers per patient, per day). The DSD was asked to provide documentation to show the facility had a Registered Nurse working for eight consecutive hours on the sampled dates of August 4, 2024 (from FY Quarter 4, of 2024) and May 11, 2025 (from FY Quarter 3, of 2025). The DSD stated the facility used a DHPPD calculation worksheet (a worksheet used to calculate the total number of DHPPD hours) and payroll records for the calculation. The DSD further stated he would provide copies of the DHPPD worksheet and for both sampled dates.During a review of the DHPPD calculation worksheets and payroll records, dated August 4, 2024, and May 11, 2025, there was no documented evidence of any RN had worked at all on either of the two sampled days.During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on September 18, 2025, at 12:18 PM, the DHPPD calculation worksheets and payroll records, dated August 4, 2024, and May 11, 2025, were reviewed. The ADON acknowledged there was no documented evidence that an RN worked in the facility on those dates (August 4, 2024, and May 11, 2025) and stated on the dates sampled, she was the Director of Nursing (DON) at that time and although they had an RN scheduled to work on those days, they had call-offs and did not have RN coverage at all. The ADON further stated that the facility had some trouble with RN coverage on the weekends in the past as was indicated on the PBJ staffing report.During a follow up interview on September 18, 2025, at 1:45 PM, with the ADON, the ADON stated the RNs in the facility were responsible for tasks such as administering intravenous medications (medications administered into the veins), admitting patients, assessment of residents and provided supervision and clinical oversight for all Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs).During an interview on September 18, 2025, at 1:52 PM, with the Administrator (ADMIN), the ADMIN stated an RN was supposed to be working in the facility every day, seven days a week, for at least 8 consecutive hours. The ADMIN further stated he was not currently aware the facility had issues with RN coverage on the weekends and stated he himself had only been working at the facility since August 4, 2025 (about a month and a half prior to the interview).During a review of the facility's job description for a Registered Nurse titled, RN Nurse Supervisor, (undated), the job description indicated, The primary purpose of your position is to supervise the day-to-day clinical activities of the facility to ensure that the highest quality of care is maintained at all times. Such supervision must be in compliance with all current federal, state, and local laws, rules, regulations, and guidelines.During a review of the facility policy and procedure titled, Staffing, Sufficient and Competent Nursing, Revised August 2022, the policy indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 10) reviewed for pressure ulcers (injury to skin and underlying tissues that develops as a result of prolonged pressure, shear, or friction) had a low air loss mattress (LAL mattress - a specialized mattress which is air filled and is designed to help prevent and treat pressure ulcers) which was programmed for Resident 10's weight. Additionally, documentation regarding verification for the settings the low air loss mattress was incomplete in Resident 10's clinical record.These failures resulted in the low air loss mattress to not have the most therapeutic effect for the prevention and treatment of pressure ulcers and for Resident 10 to have increased risk for the development of new pressure ulcers and a delay in wound healing.During a review of Resident 10's admission Record (contains medical and demographic information) indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included muscle wasting and atrophy (loss of muscle tissue and mass), protein-calorie malnutrition (inadequate intake of protein and calories), and dementia (condition which causes a decline in mental functioning that can interfere with daily life).During a review of Resident 10's physician's orders, an order dated August 22, 2025, indicated, LAL mattress every shift for wound management.During a review of Resident 10's physician's orders, an order dated September 1, 2025, indicated, Set LAL [mattress] setting according to patients weight every shift.During a review of Resident 10's care plan (an individualized plan for the medical care of a resident) titled, At risk for skin breakdown and/or development of pressure injury due to: Impaired ADL [activities of daily living] function.thin and fragile skin . dated July 21, 2025, the care plan included the goal, skin will remain free from tissue or skin injury through preventative nsg [nursing] measures x 3 months [for three months]. Interventions for the care plan included, .maintenance tx [treatment] as ordered [as ordered by the physician].During a review of Resident 10's care plan titled, The resident has potential/actual impairment to skin integrity r/t [related to] fragile skin. The goal of the care plan indicated, the resident will maintain or develop clean and intact skin by the review date. Interventions listed included, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible.During a review of Resident 10's History and Physical Examination, (H&P) dated August 22, 2025, the H&P indicated Resident 10 weighed 153 pounds (lbs - unit of measure).During a review of Resident 10's Treatment Administration Record (TAR - a document used to record the completion of treatments and tasks), dated September 1, 2025, through September 30, 2025, the TAR indicated the following:-For the task LAL mattress every shift for wound management, there were six out of 15 days where staff did not document completion of the task for at least one shift (September 1, 2, 3, 7, 11, 14) and the documentation was blank.-For the task Set LAL setting according to patient's' weight every shift, there were 48 out of 51 shifts where staff did not document completion of the task and the documentation was left blank.During an observation on September 18, 2025, at 9:20 AM, in Resident 10's room, Resident 10 was lying in a bed with a LAL mattress. The LAL mattress had a setting for 150 lbs but it was not set to that setting and instead was set to 210 lbs.During an interview on September 18, 2025, at 9:27 AM, with the Wound Care Nurse 1 (WCN 1), WCN 1 confirmed Resident 10's low air loss mattress was set to 210 lbs incorrectly and stated it should have been set to 150 lbs but it wasn't. WCN 1 further stated she changed the weight setting when she noted it was incorrect.During a concurrent interview and record review on September 18, 2025, at 9:51 AM, with the DON, Resident 10's TAR dated September 1, 2025, through September 30, 2025, was reviewed. The DON stated It was important that LAL mattresses are set to the correct weight because the weight setting changes the airflow of the mattress to be most beneficial to the resident. The DON further acknowledged there were blanks on the TAR for the tasks LAL mattress every shift for wound management, and set LAL mattress according to patient's weight every shift, and stated the LAL mattress was supposed to be documented by staff to ensure it was programmed for the correct weight but the documentation was missing on multiple shifts.During a review of the facility's policy and procedure tilted, Support Surface Guidelines, revised September 2013, the policy indicated, The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown.4. Elements of support surfaces that are critical to pressure ulcer prevention and general safety include pressure redistribution, moisture control, shear reduction, heat dissipation/temperature control, friction control, infection control.1. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed.During a review of the facility's policy and procedure titled, Charting and Documentation, revised July 2017, the policy indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.3. Documentation in the medical record will be objective.complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 6) reviewed for accidents had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) on both sides of her bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident), and physician's orders. In addition, documentation verifying the placement of the fall mats was inconsistent in Resident 6's clinical record.This failure had the potential for Resident 6 to sustain a serious injury during a fall in which the severity of the injury may have been lessened if the fall mat had been in place.During a review of Resident 6's admission Record (contains medical and demographic information), the admission Record, indicated Resident 6 was admitted on [DATE], with diagnoses which included dementia (a brain disorder that causes a progressive decline in memory, thinking, and social abilities), hypertension (high blood pressure), unspecified psychosis (when a person presents with hallucinations, delusions, or disorganized thinking or behavior without a clear underlying cause), and disorders of bone density and structure (conditions that weaken bones, making them more susceptible to fractures).During an interview on September 16, 2025, at 10:09 AM, with Resident 6's family representative (FR), FR stated Resident 6 sustained a fall in the facility but could not recall when it occurred. FR further stated Resident 6 had an accident which left her with neurological damage (damage affecting the brain, spinal cord, and/or nerves) and as a result, Resident 6 constantly felt as though she was experiencing the feeling of falling.During an observation on September 18, 2025, at 2:43 PM, in Resident 6's room, with Wound Care Nurse 1 (WCN 1), Resident 6 was observed to be lying on her left side while in her bed. Resident 6 had a fall matt on one side of her bed while the other side of her bed had no fall matt. WCN 1 acknowledged Resident 6 only had a fall mat on only one side of her bed and stated she did not know why the resident did not have a fall matt on each side of the bed.During an interview on September 18, 2025, at 2:55 PM, with the Assistant Director of Nursing (ADON), the ADON stated Resident 6 was supposed to have floor mats on each side of her bed.During an interview on September 18, 2025, at 3:22 pm, with the Director of Nursing (DON), the DON stated the purpose of floor mats next to a resident's bed was to help prevent injury in case the resident experienced a fall.During a review of Resident 57's physician's orders, an order dated August 26, 2025, indicated May have bilateral padded floormats as safety precaution R/T [related to] fall risk. Monitor placement every shift.During a concurrent interview and record review on September 18, 2025, at 4:23 PM, with the ADON, Resident 6's Medication Administration Record (MAR - a document used to record the administration of medications) dated September 1, 2025, through September 30, 2025, was reviewed. The MAR indicated, May have bilateral padded floormats as safety precaution R/T [related to] fall risk. Monitor placement every shift. The responses to this were either Y (yes) or N (no) and 11 out of 52 shifts indicated N (no) for the verification of bilateral floor mats. The ADON acknowledged there were multiple shifts where N was documented and the ADON stated nursing staff was not correctly documenting the verification of floor matts in Resident 6's clinical record.During a review of Resident 57's care plan titled Risk for falls, dated July 27, 2025, the care plan goal indicated, Her [Resident 6's] risk for fall will be reduced. Interventions for this care plan included, .Bilateral Padded floor mats.During a review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, revised March 2018, the policy indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.will implement a resident - centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.During a review of the facility's policy and procedure titled, Charting and Documentation, Revised July 2017, the policy indicated, .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) administered medications within 1 hour of their scheduled administration time for one of twelve (12) sampled residents (Resident 57) reviewed for medication administration when Resident 57 received two medications (omeprazole - a medication used to decrease the amount of acid in the stomach, and empagliflozin - a medication used to treat diabetes [condition characterized by high blood sugar] or heart failure) one hour and twenty five minutes before they were scheduled to be administered on September 16, 2025.This failure resulted in the medications to not be administered in accordance with the facility's policy and procedure and for the omeprazole to not be administered as specified by the physician's orders (30 minutes prior to a meal). This had the potential for the omeprazole medication to have a diminished effect in preventing acid reflux.A review of Resident 57's admission Record (contains medical and demographic information), indicated Resident 57 was admitted to the facility on [DATE], with diagnoses which included morbid (severe) obesity (overweight), heart failure (condition where the heart cannot pump blood effectively enough to meet the body's needs), and dependence on supplemental oxygen (requires the use of oxygen when breathing).During an observation on September 17, 2025, at 5:03 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was preparing to administer medications to Resident 57. LVN 1 was reviewing the electronic Medication Administration Record (MAR - a document used to record medications administered to the resident which includes scheduled administration times of medications). LVN 1 stated Resident 57's Omeprazole and empagliflozin medications were scheduled to be administered at 0630 but he was going to administer it now (at 5:05 am).During an observation on September 17, 2025, at 5:05 AM, with LVN 1, LVN 1 administered one capsule of Omeprazole 20 milligrams (mg - unit of measure) DR (delayed release) and one tablet of empagliflozin 25 mg to Resident 57 by mouth.During an interview on September 17, 2025, at 5:41 AM, with LVN 1, LVN 1 acknowledged he administered Resident 57's omeprazole and empagliflozin medications one hour and twenty five minutes prior to their scheduled administration time and stated he did it because the resident preferred to receive all her medications as soon as she woke up.During an interview on September 17, 2025, at 5:42 AM, with the Infection Preventionist (IP), the IP stated medications were only supposed to be administered up to one hour before or one hour after their scheduled administration time. The IP further stated if a resident had a preference to receive their medications at a different time than was scheduled, the facility was supposed to get a physician's order to administer the meds at a different time or the facility could change the scheduled administration time on the MAR.During a follow up interview on September 17, 2025, at 5:50 AM, with the IP, the IP stated she reviewed Resident 57's physicians orders and was unable to find an order indicating it was ok acceptable to administer medications more than one hour prior to their scheduled administration time.During a concurrent observation and interview on September 17, 2025, at 8:39 AM, with Resident 57, in Resident 57's room, a staff member brought in Resident 57's breakfast food tray. Resident 57 stated she had not received food or snacks after she took her am medications at 5:05 AM (over three and a half hours had passed since she was given omeprazole to the time she received her breakfast tray). Resident 57 stated she occasionally gets acid reflux (heartburn) and stated she had never told anybody she prefers to receive her omeprazole at 5:00 AM. Resident 57 further stated, that's just the time they have given it to me since I've been here.During a review of Resident 57's MAR dated September 1, 2025, through September 30, 2025, the MAR indicated Resident 57's omeprazole and empagliflozin medications were both scheduled to be administered at 6:30 AM (LVN 1 had administered both medications one hour and twenty five minutes early).During a review of Resident 57's physician's orders, an order dated April 18, 2025, indicated Omeprazole oral tablet delayed release 20 mg.give 1 tablet by mouth one time a day for acid reflux.give 30 mins (minutes) before meals.During an interview on September 17, 2025, at 9:16 AM, with the Director of Nursing (DON), the DON stated medications were supposed to be administered up to one hour before or one hour after their scheduled administration time.During a review of the facility's policy and procedure titled, Administering Medications, revised April 2019, the policy indicated, .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. 5. Medication administration times are determined by resident need and benefit, not staff convenience.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% when the medication error rate was 7.69%, with two errors in 26 opportunities, when Licensed Vocational Nurse 1 (LVN 1) administered two medications (Omeprazole - a medication used to help prevent acid reflux [condition where stomach contents flow back up to the esophagus causing irritation and inflammation] and Jardiance - a medication used to treat people with heart failure or diabetes [condition characterized by high blood sugar] to one of 12 sampled residents observed for medication administration (Resident 57).This failure resulted in the medications to not be administered in accordance with the facility's policy and procedure and for the omeprazole to not be administered as specified by the physicians' orders (30 minutes prior to a meal). This had the potential for the omeprazole medication to have a diminished effect in preventing acid reflux.A review of Resident 57's admission Record (contains medical and demographic information), indicated Resident 57 was admitted to the facility on [DATE], with diagnoses which included morbid (severe) obesity, heart failure, dependence on supplemental oxygen (requires the use of oxygen).During an observation on September 17, 2025, at 5:03 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was preparing to administer medications to Resident 57. LVN 1 was reviewing the electronic Medication Administration Record (MAR - a document used to record medications administered to the resident which includes scheduled administration times of medications). LVN 1 stated Resident 57's Omeprazole and empagliflozin medications were scheduled to be administered at 0630 but he was going to administer it now (at 5:05 am).During an observation on September 17, 2025, at 5:05 AM, with LVN 1, LVN 1 administered one capsule of Omeprazole 20 milligrams (mg - unit of measure) DR (delayed release) and one tablet of empagliflozin 25 mg to Resident 57 by mouth.During an interview on September 17, 2025, at 5:41 AM, with LVN 1, LVN 1 acknowledged he administered Resident 57's omeprazole and empagliflozin medications one hour and twenty five minutes prior to their scheduled administration time and stated he did it because the resident preferred to receive all her medications as soon as she woke up.During an interview on September 17, 2025, at 5:42 AM, with the Infection Preventionist (IP), the IP stated medications were only supposed to be administered up to one hour before or one hour after their scheduled administration time. The IP further stated if a resident had a preference to receive their medications at a different time than was scheduled, the facility was supposed to get a physician's order to administer the meds at a different time or the facility could change the scheduled administration time on the MAR.During a follow up interview on September 17, 2025, at 5:50 AM, with the IP, the IP stated she reviewed Resident 57's physicians orders and was unable to find an order indicating it was ok acceptable to administer medications more than one hour prior to their scheduled administration time.During a concurrent observation and interview on September 17, 2025, at 8:39 AM, with Resident 57, in Resident 57's room, a staff member brought in Resident 57's breakfast food tray. Resident 57 stated she had not received food or snacks after she took her am meds at 5:05 AM (over three and a half hours had passed since she was given omeprazole to the time she received her breakfast tray). Resident 57 stated she occasionally gets acid reflux (heartburn) and stated she had never told anybody she prefers to receive her omeprazole at 5:00 AM. Resident 57 further stated, that's just the time they have given it to me since I've been here.During a review of Resident 57's MAR dated September 1, 2025, through September 30, 2025, the MAR indicated Resident 57's omeprazole and empagliflozin medications were both scheduled to be administered at 6:30 AM (LVN 1 had administered both medications one hour and twenty five minutes early).During a review of Resident 57's physician's orders, an order dated April 18, 2025, indicated Omeprazole oral tablet delayed release 20 mg.give 1 tablet by mouth one time a day for acid reflux.give 30 mins (minutes) before meals.During an interview on September 17, 2025, at 9:16 AM, with the Director of Nursing (DON), the DON stated medications were supposed to be administered up to one hour before or one hour after their scheduled administration time.During a review of the facility's policy and procedure titled, Administering Medications, revised April 2019, the policy indicated, .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. 5. Medication administration times are determined by resident need and benefit, not staff convenience.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure one discontinued medication was removed from the Intravenous (IV) medication cart when one box of Bio Patches (specialized disc dressings that are used to prevent insertion site infections) were expired and available for use.This failure had the potential for the medication to be administered incorrectly which may cause harm to 56 residentsFindings:During a concurrent observation and interview on [DATE], at 2:20 PM, with a Licensed Vocational Nurse (LVN), the LVN inspected a box of Bio Patches from the IV medication cart. The box contained 10 patches, and the label indicated an expiration date of [DATE]. The LVN stated, Yes they are expired. During a concurrent interview and observation on [DATE], at 3:15PM, with the Director of Nursing (DON), the DON inspected and acknowledged the expiration date of the Bio Patches. The DON further stated the expired box should not have been in the IV cart.During a concurrent interview and record review on [DATE], at 3:45 PM, with the DON, the facility's policy and procedure (P&P), titled, [name of the pharmacy] Policy and Procedure Manual, dated, [DATE] was reviewed. The P&P indicated, Procedures. m. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures shall be immediately removed from stock, disposed of according to procedures for medication disposal (and reordered from the pharmacy if a current order exits). The DON stated the policy was not followed.During a concurrent interview and record review on [DATE], at 4:00 PM, with the DON, the P&P titled, Medication Labeling and Storage, dated February 2023, was reviewed. The P&P indicated, . 3. If the facility has discontinued, outdated, or deteriorated [medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The DON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control policies and procedures when:1) Licensed Vocational Nurse 2 did not perform hand hygiene (hand washing or the use of alcohol-based hand rub [ABHR]) between the administration of medications to two Residents (Residents 53 and 47). In addition, Resident 47 was on Enhanced Barrier Precautions (EBP - a set of infection control practices designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes. They focus on using personal protective equipment (PPE) like gowns and gloves during specific high-contact resident care activities for residents at increased risk of acquiring or known to be colonized or infected with an MDRO).2) Licensed Vocational Nurse 2 (LVN 2) only had one glove on when checking Resident 47's blood sugar (measurement of the amount of blood glucose [sugar] by pricking the finger and obtaining a drop of blood for sampling). Additionally, LVN 2 also only wore one glove when administering a shot of insulin (medication administered under the skin to help regulate blood sugar levels).These failures resulted in increased risk for the cross contamination (the spread of microorganisms from one surface to another) of infectious microorganisms within the environment and amongst a vulnerable population of 57 residents who lived in the facility.1)A review of Resident 53's admission record, indicated Resident 53 was admitted to the facility on [DATE], with diagnoses which included muscle weakness, anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear and nervousness that can interfere with daily life, and schizophrenia (a mental health condition that affects how people think, feel and behave). A review of Resident 47's admission Record (contains medical and demographic information), indicated Resident 47 was admitted to the facility on [DATE], with diagnoses which included Chronic viral Hepatitis C (a long-term liver infection caused by the Hepatitis C virus), hemiplegia and hemiparesis (weakness and paralysis) affecting right dominant side, and hypertension (high blood pressure).During an observation on September 17, 2025, at 5:30 AM, with LVN 2, in Resident 53 and Resident 47's shared room, the doorway leading into the room had a sign which indicated Resident 47 was on EBP. LVN 2 administered an oral (by mouth) medication levothyroxine (medication used to treat low thyroid activity) to Resident 53. LVN 2 did not perform hand hygiene after administering the medication and went to the medication cart (med cart - a cart which contains medications) and retrieved Resident 47 pantoprazole (medication used to decrease the amount of acid in the stomach).During continued observation on September 17, 2025, at 5:32 AM, with LVN 2, in Resident 53 and Resident 47's shared room, LVN 2 administered Resident 47 pantoprazole medication and had not performed hand hygiene at any time after administering medications to Resident 53.During an interview on September 17, 2025, at 5:42 AM, with the Infection Preventionist (IP), the IP stated staff were supposed to perform either hand washing or use hand sanitizer between residents.During an interview on September 18, 2025, at 2:31 PM, with the Director of Nursing (DON), the DON stated it was important that staff perform hand hygiene between residents to help prevent the spread of infection. The DON further stated residents on EBP have a history of infection or have an indwelling medical device that makes them susceptible to infection.During a review of Resident 47's physician's orders, an order dated September 15, 2025, indicated Resident 47 had a foley catheter (a thin, flexible tube inserted into the bladder to drain urine).During further review of Resident 47's physician's orders, an order dated September 15, 2025, indicated, Foley catheter use: monitor for s/s [signs and symptoms] of infection.During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised August 2019, the policy indicated, This facility considers hand hygiene the primary means to prevent the spread of infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents; c. Before preparing or handling medications.2) A review of Resident 47's admission Record (contains medical and demographic information), indicated Resident 47 was admitted to the facility on [DATE], with diagnoses which included Chronic viral Hepatitis C (a long-term liver infection caused by the Hepatitis C virus), hemiplegia and hemiparesis (weakness and paralysis) affecting right dominant side, and hypertension (high blood pressure).During an observation on September 17, 2025, at 5:35 AM, with LVN 2, in Resident 47's room, LVN 2 put on one glove on his right hand and did not put a glove on his left hand. LVN 2 then checked Resident 47s blood sugar by using his ungloved hand to hold a lancet (a device which creates a pinprick to create a drop of blood) and prick Resident 47's finger. After lancing Resident 2's finger, LVN 2 then used his ungloved hand to grasp a glucometer (device which tests blood for blood sugar measurement) and test Resident 47's drop of blood. After LVN 2 was finished checking Resident 47's blood sugar, he removed his glove and discarded it.During an observation on September 17, 2025, at 5:38 AM, with LVN 2, in Resident 47's room, LVN 2 obtained two units of Insulin into a syringe with needle. LVN 2 then put on one glove on his right hand and did not put a glove on his left hand. LVN 2 then used his ungloved hand to administer Resident 47's shot of insulin subcutaneously. As LVN 2 was administering the shot, the Infection Preventionist (IP) walked into Resident 47's room and observed LVN 2 administer the insulin injection to Resident 47 with an ungloved hand.During an interview on September 17, 2025, at 5:41 AM, with LVN 2, LVN 2 acknowledged he only used an ungloved hand when checking Resident 47's blood sugar and when administering Resident 47's subcutaneous shot of insulin. LVN 2 further stated he only put on one glove during these two tasks because he was so focused on ensuring he was performing handwashing correctly.During an interview on September 17, 2025, at 5:42 AM, with the IP, the IP stated staff were supposed to wear two gloves when checking residents' blood sugar levels and when administering injections and staff were not supposed to only have one gloved hand.During an interview on September 18, 2025, at 2:30 PM, with the Director of Nursing (DON), the DON stated staff should be wearing two gloves when performing a task which requires the use of gloves which included administering an injection or using a glucometer to check blood sugar levels.During a review of the facility's policy and procedure titled, Personal Protective Equipment - Gloves, dated 2001, the policy indicated, .3. The use of gloves will vary according to the procedure involved. The use of disposable gloves is indicated: a. when it is likely that the employee's hands will come in contact with blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin while performing the procedure; .g. During invasive procedures.

Based on interviews, and record reviews, the facility failed to follow its policy and procedure for activities of daily living (ADL) to provide care and services for residents who are unable to carry out ADLs independently for one of four sampled residents. This failure has the potential to put clinically compromised resident (Resident 1) health and safety at risk when Resident 1 ' s request for a diaper change was approximately delayed for 3 hours. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses that hemiplegia ( is a condition that causes paralysis or weakness on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing). During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated February 5, 2025, indicated, Resident 1 ' s score was a 11, which indicated Resident 1 had moderate cognitive (ability to think, learn, remember and make decisions) impairment. During a review of the Minimum Data Set (MDS) section GG-Functional Abilities (focuses on a resident ' s functional abilities and goals, specifically assessing self-care and mobility performance to capture the level of assistance needed), dated February 5, 2025, indicates Resident 1 scored a 1 in toileting hygiene, reflecting complete dependence and inability to maintain personal hygiene independently. During an interview with Resident 1 on March 18, 2025, at 9:35 AM, Resident 1 stated on one occasion, she had requested a diaper change with her assigned certified nursing assistant (CNA 1), to which CNA 1 responded that she only perform diaper changes once per shift. During a telephone interview with CNA 1 on March 18, 2025, at 11:16 AM, CNA 1 stated she changed Resident ' s 1 diaper around 5:00 PM and again at around 10 PM during her shift, when Resident 1 asked for another diaper change, CNA 1 stated she did not fulfill Resident 1 ' s request because it was already 11:00 PM and her shift had ended. During a telephone interview on March 18, 2025, at 12:09 PM, with the certified nursing assistant (CNA 2) assigned to Resident 1 following CNA 1 ' s shift. CNA 2 stated she did not see who the outgoing CNA (CNA 1) was, who worked the 3:00 PM to 11:00 PM shift. CNA 2 stated she remembers changing Resident 1 ' s diaper twice during her shift, once at around 2:00 AM and again at around 5:00 AM. During a review of Resident 1 ' s care plan, initiated on June 4, 2024, it was noted that Resident 1 has a care plan addressing bowel incontinence related to immobility, as well as a separate care plan for bladder incontinence also related to impaired mobility. Both care plans include interventions to provide peri-care (refers to cleaning and maintenance of the genital and anal areas) following episodes of incontinence. During a concurrent interview and record review on March 18, 2025, at 12:16 PM, with the Director of Nursing (DON), the DON was informed about CNA 1 not changing the diaper of Resident 1 and failing to communicate this to CNA 2, as a result, Resident 1 ' s request for diaper change was delayed for approximately three hours. The DON stated it should have been communicated properly and that she would investigate the matter. During a review of the facility ' s policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated April 2018, the P&P indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, . The DON acknowledged that this policy was not followed.

Based on observation, interview and record review, the facility failed to follow the menu on Monday August 5, 2024, for lunch for 45 residents when: 1. The cook served 1/2 cup of mashed potatoes instead of 1/3 cup as indicated on the menu for the CCHO (carbohydrate controlled- diet involves eating the same number of carbohydrates every day, and the purpose is to help people manage their blood sugar levels) diets. 2. Facility did not have a way to ensure 4 oz (ounce - unit of measure) of meat was served for residents on the CCHO and regular diets, for lunch on August 5, 2024, as indicated on the menu. These failures have the potential for 45 of 52 highly vulnerable residents to have altered nutrition intake and weight loss. Findings: 1. During an observation of the kitchen's meal preparation and tray line (process where the cook serves food on plates for each resident) for lunch on August 5, 2024, at 11:45 AM with the Dietetic Services Supervisor (DSS) and [NAME] (Cook), [NAME] served residents on a CCHO diet, mashed potatoes using a #8 scoop (4 oz). During a review of the Cooks Spreadsheet, [undated], the lunch menu indicated the following serving sizes, Herb Mashed Potatoes for the CCHO diet, #12 scoop (3.25 oz). During an interview on August 5, 2024, at 3:37 PM with the Dietetic Services Supervisor (DSS), DSS stated the cook should follow the menu. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), the RD stated that the staff should always follow the menu. 2. During an observation of the kitchen's meal preparation and tray line for lunch on August 5, 2024, at 11:45 AM, with the DSS and Cook, after the cook plated a meal for a resident on a regular diet, the surveyor asked to validate the weight of the portion of meatloaf. DSS stated he could not verify the weight of the meatloaf served because they did not have an ounce scale. During an interview on August 5, 2024, at 3:37 PM with the Dietetic Services Supervisor (DSS), DSS stated the cook should follow the menu. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), the RD stated that the staff should always follow the menu. RD further stated that the expectation is that the menu is followed to ensure that the portion size is correct and a scale is needed to ensure portion size is correct. During a record review of the facility document titled, Cooks Spreadsheet the lunch menu indicated the meatloaf portion size for the regular diet as 4 oz. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2000, the P&P indicated: #4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician Orders, to the extent medically possible.

Based on observation, interview and record review, the facility failed to ensure food was stored/prepared under sanitary conditions when: 1. Shelf under coffee maker had crumbs and dust and this had the potential to attract pests and for microorganism (bacteria) growth. 2. Floor under shelves in the dry storage had a build-up of food crumbs, white crumbs under one shelf and a liquid spill which can attract pests and cause microorganism growth. 3. Old food and dust under the fridges stored in the staff lounge and this had the potential to attract pests and microorganism growth. 4. Ice machine had some black and yellow discoloration in the area where ice is formed which can potentially contaminate the ice. These failures had the potential to contaminate resident's food and cause food illness to 52 out of 52 vulnerable residents who receive food from the kitchen. Findings: 1. During an observation on August 5, 2024, at 9:40 AM in the kitchen, there was crumbs and dust in the bottom shelf where the coffee maker is stored. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), the RD stated the expectation is for everything to be tidy and there should be no crumbs or dust. During a review of the facility's policy and procedure (P&P) titled, Sanitation dated 2018, the P&P indicated, 9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 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. 2. During an observation on August 5, 2024, at 9:50 AM in the dry storage room, there was a build-up of food crumbs on the floor around the wheels of the metal shelves. There were white crumbs under one side of the shelves on the floor and a liquid spill present. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), the RD stated the floors should be kept clean. During a review of the facility's policy and procedure (P&P) titled, Sanitation dated 2018, the P&P indicated, 9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. 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. 3. During a concurrent observation and interview on August 5, 2024, at 3:31 PM with Dietetic Services Supervisor (DSS) in the break room, there was dust and old food underneath the refrigerator and freezer. The DSS acknowledged the presence of dust and old food underneath the refrigerator and freezer. DSS stated that housekeeping is responsible for cleaning around the refrigerator and freezer in the breakroom. During an interview on August 8, 2024, at 2:15PM with the RD, the RD stated the area underneath the refrigerator and freezer should be kept clean, up to the same standards that they have in the main kitchen. During a review of the facility's policy and procedure (P&P) titled, Sanitation dated 2018, the P&P indicated, 9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair. 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. 4. During a concurrent observation and interview on August 5, 2024, at 3:42 PM with Maintenance (MTN), in the presence of DSS, the area of the ice machine where the ice is formed was noted to have some black and yellow buildup. MTN acknowledges that there is black and yellow buildup in the ice machine. During an interview on August 8, 2024, at 2:15P with the RD, the RD stated that the ice machine is expected to be clean and free of any discoloration. During a review of Blueair Installation and User's Manual, dated 2022, indicated Depending on the installation condition, the machine may need more frequent cleaning and sanitizing. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, the P&P indicated, The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacture recommendations . During a review of the FDA Federal Food Code, dated 2022, 4-602.11 indicated, (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 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 ensure food was prepared in a form designed to meet individual needs when the regular diet (no modifications) meatloaf was not served to 26 residents who are on a medically prescribed mechanical soft diet (designed for people who have trouble chewing and swallowing) instead of meatloaf that is mashable and topped with gravy. This failure had the result to increase the risks of choking and aspiration (process when swallowing food enters the lungs) for 26 out of 52 highly vulnerable residents. Findings: During an observation in the kitchen on August 5, 2024, at 11:46 AM, the [NAME] (Cook) prepared a plate for a resident on a mechanical soft diet. She served the resident the regular diet meatloaf. During a review of the facility document titled, Cooks Spreadsheet - Summer Menus, [undated], indicated that mechanical soft diet meatloaf should be served mashable & moist with gravy. During an interview on August 5, 2024, at 3:37 PM with the Dietetic Services Supervisor (DSS), DSS stated the cook should follow the menu. During an interview on August 8, 2024, at with the Registered Dietitian (RD), the RD stated that the cook should serve the meatloaf with gravy to prevent aspiration and should follow the menu. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2000, the P&P indicated: #4. The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician Orders, to the extent medically possible.

Based on interview and record review, facility failed to ensure that a Minimum Data Set (MDS- a computerized assessment instrument) Discharge Assessment was completed and transmitted in accordance with federal guidelines for one of three residents (Resident 53) reviewed for residents assessment. This failure resulted in Resident 53's assessment not completed upon discharge on March 28, 2024. Findings: During a review of Resident 53's Admission Record (a document that contains demographic and clinical data), the Admission Record indicated, Resident 53 was admitted to the facility on [DATE], with diagnoses which included hyperlipidemia (an abnormally high concentration of fats or lipids in the blood) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a concurrent interview and record review, on August 9, 2024, at 9:15 AM, with the License Vocational Nurse/Minimum Data Set Nurse (LVN/MDS Nurse), the LVN/MDS Nurse reviewed Resident 53's clinical record dated March 28, 2024, indicated Resident was discharged home with home health services . Further review of Resident 53's MDS assessment, indicated last assessment was MDS Admission Assessment completed on February 15, 2024. The LVN/MDS nurse, confirmed no other MDS assessments had been completed since February 15, 2024. The LVN/MDS nurse stated he missed completing the discharged assessment for Resident 53 and it should have been completed on March 28, 2024. During an interview on August 9, 2024, at 9:25 AM with the Director of Nurses (DON), the DON stated the discharge assessment should have been completed on March 28, 2024. (The assessment was neither completed nor transmitted, and 133 days had passed since Resident 53's discharge date ). During a concurrent interview and record review on August 9, 2024, at 9:40 AM with DON, The DON reviewed the facility Policy and Procedure titled Resident Assessment, revised March 2022, which indicated, . A comprehensive assessment of every, resident's needs is made at intervals designated by OBRA[Omnibus Budget Reconciliation Act] and PPS [Prospective Payment System] requirements. Policy Interpretation and Implementation. Definitions OBRA-Required Assessments - are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes . 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. required assessments - conducted for all residents in the facility: . (7) Discharge Assessment (return anticipated and return not anticipated) . The DON stated that the facility did not follow the policy. During a review of CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) revised October 2023, it indicated, . OBRA -Required Tracking Records and Assessments are Federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. These assessments are coded on the MDS 3.0 in items A0310A (Federal OBRA Reason for Assessment) and A0310F (Entry/discharge reporting). They include: Tracking records o Entry o Death in facility Assessments o Admission (comprehensive) o Quarterly o Annual (comprehensive) o SCSA (comprehensive) o SCPA (comprehensive) o SCQA o Discharge (return not anticipated or return anticipated) .

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one of 55 sampled residents (Resident 58) when tube feeding (process where food is delivered into the stomach by a machine) was not administered based on physician order. This failure had the potential to result in decline in function and unplanned weight change to Resident 58. Findings: A review of Resident 58's Admission Record, (contains demographic and medical information), indicated Resident 58 was initially admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disruption of blood supply to the brain), aphasia (difficulty in talking), dysphagia (difficulty in swallowing), and debility (physical weakness). During an observation on August 6, 2024, at 9:45 AM, Resident 58 was laying in his bed. He was not able to answer questions and he appeared frail. His tube feeding was not connected and the machine was off. There was no tube feeding bag hanging next to the machine. During a concurrent interview and record review on August 6, 2024, at 10:00AM with Licensed Vocational Nurse/Minimum Data Set (LVN/MDS), LVN/MDS stated that the tube feeding was stopped at 9:40AM. During a review of Resident 58's physician orders, dated August 2, 2024, Physician order indicated, Osmolite 1.5 (therapeutic nutrition that provides complete, balanced nutrition for tube feeding for patients) at 60ml (milliliters - unit of measure) / hr (hour) x (times) 20 hours via enteral pump (a machine that delivers food to the stomach) .Turn on @ [at] 2:00PM, turn off @10:00 AM or until dose is consumed . During a concurrent observation and interview on August 6, 2024, at 10:30AM in Resident 58's room, LVN/MDS stated he discarded the tube feeding bottle in the trash can. The tube feeding bottle was labeled with Resident 58's name, room number, August 5, 2024 (date the formula bottle had been hung) and time 0900 [9:00AM] (date and time the feeding was started) and the rate of the administration which was 60 mls an hour (60 ml/hr - rate of nutrition administration via enteral pump). LVN/MDS stated that he was not able to calculate how much in total the resident received during his last feeding. During an interview on August 6, 2024, at 11:45AM with the Director of Nurses (DON), DON stated that the resident's tube feeding should be on for 20 hours from 2:00PM through 10:00AM at a rate of 60ml/hr. She stated that the tube feeding bottle was last hung on August 5, 2024 at 9:00AM and resident received 60ml from 9am to 10am. DON further stated that the enteral bottle would have 940 ml left when the feeding was scheduled to be turned on at 2:00PM. DON stated that a new bag should have been hung on August 6, 2024, at 6:00AM until 10:00am so that the resident could get the total 1200ml that is ordered by the physician. She stated that the resident did not get the required dose as ordered by the physician. During an interview on August 8, 2024, at 2:15 PM with the Registered Dietitian (RD), RD stated if the tube feeding is not running, they are not getting their nutrition and residents on tube feeding are more prone to losing weight. During a review of Resident 58's Nutrition Assessment, dated August 6, 2024, the nutrition summary indicated that the resident has malnutrition r/t (related to) dysphagia secondary to dementia (decreased ability to think), severe muscle wasting, severe fat loss, BMI 19, and G-tube dependent. During a review of Resident 58's Care Plan (a plan that provide directions on thre type of care an individual needs), dated August 6, 2024, the care plan indicated, Resident 58 has the potential for nutritional problem r/t (related to) tube feeding, dysphagia, unspecified protein-calorie malnutrition. During a review of Resident 58's Nutrition Assessment, dated August 6, 2024, the nutrition assessment indicated Resident 58 had a recent weight of 131 pounds and a current BMI (body mass index - weight and height measurement) of 19.3. Resident 58's goal weight range is 160-170 pounds. During a review of Resident 58's Speech Therapy Evaluation and Plan of Treatment, dated August 1, 2024 through August 28, 2024, the Speech Therapy Evaluation and Plan of Treatment indicated, Resident 58's risk factor . without skilled therapeutic intervention, the patient is at risk for weight loss and malnutrition.

Based on observation, interview, and record review, the facility failed to have nursing staff with appropriate competencies and skills set to provide nursing services to Resident 58 when he only received 940 ml (milliliters - unit of measure) of tube feeding (supply of food delivered via tube to the stomach) but should have received 1200 ml (millimeters) of medically prescribed enteral tube feeding formula as ordered by his physician on August 6, 2024. This failure had the potential to result in altered nutrition status for one of 55 medically compromised residents. Findings: A review of Resident 58's Admission Record, (contains demographic and medical information), indicated Resident 58 was initially admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disruption of blood supply to the brain), aphasia (difficulty in talking), and dysphagia (difficulty in swallowing). During a concurrent interview and record review on August 6, 2024, at 10:00AM with Licensed Vocational Nurse/Minimum Data Set (LVN/MDS), LVN/MDS reviewed the electronic medical record and verified that the tube feeding order as Osmolite 1.5 (therapeutic nutrition that provides complete, balanced nutrition tube-feeding for patients) @ 60 ml / hr (hour) x (times) 20 hours via enteral pump (infusion pump used for continuous tube feedings). Turn on @2:00PM, turn off at 10:00AM or until dose is consumed. May hold feedings during ADL care, showers, and transfers. LVN/MDS stated that the tube feeding was stopped at 9:40AM. During a concurrent observation and interview on August 6, 2024, at 10:30AM in Resident 58's room, with LVN/MDS stated he discarded the tube feeding bottle in the trash can. The 1000 ml tube feeding bottle was labeled with the resident's name, room number, August 5, 2024 (date the formula bottle had been hung) and time 0900 [9:00AM] (date and time the feeding was started) and the rate of the administration which was 60 mls an hour (60 ml/hr - rate of nutrition administration via enteral pump). During an interview on August 6, 2024, at 10:35AM with LVN/MDS, LVN/MDS stated that he determined the feeding was complete when he had heard the enteral pump alarm go off. LVN/MDS further stated that he was not able to calculate how much in total the resident received, because he did know how much was infused during the prior shift. During an interview on August 6, 2024, at 11:45AM with the Director of Nurses (DON), the DON stated that the tube feeding bottle was last hung on August 5, 2024 at 9:00AM and resident received 60ml and it was turned off at 10:00AM. The DON further stated that the enteral bottle would have 940 ml left when the feeding was scheduled to be turned back on at 2:00PM. The DON stated that a new bag should have been hung on August 6, 2024, at 6:00AM and that the resident did not get the required dose as ordered by the physician. She [ DON] stated she would have to conduct an investigation to determine why the tube feeding was stopped overnight and why a new bag was not hung at 6:00 AM. The DON stated the LVN/MDS should be able to calculate how much feeding was provided on the shift prior. During a concurrent interview and record review on August 7, 2024 at 12:00PM with the DON, the Licensed Vocational Nurses Competency Evaluation and Performance Satisfactory Completion, Gastric Tube Medication Administration competency was reviewed. The DON stated there is no competency for licensed nursing staff on how to determine how much feeding was administered on the shift prior based on physician orders. During an interview on August 8, 2024 at 2:15PM with the Registered Dietitian (RD), the RD stated the licensed nurses should always give the full dose of the tube feeding. The RD further stated the licensed nurses are responsible for knowing when to change the bottle and how to calculate how much was given per shift. During a review of Resident 58's physician's orders, dated August 2, 2024, the physician's order indicated, Osmolite 1.5 @ [at] 60ml / hr x 20 hours via enteral pump (a machine that delivers food to the stomach) .Turn on @2:00PM, turn off @10:00A or until dose is consumed . During a review of the facility's policy and procedure titled, Alliance Pharmacy Pharmaceutical Services Policy and Procedure Manual, titled Enteral Tube Medication Administration dated November 2020, the P&P indicated, c. Inservice training on .monitoring of enteral solutions and medications via the enteral tube shall be provided by the facility to nursing personnel.

Based on observations, interview and record review, the facility failed to ensure medication for one of seven sampled residents (Resident 42) observed for medication administration, was administered according to the physician's orders, when Resident 42 received Omeprazole [medication prescribe to minimize the acid reflex] after breakfast, on August 7, 2024. This failure has the potential to cause less effective management of Resident 42's condition, as the medication may not work as intended when taken after meal. Findings: During a record Review of Resident 42's Admission Record (contains demographic and medical information) the admission record indicated, Resident 42 was admitted to the facility on [DATE], with the diagnosis which included hepatic encephalopathy (a condition that affects the brain and occurs when the liver isn't working properly), morbid (severe) obesity due to excess calories (the person has an extremely high amount of bodyfat), and phantom limb syndrome with pain (a condition where a person who has had a limb amputated still feels sensation in the missing limb). A medication administration observation for Resident 42 by a License Vocational Nurse 2 (LVN 2) was conducted on August 7, 2024, at 8:20 AM, in Resident 42's room, LVN 2 administered Omeprazole DR [Delayed release, is designed to release medication slowly overtime, used to control acid reflex] 20 mg (mg - milligrams unit of measurement). Resident 42 stated, she already had her breakfast. During a review of Resident 42's physician's orders, dated June 3, 2024, at 2:12 PM the physician's orders indicated, Omeprazole Cap [capsule] Delayed Release 20 mg. Give 1 capsule by mouth in the morning for Gastroesophageal Reflux Disease (GERD - When the stomach acid irritates the food pipe lining). During a follow up interview on August 7, 2024, at 8:42 AM with LVN 2, LVN 2 stated Resident 42 received Omeprazole after breakfast, despite the physician's order to administer it before breakfast. During a concurrent interview and record review on August 8, 2024, at 9:57 AM, with the Director of Nurses (DON), the DON reviewed Resident 42's physician's orders, dated June 3, 2024, and indicated Omeprazole Cap Delayed Release 20 mg cap, to administer 1 cap by mouth in the morning for GERD give before breakfast. The DON stated, Omeprazole should have been given before breakfast. The DON further stated that it would not have the same effect if given after breakfast. During a concurrent interview and record review on August 8, 2024, at 9:59 AM, with the DON, the facility's policy and procedure titled, Pharmaceutical Services Policy and Procedure Manual indicated, Administration .J. Medications shall be administered in accordance with written orders of the attending physician. The DON stated, the nurse should have followed the policy, but she did not.

Based on observation, interview and record review, the facility failed to store medications under proper temperature control, as specified by the manufacturer when two vaccine solutions were found inside the medication cart (used to transport medication between patients' rooms), instead of the refrigerator. This failure had the potential to increase the risk of residents receiving vaccine medications with decreased efficacy. Findings: During a concurrent observation and interview on August 6, 2024, at 12:10 PM, while inspecting the 30's hall medication cart with Licensed Vocational Nurse 1 (LVN 1) 1 unopened vial of Covid Spikevax 23-24 (an updated COVID-19 vaccine for the 2023-[AGE] year), was stored inside the medication cart, the vial was labeled Do not freeze. Keep Medicine in Refrigerator. In addition, 1 unopened syringe of medication Afluria Quad 2023-2024 (a flu vaccine for the 2023-2024 flu season), labeled Refrigerator, was stored inside the medication cart. LVN 1 stated the vaccines had been in the medication cart since the start of his shift at 7:00 AM. Furthermore, LVN 1 stated that both vaccines should not have been in the medication cart and should had been stored in the refrigerator. During an interview on August 6, 2024, at 1:10 PM, with the Director of Nurses (DON), the DON acknowledge the two vaccines were inside the medication cart. The DON further stated the two vaccines should had been stored in the refrigerator. During an interview and concurrent record review with the DON, on August 9, 2024, at 10:11 AM, the DON reviewed the facility's policy and procedure titled, Storage of Medication, effective date November 2020, which indicated, Policy Statement. Medications and biologicals shall be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . K. Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) shall be kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place shall be refrigerated unless otherwise directed on the label . The DON stated, the facility did not follow the policy. Manufacture product information quick guide for Spikevax (COVID-19 Vaccine, mRNA) by Moderna 2023-2024 Formula, dated September 2023, indicated, . Store Refrigerated (up to 30 days, until expiration date) 36 F to 46 F (2 C to 8 C) Thawed vials and syringes can be handled in room light conditions . CDC Dosage, Administration, and Storage of Influenza Vaccines, indicated, Storage of Influenza Vaccines In all instances, approved manufacturer packaging information should be consulted for authoritative guidance concerning storage of all influenza vaccines. Vaccines should be protected from light and stored at recommended temperatures. In general, influenza vaccines should be refrigerated between 2 to 8 C (36 to 46 F) and should not be frozen; vaccine that has frozen should be discarded .

Based on observation, interview, and record review, the facility failed to ensure a representative (ensures residents wishes are respected) was in place for two of three sampled residents (Resident 1 and Resident 2). Resident 1 and Resident 2 had impaired decision making abilities and did not have a representative in place to give consent for medical decisions. This failure resulted in two clinically compromised residents making medical decisions in which resident 1 and resident 2 were unable to understand or comprehend based on their History and Physical. Findings: An abbreviated survey was conducted on October 23, 2023, at 3:55 PM, to investigate a complaint related to Resident Rights. 1.A review of Resident 1's, face sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included: schizoaffective disorder (affects your thoughts, mood, and behavior), bipolar disorder (feelings of extreme happiness and sadness), psychosis (not in touch with reality), depression, and anxiety, A review of Resident 1's, History and Physical (physicians' exam) dated August 26, 2023, indicated Resident 1 cannot make medical decisions. A review of Resident 1's, Informed Consent for Medical Treatment (permission granted in the knowledge of the possible consequences) dated August 25, 2023, indicated a representative for Resident 1 had not given consent for medical treatment. A further review of the Informed Consent indicated The resident and responsible party hereby consent to the facility providing such routine nursing care as may be directed by said attending physician. Resident 1's Informed Consent for medical treatment was not signed by Resident 1's representative, a facility representative or the attending Physician. A review of the Resident 1's record titled Physicians Orders for Life Sustaining Treatment (POLST- presents a person's wishes for care in the event of incapacity or inability to communicate), dated August 28, 2023, indicated Resident 1 declined to complete the POLST. The POLST was not signed by a representative of Resident 1. 2.A review of Resident 2's face sheet (contains demographic information) indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included: Depression, and Anxiety. A review of Resident 2's History and Physical dated August 3, 2023, indicated Resident 2 cannot make medical decisions. A review of Resident 2's record titled Physician Orders for Life-Sustaining Treatment (POLST), dated August 2, 2023, indicated Resident 2 signed this medical document as a legally recognized decision maker. A responsible party for Resident 2 did not sign this document. A review of Resident 2's Informed Consent to (give a) Psychotropic Drug undated, indicated I have obtained informed consent from the resident and/or responsible party for the use of Olanzapine (medication used to treat schizophrenia). I have obtained informed consent from Resident 2. This document was signed by a staff member. This form did not indicate Resident 2's representative gave consent for this medication. During an observation and concurrent interview of Resident 2 on October 23, 2023, at 4:08 PM, Resident 2 stated, I am supposed to be leaving in November. They (facility staff) are supposed to find me a place. I make all the decisions here. If I can't make my decisions, then I don't know who will make my decisions. During an interview and concurrent record review with the Director of Nursing (DON), on October 23, 2023, at 4:58 PM, DON stated, Resident 1 and Resident 2 do not have a responsible person. I didn't find any notes from the Social Services Director or Interdisciplinary Team about finding a responsible person or informing the ombudsman about Resident 1 and Resident 2 receiving representation. DON stated further, the documentation does not state that the SSD tried to contact anyone regarding a responsible person for Resident 1 and Resident 2. After the DON reviewed resident 1's consents, in which resident 1 either refused to sign or there were no signatures, the DON stated for the ' Consent for Medical Treatment' which was unsigned, the doctor should have signed it and the Ombudsman should have been contacted at the start of Resident 1's stay for representation. The DON then reviewed the H&P for resident 2 and stated, Resident 2, is not supposed to sign or give consent. It is a medical decision. During an interview and concurrent record review on October 23, 2023, at 5:44 PM, the Administrator, stated, To find out if the resident can make decisions we go by the H&P. After reviewing Resident 1 and Resident 2's H&P, the Administrator stated, There should be documentation to indicate we notified the ombudsman and attempted to find representation. They should have had representation. The facility could not provide documentation that indicated they informed the ombudsman or attempted to locate a responsible party or a family member for medical consents for Resident 1 and Resident 2. During a review of the facility's Policy and Procedure titled Informed Consent undated indicated To facilitate the Attending physician informed consent procedure and to meet the requirements of section 772528(a)(b) of Title 22 of the California Code of Regulations, California Health, and Safety Code Section 1418.8 and the State Operations Manual. It is the policy of this Facility to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic days, physical restraints and medical devices which may lead to the inability to regain use of a body function and prolonged use. Procedure A. The facility informs Attending Physicians of the informed consent process and their responsibilities according to the regulations. B. The Attending Physician determines the capacity of the resident to make decisions and give informed consent on his/her History and Physical. If the resident is determined to not have the capacity to make informed decisions, a surrogate decision maker is identified G. If the resident is not capable of making decisions and there is no surrogate, the Interdisciplinary Team may give consent on behalf of the resident.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a repeated resident to resident altercation, for one of three sampled residents (Resident 2) when Resident 2 had been placed on 1:1 (one-to-one) monitoring (one-to-one monitoring uses continuous staff observation to safeguard patients judged likely to harm themselves or others) and the monitor stepped away from Resident 2 leaving him unattended. This failure had the potential to cause Resident 2 to begin an altercation with another resident. Findings: An unannounced visit was made to the facility on [DATE], at 10:28 AM, to investigate a facility reported incident regarding a resident-to-resident altercation. A review of Resident 2's face sheet (a document that gives a summary of resident information), undated, indicated an admitted [DATE], with diagnoses that included: psychosis (a mental disorder characterized by a disconnection from reality), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizoaffective disorder (a mental illness that affects thoughts, mood and behavior), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During an interview with the Administrator (Admin) on September 19, 2023, at 11:03 AM, the Admin stated the incident happened when both Resident 1 and Resident 2 were waiting to go out to the smoking patio. The Admin stated Resident 2 had been speaking in a very loud voice and Resident 1 asked him to be quiet which triggered Resident 2 to assault Resident 1. Staff intervened quickly and neither resident sustained injury. The Admin stated the facility was working on placement in another facility for Resident 2 as his unpredictable and aggressive behavior was escalating towards other residents and staff. The Admin stated Resident 2 had received a psychiatric evaluation and the physician had changed some of Resident 2's medications. The Admin stated Resident 2 would stay on 1:1 monitoring until appropriate placement had been secured. During an observation and interview with a Minimum Data Set Coordinator (MDS Coord) and Resident 2 on September 19, 2023, at 11:58 AM, The MDS Coord walked down the hallway towards the nursing station. The MDS Coord. pointed to Resident 2 and stated, That is [name of Resident 2] walking toward us. Resident 2 was independently and rapidly walking down the hallway. There was no 1:1 monitor following Resident 2. The MDS Coord. stated he did not know where the 1:1 monitor was. Resident 2 stopped walking and came very close and stated very loudly, What questions?! What questions?! My psychiatrist told me I don't have to answer any questions! Resident 2 was asked if he was doing OK. Resident 2 turned away and continued walking down the hallway and shouted, No! No! No! Resident 2 was followed, and Resident 2 ended up at the front office and spoke briefly with an Activities Director (AD) and then turned and walked back down the hallway unmonitored. During an interview with the Activities Director (AD) and MDS Coord on September 19, 2023, at 12:06 PM, The AD stated she had been assigned the 1:1 monitoring duty for Resident 2. The AD stated she understood she needed to always maintain a line of sight on Resident 2. The AD stated she had passed off the duty to a Director of Staff Development (DSD) so she could come to the front office and make popcorn. The MDS Coord stated neither the AD nor DSD had been with Resident 2 when Resident 2 was observed walking down the hallway. During an interview with the DSD on September 19, 2023, at 12:16 PM, The DSD stated the AD had not passed off the 1:1 monitoring duty for Resident 2 until she had been questioned about it. The DSD stated he understood that during a 1:1 monitoring one must always remain within a line of sight of the resident. During an interview with the Admin and Director of Nursing (DON) on September 19, 2023, at 12:21 PM, The Admin and DON stated during a 1:1 monitoring of a resident a line of sight must be always maintained. The Admin and DON stated the AD had not maintained the line of sight for Resident 2's monitoring. A review of the facility's policy and procedure titled, 1:1 SUPERVISION/ SITTERS, undated, indicated, PURPOSE: 1. To assist residents who need additional supervision . POLICY: . Sitters must agree to comply with the facility sitter 1:1 supervision policy approved by the facility. 2. Sitters Responsibilities: . 4. Accompanying the resident to the bathroom if the resident is able to ambulate independently. 5. Notifying facility's staff of any resident's needs. D. The sitter will notify the facility staff when taking a break or when the sitter will be away from the resident during his/ her work shift. G. Sitter(s) must report to nurse supervisor/ charge nurse when coming on and going off duty.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure to ensure the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2's care being prolonged and put them at risk for physical and psychosocial harm. Findings: 1.During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: joint replacement surgery, left artificial hip, left artificial knee and morbid obesity. During a review of the clinical record for Resident 1, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated July 3, 2023, indicated, Resident 1's score was a 15, which indicated that there was no mental impairment. In an interview with Resident 1, on August 24, 2023, at 3:41 PM, Resident 1 stated, Call lights. It takes 45 minutes to answer the call lights. I am calling them for basic stuff, like drink refills, urinals, or a message out to the front desk (nurses' station) because they're not answering the call lights. I ' ll call the front desk (nurses' station) because they are not answering the call lights. 2.During a review of Resident 2's clinical record, the face sheet (contains demographic and medical information), indicated Resident 3 was admitted on [DATE], with diagnoses which includes: rheumatoid arthritis (painful swelling of the joints) and abnormalities of gait. During a review of the clinical record for Resident 2, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated June 29, 2023, indicated, Resident 2's score was a 15, which indicated there was no mental impairment. In an interview with Resident 2 on August 24, 2023, at 4:09 PM, Resident 2 stated, I turn on my call light and it may take a while for them to come in. What they do is when they come into my room they say, I am going to tell the person that is listed as my certified nursing assistant. They then turn off the call light and the cna that is assigned to provide care doesn't come into my room. So, what I do is call again and then by the third call for help. I'm frustrated. I'm calling because I need to be changed or I'm ready for my patient care, fresh water. I try not to call. I call for my medications. From beginning to end, it takes maybe a half an hour. During a record review of the Resident Council Meeting Minutes, dated June 27, 2023, and July 27, the Resident Council Minutes indicated the Residents complained of staff not answering the call lights in a timely manner. The Resident Council Minutes did not indicate the call light complaints were resolved or addressed. During a concurrent interview and record review of the resident council meeting minutes with the Director of Staff Development (DSD) on August 24. 2023, at 4:26 PM, DSD stated, I deal only with the resident council minutes if there are problems with the call lights or resident care. After the DSD reviewed the resident council minutes and searched for in-services related to call lights the DSD stated, There are no in-services for July or June for the call lights. DSD stated further, Call lights should be answered in 5 minutes. Why? To make sure the residents are not in immediate danger, an emergency, or not able to breathe. The facility was unable to provide documentation that stated the resident councils' concerns were addressed. During an interview with the Director of Nursing (DON) on August 24, 2023, at 4:42 PM, DON stated, Call lights. Everyone is to answer the call lights. It should be within 5 minutes. We answer the call lights to prevent falls, prevent any unusual occurrence and to answer their needs. DON was informed of the time residents stated that it takes staff to answer the call lights, 30 to 45 minutes. The DON stated further, That should not be happening because it is our duty to take care of the resident's needs. The facility policy and procedure titled, Answering the Call Light dated October 2010, indicated The purpose of this procedure is to respond to the resident's request and needs. General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .8. Answer the resident's call as soon as possible .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Three oranges and seven onions with mold were found in the kitchen inside of a plastic box. 2. A box of 14 yellow squash was wet and leaking inside of the refrigerator, that was stored in the central supply room. 3. Thirty two ounces (unit of weight) of plain yogurt container found inside the refrigerator expired. 4. The ice machine was found dusty outside and inside with dark black stain seen on both sides of the ice maker tray. 5.A shelf storing clean water pitchers were stored in the Central Supply room, near the laundry room. These failures had the potential to contaminate resident's food and cause food -borne illness to a population 56 medically compromised residents who receive food from the kitchen. Findings: 1. During a concurrent observation and interview on [DATE], in the kitchen at 8:06 AM, there were three oranges with mold inside a plastic box inside at the bottom of a stainless steel shelf. Dietary Staff Aid 2 (DA 2) stated the oranges should be thrown away because they have mold. During a concurrent observation and interview on [DATE], at 8:11AM, in the kitchen, there were seven onions with mold found inside a plastic box on the bottom of a stainless shelf. DA 1 stated the onions should be thrown away because they have mold. During an interview on [DATE], at 8:20 AM, Dietary Services Supervisor (DSS), acknowledged the mold and stated, they should be thrown away. During a record of the facility's policy and procedure titled PRODUCE STORAGE GUIDELINES, dated 2018, indicated, May use longer if no signs of spoilage are visible. 2. During an observation on [DATE], at 9:09 AM, in the Central Supply Room Area, there was a box of 14 yellow squash that was wet and leaking inside of the refrigerator. During an interview with the DSS on [DATE], at 9:10 AM, DSS acknowledged the wet yellow squash, and stated the refrigerator should be fixed. During a review of the FDA Federal Food Code 2022, ,d+[DATE].11 indicated, (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) in clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; Pathogens can contaminate and/ or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food. 3. During a concurrent observation and interview on [DATE], at 9:12 AM, with the DSS in the Central Supply Room Area, there was a 32 ounces (2 pounds) plain yogurt container that was expired in Refrigerator 3. The DSS acknowledged that the yogurt was expired and should not be used. During a review of the facility's policy and procedure titled REFRIGERATED STORAGE GUIDE, dated 2019, indicated, .Yogurt .follow expiration date or 7 days after opening, whichever comes first. 4. During an observation on [DATE], at 9:31 AM, the ice machine was found with dry, chalky dust like particles outside and inside with dark black stains seen on both sides of the ice maker tray. During an interview with the Maintenance Supervisor (MS) on [DATE], at 9:42 AM, in the Central Supply room, he acknowledged that the ice machine was found dusty. During a record review of facility document titled Ice Machine Cleaning Log, indicated Frequency of Cleaning: Monthly .PROCEDURE FOR CLEANING STORAGE COMPARTMENT OF ICE MACHINE .1. The ice machine storage compartment will be cleaned monthly .7. The outside of the machine is cleaned weekly or wiped down as need with clean cloth and approved cleaning agent. During a record review of facility document titled, Invoice from [Company Name] dated, [DATE], indicated Last ice Machine Maintenance was performed on [DATE] nine months ago. During a review of the FDA Federal Code, dated 2022, ,d+[DATE].11 indicated 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. 5. During an observation on [DATE], at 10:43 AM, a shelf, storing clean water pitchers was stored in the Central Supply Room. During an interview on [DATE], at 10:45AM, with the Housekeeper Supervisor (HKS) stated the pitchers should not be there. During a review of the FDA Federal Food Code 2022, ,d+[DATE].11 indicated, (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination;. In addition, Clean equipment and multiuse utensils which have been cleaned and sanitized, laundered linens, and single-service and single-use articles can become contaminated before their intended use in a variety of ways such as through water leakage, pest infestation, or other unsanitary condition. The improper storage of clean and sanitized equipment, utensils, laundered linens, and single-service and single-use articles may allow contamination before their intended use. Contamination can be caused by moisture from absorption, flooding, drippage, or splash. It can also be caused by food debris, toxic materials, litter, dust, and other materials. The contamination is often related to unhygienic employee practices, unacceptable high-risk storage locations, or improper construction of storage facilities

Based on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety when: 1. The facility failed to thaw meat properly when: a. Meat was thawed at room temperature which allows for an environment for bacteria to grow. b. Thawed pork inside the refrigerator had no label or date. Not having a date means staff could not determine when food was initially thawed and how long it is good for. c. Chicken thawing in the sink was not completely submerged in running water. When thawing food, it must maintain a temperature of 41 degrees or less to control the growth of pathogens. When food is exposed to ambient (room temperature) temperatures it allows for bacterial growth. d. Staff could not verbalize the correct process for thawing meat (cross-reference F 802). Since staff did not know how to thaw meat, the likelihood that contaminated food was served to residents is high. 2. A food preparation sink was leaking and there was chicken thawing in the sink under running water. The water from the sink leaked onto the floor, where staff were walking. This had the potential to contaminate other parts of the kitchen when staff inadvertently step on the water and walk to other parts of the kitchen. 3. The ice machine was not clean, which could lead to ice being contaminated. 4. The top of the dishwasher was not clean, this had the potential to contaminate clean dishes. 5. Metal pans stored dirty under the steam table, could potentially lead to food being contaminated. 6. Clean metal pans were stacked and stored wet, stacking wet items prevents them from drying and may allow an environment where microorganisms can begin to grow. 7. A drawer storing clean utensils was dirty, which had the potential for the clean utensils to be contaminated. 8. A food preparation sink and dishwasher did not have an air gap (a backflow prevention apparatus used to stop any contaminants in the sink from flowing into the potable water system by siphonage). This had the potential for waste water to enter and contaminate the sink or dishwasher. The facilities multiple areas of non-compliance in regards to: the growth of microorganisms on food when meat was not being thawed according to facility policy and standards of practice staff responsible for thawing had not been trained and did not know the standard of practice for thawing and multiple other sanitation issues listed above in the kitchen led to a high likelihood that food could be contaminated and cause food borne illness in a medically compromised population of 53 of 53 residents who received food from the kitchen. An immediate jeopardy (IJ) was called on 483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety, on (MONTH) 5, 2020 at 12:07 PM. The survey team notified the Administrator, Director of Nursing (DON) and the Dietary Services Supervisor of IJ due to improper thawing of meat in the kitchen. Failure to properly thaw meats had the potential to cause food-borne illness to the highly susceptible residents currently eating food from the kitchen. Findings: 1. a. During an observation and a concurrent interview on (MONTH) 5, 2020 at 8:39 AM, with Cook 1, two packs of lunch meat were sitting on the counter inside a 1/4 hotel pan (metal pan that is 4 inches deep, by 10 ½ inches long and 6 ½ inches wide). Cook 1 stated he pulled out the lunch meat from the freezer at 5:30 AM to thaw on the counter. He stated once thawed he plans to make sandwiches for residents going to [MEDICAL TREATMENT] (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) for lunch. Temperature of the lunch meat was taken with a thermometer and it read 60.8 degrees Fahrenheit. Cook 1 asked if it was ok to thaw on the counter. During an interview on (MONTH) 5, 2020, at 8:39 AM, Diet Aide 1 stated that they would need to put the lunch meat in the refrigerator to cool it down before making the sandwiches. However, neither she nor Cook 1 could verbalize to what temperature and what time frame they had to cool it down in. During an observation on (MONTH) 5, 2020 at 9:30 AM, Cook 1 was pulling the lunch meat from an ice bath and he used a facility thermometer and took the temperature, it read 45.1 degrees Fahrenheit. At this time, it had been four hours since the lunch meat had been initially pulled from the freezer and left to thaw on the counter. During an interview on (MONTH) 5, 2020 at 9:32 AM, the Dietary Services Supervisor (DSS) stated that lunch meat should never be thawed on the counter. She stated since he thawed it on the counter there is no way to determine if it is safe and it should be thrown away. During an interview on (MONTH) 6, 2020 at 4:11 PM, the DSS stated that Cook 1 had worked at the facility for two months. So far he had only received the handwashing training. She stated she does not consider his training or experience when scheduling him to work on the weekend by himself with one other person (dietary aid). During a review of the staff schedule, dated January, every Saturday and Sunday Cook 1 was scheduled to work. The DSS was not scheduled to work on the weekends. During an interview with the Registered Dietitian on (MONTH) 6, 2019 at 4:11 PM, she stated she left all the training and scheduling of staff up to the DSS. According to the FDA Federal Food Code (YEAR), Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacterial to grow to harmful numbers and/or produce toxins. Lunch meat in particular is associated with the bacteria Listeria monocytogenes that is the leading cause of death from foodborne illness, according to the FDA's Bad Bug Book: Foodborne Pathogenic Microorganisms and Natural Toxins Handbook, dated (YEAR) (https://www.fda.gov/food/foodborne-pathogens/bad-bug-book-second-edition). The main target populations for listeriosis is: .Persons immunocompromised (having a weak immune system) by, corticosteroids (drug to reduce inflammation in the body), anticancer drugs, cancer patients, diabetic (when your blood sugar is to high), cirrhotic (scarring of the liver), asthmatic (condition where your airways narrow and swell), and ulcerative [MEDICAL CONDITION] (inflammation and sores in digestive tract) patients and the elderly . The Food Code outlines these proper ways to thaw: .time/temperature control for safety food (Foods that need time and temperature control for safety, such as dairy, eggs, meat, poultry, etc.) shall be thawed: (A) Under refrigeration that maintains the food temperature at 41 degrees Fahrenheit or less; or (B) completely submerged under running water: (1) At a water temperature of 70 degrees Fahrenheit or below, (2) with sufficient water velocity to agitate and float off loose particles in an overflow, and (3) for a period of time that does not allow thawed portions of ready-to-eat food to rise above 41 degrees Fahrenheit . (C) as part of a cooking process if the food that is frozen is: (1) Cooked . (2) thawed in a microwave oven and immediately transferred to conventional cooking equipment, with no interruption in the process During a review of facility Food Preparation Policies, titled Thawing of Meats, dated (YEAR), indicates Thawing of meats can be done in four ways: 1. In a refrigerator at 41 degrees F or colder. Allow 2 to 3 days to defrost, depending on quantity and total weight of meat. Label defrosting meat with pull (date removed from freezer and put into the refrigerator) and use by date. 2. In a microwave if foods are to be cooked immediately following the thawing process. 3. Submerge under running water, potable water at a temperature of 70 degrees Fahrenheit or lower . 4. Foods can be thawed as part of the cooking process. 1.b. During an observation and concurrent interview on (MONTH) 5, 2019 at 8:11 AM, with Cook 1, there was a large piece of thawed raw meat (about 3 lbs) in the reach-in refrigerator. Cook 1 stated that the meat was pork and he pulled it out of the freezer on Friday to make pozole (traditional soup from Mexican cuisine) for Friday dinner. He stated he only needed half of the large piece of meat for the soup so he planned to refreeze the remainder of the meat. During an interview on (MONTH) 6, 2019 at 4:11 PM, the DSS stated that when thawing in the refrigerator the meat should be labeled and dated. She stated once thawed all the meat should be cooked. They are not supposed to hold meat in the refrigerator or refreeze meat. According to the FDA Federal Food Code (YEAR), Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacterial to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved. According to the Food Preparation policy titled Thawing of Meats, dated (YEAR), indicated 3. Once thawed, uncooked meat is to be used within 2 days. 1.c. During an observation on (MONTH) 5, 2020, at 8:39 AM, there were 2 bags of raw chicken legs thawing under running water in a 1/16 hotel pan (metal pan that is 12 inches, by 10 ½ inches long), not completely submerged in water. Cook 1 stated he put the chicken in the sink to thaw at 7:00 AM. During an interview with the DSS on (MONTH) 6, 2020, at 4:11 PM, The DSS stated that when thawing meat in the sink it should be completely submerged. Also, per their policy, they can only thaw in the sink for 2 hours and then have to transfer the chicken back to the refrigerator. The DSS stated she has not in-serviced staff on this policy because she just started 2 months ago. Also Cook 1 started the same time she did. The DSS stated, Cook 1 has only been trained on handwashing. According to the Food Preparation policy titled Thawing of Meats, dated (YEAR), indicated 3. Submerge under running, potable water at a temperature of 70 degrees Fahrenheit or lower, with a pressure sufficient to flush away loose particles. 1.d. During an observation and interview on (MONTH) 5, 2020, at 8:21 AM, with Cook 1, there were 2 packages of turkey lunch meat thawing on the counter. Cook 1 stated he planned to make sandwiches for lunch with the lunch meat for the residents on [MEDICAL TREATMENT]. He asked if it was ok to thaw lunch meat on the counter. He was not able to verbalize that the meat needed to maintain a temperature of 41 degrees or less and he also did not know how long the lunch meat could be in the food temperature danger zone (135 degrees to 41 degrees, is the temperature range where bacteria grows best). During a review of Cook 1's employee file, document titled Application for Employment, indicated that Cook 1 was employed as a cook at another facility from (MONTH) 1, 2019 to October, 2019 and prior to that he worked as a security guard from (MONTH) 23, 2019 to (MONTH) 1, 2019. During a review of Cook 1's competencies and trainings, document titled Handwashing and Hand Hygiene Competency Checklist, dated (MONTH) 1, 2019, indicated employee completed this training. During an interview with the DSS, on (MONTH) 6, 2020 at 8:38 AM, she stated that Cook 1 started two months ago and so far has been trained on Handwashing. She stated he has not had any other formal training. She also stated that with new employees she usually does one week of on the job training. The DSS stated that she marked on the calendar with a T for the one week that they were training. She does not have a record of Cook 1's on the job training because he started just after she did and during that time the previous DSS was still managing the operations so she is not sure what training he received. 2. During an observation on (MONTH) 5, 2019 at 8:35 AM, the liquid from the food preparation sink, that was being used to thaw raw chicken was leaking onto the floor. The bottom of the sink had a small hole where water was leaking from. During an interview on (MONTH) 5, 2020, at 4:09 PM, the DSS stated that she had known about the leak and that maintenance is working on getting it fixed. She stated when they need something fixed in the kitchen the process is to write it in the maintenance request log in the nursing station. However, she did not do that for the sink, she only verbally told the Maintenance Supervisor. During an interview on (MONTH) 5, 2020, at 3:52 PM, the Maintenance Supervisor stated that he ordered the part on Friday, (MONTH) 3rd and was expecting it on Monday, (MONTH) 6th. However, he stated he was able to go to the hardware store today and fix the leak. According to the FDA Food Code (YEAR), Improper repair or maintenance of any portion of the plumbing system may result in potential health hazards such as cross connections, backflow, or leakage. These condition may result in the contamination of food, equipment, utensils, linens, or single-service or single-use articles. It is important to separate foods in a ready-to-eat form from raw animal foods during storage, preparation, holding and display to prevent them from becoming contaminated by pathogens that may be present in or on the raw animal foods. Also great numbers and varieties of pathogens generally are found on poultry than on other raw animal foods. 3. During an observation on (MONTH) 5, 2020, at 4:07 PM, in the presence of the Maintenance Supervisor (MS), the ice machine had some hard yellow deposits and some black gelatinous deposits around the ice chute (where ice drops into the ice bin). The MS acknowledged the deposits. During an interview on (MONTH) 7, 2020, at 10:04 AM, the MS confirmed his cleaning process was what the manufacturer recommended. He stated that although he cleans the ice machine once a month he missed that area that had the deposits. He stated it was hard to reach and see the area so he missed it when cleaning. A review of the manufacturer's recommendation for (Brand Name), dated (MONTH) 26, 2019, indicated ice machine cleaning removes the limescale buildup on the inside of the unit. It is important to sanitize your ice machine everytime you clean the unit. Cleaning removes, dirt, debris, and hard water buildup from the machine, but sanitizing is important to help remove bacteria to ensure the machine and bin are able to hold ice without contaminating it. According to the FDA Food Code, .Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: in equipment such as ice bins . (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, surfaces of utensils and equipment contacting food that is no time/temperature control for safety food such as . 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 the accumulation of microorganisms. 4. During an observation and concurrent interview on (MONTH) 5, 2020, at 7:45 AM,with DA 1, the top of the dishwasher had what looked like food crumbs. DA 1 stated that it should be cleaned. During a review of facility policy titled Sanitation, dated (YEAR), indicates 9. All utensils, counters, shelves, and equipment shall be kept clean . According to the FDA Federal Food Code (YEAR), Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. 5. During an observation and concurrent interview on (MONTH) 5, 2020, at 8:08 AM, with Cook 1, metal pans stored under the steam table had a greasy residue on the bottoms. Cook 1 was observed removing the metal tops of the steam table bins and storing on top of the dirty pans under the shelf while he took the temperature of the food. Cook 1 stated he stored the lids here because there was not enough space on the top. During an interview on (MONTH) 5, 2020, at 8:10 AM, Diet Aide 1 stated that the pans should all be cleaned. She stated the pans are used daily to store food. During a review of facility policy titled Sanitation, dated (YEAR), indicates 9. All utensils, counters, shelves, and equipment shall be kept clean . According to the FDA Federal Food Code (YEAR), Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris 6. During an observation and concurrent interview on (MONTH) 5, 2020 at 8:21 AM, with DA 1, metal pans and sheet pans were stacked and stored wet on a shelf. The DA 1 stated that the night before someone called off sick, so there was only one person here and they probably did not have enough time to air dry the metal pans. During an interview on (MONTH) 6, 2020, at 4:11 PM, the DSS stated that she expects staff to stay as long as they need to for pans to be air dried. She stated they should not be stacked and stored wet. According to the FDA Federal Food Code (YEAR), After cleaning and sanitizing equipment and utensils: (A) shall be air-dried . Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 7. During an observation and concurrent interview on (MONTH) 5, 2020, at 8:34 AM, with DA 1, there was a drawer storing clean measuring cups and spoons that had a red sticky residue. The DA 1 stated that the drawer should be kept clean. During an interview on (MONTH) 6, 2020, at 4:11 PM, the DSS stated that she expects all the drawers to be kept clean. According to the FDA Federal Food Code (YEAR), Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. 8. During an observation on (MONTH) 5, 2020, at 7:45 AM, the dish washer and a food preparation sink drain did not have an air gap. There was no separation in the pipe leading from the food preparation sink to the sewer. The drain pipe of the dishwasher was inside of the floor drain. During a review of the facilities policy titled, Accident Prevention-Safety Precautions, dated (YEAR), indicates an air gap is the most reliable back flow prevention device. It is a physical separation of the potable and non-potable water supply systems by an air space. All steam tables, ice machines and bins, food preparation sinks, . and other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink. An air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. According to the FDA Federal Food Code (YEAR), During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If the connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue. The IJ was lifted on (MONTH) 6, 2020 at 3:41 PM, in the presence of Administrator and the Director of Nursing after an IJ Removal Plan was provided by the administrator and verified to be implemented by observation and interviews. The IJ Removal Plan included the following: On 1/5/2020 at around 9 am, lunch meat was disposed by the dietary supervisor. Lunch meat was not served to the residents. Lunch meat will be replaced with ham and turkey. On 1/5/2020 RD will start in-service to all dietary staff scheduled today, which includes the cook, dietary aid, and dietary supervisor regarding Thawing of Meats policy and procedure. Dietary staff that are not scheduled will be in-serviced prior to start of shift. Dietary supervisor, RD or designee will monitor proper thawing each meal for 30 days and as needed. On 1/5/2020, Dietary Aid cleaned the leak on the floor immediately. Maintenance Supervisor fixed the leak of the food prep sink used for thawing. Dietary Supervisor or designee will monitor for leakage daily. Kitchen floor will be cleaned by dietary aid or designee daily and as needed. Clean metal pans that were stored wet were removed by Dietary Supervisor immediately. On 1/5/2020, RD will provide in-service training to all dietary staff scheduled today, which Includes cook, dietary aid, and dietary supervisor regarding Storage of Food and Supplies and sanitation policy and procedure. Dietary staff that are not scheduled will be in-serviced prior to start of shift. On 1/5/2020, at around 10 am, pork was disposed of by dietary supervisor and not served to the residents. Pork will be replaced with ham and turkey. RD will provide in-service training to all dietary staff scheduled today, which includes cook, dietary aid, and dietary supervisor regarding Labeling and Dating of Food policy and procedure. Dietary staff that are not scheduled will be in-serviced prior to start of shift. Drawer with sticky residue was immediately cleaned on 1/5/2020 by Dietary Supervisor. Dietary Supervisor or designee will monitor the cleanliness of the drawers daily and will be corrected accordingly.

Based on observation, interview, record review, the facility failed to ensure residents were free from significant medication errors in accordance with their policy and procedure affecting one of 12 sampled residents (Resident 250) when: 1. The facility failed to administer Resident 250's pain medication according to the physician's orders [REDACTED].>2. The facility failed to triple check Resident 250's pain medication label to verify the right dosage against the Medication Administration Record [REDACTED]. This failure resulted in Resident 250 receiving twice the ordered dose of [MEDICATION NAME] (a narcotic medication used to treat pain), on six occasions from five licensed nurses. This failure had the potential for Resident 250 to experience serious adverse side effects such as, [MEDICAL CONDITION] (low blood pressure), respiratory depression (slow ineffective breathing), altered level of consciousness (not able to be aroused or responsive), and oversedation requiring immediate treatment with an antidote (rescue medication). Findings: During an observation and interview on (MONTH) 6, 2020 at 11:25 AM, with Resident 250, who was up in his wheelchair, he stated he had constant pain to his right leg. He stated, Every time I ask the nurse for pain medication she only gives me Tylenol (pain medication), because the nurse tells me there is no [MEDICATION NAME] (an opioid that controls moderate to severe pain). A review of Resident 250's clinical records, the face sheet (contains demographic information), indicated Resident 250 was admitted on (MONTH) 20, 2019, with [DIAGNOSES REDACTED]. A review of Resident 250's clinical record, titled Brief interview for Mental Status (BIMS), dated (MONTH) 26, 2019, indicated Resident 250 scored a 12 out of 15 which indicates Resident 250 is cognitively intact (aware and alert). A review of Resident 250's Physicians' Orders, dated (MONTH) 27, 2019, and verified with the Assistant Director of Nursing (ADON), indicated an order, [MEDICATION NAME] 10/350 mg (milligram) one tablet by mouth every 4 hours PRN (as needed) R/T (related to) moderate to severe pain (pain scale 4-10) Order date: 12/20/19 Start Date: 12/20/19 Discontinue Date: 12/27/19 and to start a lower dose of [MEDICATION NAME] 5-325 mg tablet one tablet by mouth (PO) every 4 hours as needed for moderate to severe pain (scale 4-10). Order Date: 12/27/19. Start Date: 12/27/19. Discontinue Date was not provided. A review of Resident 250's Medication Administration Sheet (MAR), with the ADON indicated the current order for [MEDICATION NAME] was transcribed and written as ordered, [MEDICATION NAME] 5/ 325 mg one tablet by mouth every 4 hours for moderate to severe pain of 4-10). [MEDICATION NAME] was signed as given on (MONTH) 27, 2019 at 8:40 PM, (MONTH) 28, 2019 at 7:40 AM, (MONTH) 28, 2019 at 9:00 PM, (MONTH) 29, 2019 at 2:15 PM, (MONTH) 30, 2019 at 4:30 AM, (MONTH) 3, 2020 at 11:50 PM. A review of Resident 250's Controlled Drug Record, (a record coming from the pharmacy, indicating the number, name, and dose of narcotics delivered or narcotic accounting) with the ADON, indicated a different dose from the current doctor's order, and written as [MEDICATION NAME] 10/325 mg, take one tablet every four hours as needed for moderate to severe. The record also indicated, the medication was signed and taken from the medication package on six different dates, by five different Licensed Nursing staff on the following dates: 1. (MONTH) 27, 2019 at 8:40 PM, by Licensed Vocational Nurse 2 (LVN 2) 2. (MONTH) 27, 2019 at 7:40 AM, by LVN 3 3. (MONTH) 28, 2019 at 9:00 PM, by LVN 2 4. (MONTH) 29, 2019 at 2:15 PM, by LVN 1 5. (MONTH) 30, 2019 at 4:38 AM, by Registered Nurse 1 (RN 1) 6. (MONTH) 3, 2020 at 11:50 PM, by RN 1 A review of Resident 250's pharmacy Packing Slip, {Name of pharmacy} and verified with the ADON, dated (MONTH) 27, 2019, at 5:40 PM, indicated a label, [MEDICATION NAME]/APAP ([MEDICATION NAME] 10/325 mg) one tablet by mouth (PO) every 4 hours as needed for moderate to severe pain (scale 4-10) was delivered and signed by LVN 4. During an interview on (MONTH) 6, 2020 at 11:32 AM with the Pharmacist, she stated they delivered 30 pills of [MEDICATION NAME] 10/325 mg and was received by LVN 4 on (MONTH) 27, 2019. She stated the pharmacy never received the current ordered dose of 5/325 mg until (MONTH) 3, 2020 (during the survey). During an interview on (MONTH) 6, 2020 at 12:20 PM, with the ADON, she confirmed [MEDICATION NAME] 10/325 mg was discontinued and [MEDICATION NAME] 5/325 mg was ordered on (MONTH) 27, 2019. The ADON confirmed the new dose for [MEDICATION NAME] was not faxed to the pharmacy. The ADON verified, the pharmacy delivered [MEDICATION NAME] 10/325 mg on (MONTH) 27, 2019 at 5:40 PM, instead of [MEDICATION NAME] 5/325 mg. She confirmed LVN 4 received the medication, however did not double check the delivered dose. The ADON stated the 5/325 mg dose of [MEDICATION NAME] was never delivered until (MONTH) 7, 2020 at 9:37 AM. During an interview with Licensed Vocational Nurse (LVN 1), on (MONTH) 6, 2020, at 11:30 AM, she stated that Resident 250 did not take [MEDICATION NAME] 5/325 milligram (MG) because the medication was not available in the medication drawer. During a concurrent interview with LVN 1, on (MONTH) 6, 2020 at 3:05 PM, she stated on (MONTH) 29, 2019, at 2:15 PM, she administered Resident 250 [MEDICATION NAME] 10/325 mg for pain. LVN 1 stated she did not call the physician because she did not realize she had made a medication error. During a telephone interview with LVN 2, on (MONTH) 6, 2019 at 3:20 PM, she stated she worked on (MONTH) 28, 2019, PM. LVN 2 recalls giving Resident 250 [MEDICATION NAME] but does not remember checking the dosage. LVN 2 stated, If my name was on the controlled record sheet then I must have given the Resident 250 [MEDICATION NAME] 10/325 mg. I must have made a medication error. During a telephone interview with LVN 3, on (MONTH) 6, 2019, at 3:39 PM, she stated that she worked on (MONTH) 28, 2019. LVN 3 confirmed she gave [MEDICATION NAME] to Resident 250, but did not remember the dosage. LVN 3 stated, If my initials are on the medication sheet then I must have administered the medication. During an interview on (MONTH) 6, 2020 at 4:35 PM, with LVN 4, he stated he received the pharmacy packing slip for [MEDICATION NAME] 10/325 mg, on (MONTH) 27, 2019 without double checking the doctor's order against the delivered dose. He stated he can not recall signing the pharmacy packing slip because he signs a lot of them. During a telephone interview with the Medical Director (MD), on (MONTH) 6, 2020, at 6:52 PM, he stated that he was informed today by the Administrator (AD) that Resident 250 was receiving the wrong dose of [MEDICATION NAME]. The MD confirmed the facility made a medication error and stated that was a harmful mistake. During a telephone interview with the Primary Doctor (PD 1), on (MONTH) 6, 2020, at 6:55 PM, he stated he had been out of the country and was informed today by the ADON, that there was a medication error on Resident 250. He stated he ordered [MEDICATION NAME] 5/325 mg not [MEDICATION NAME] 10/325 mg and stated the nurses made a medication error During a telephone interview with Registered Nurse 1 (RN 1), on (MONTH) 6, 2020, at 7:30 PM, she stated she did not recall administering Resident 250's [MEDICATION NAME]. RN 1 stated, If my signature or initials are there than I must have administered the medication. A review of policy and procedures titled, Administering Medication, revised (MONTH) 2012, indicated .(3). Medications must be administered in accordance with the orders, including any required time frame . 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. During a review of policy and procedures titled, Adverse Consequences and Medication Errors, revised (MONTH) 2014, indicated .5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [REDACTED].(6). Examples of medication errors include: a. Omission-a drug is ordered but not administered; b. Unauthorized drug-a drug administered without a physician's orders [REDACTED].>c. Wrong dose (e.g. [MEDICATION NAME] 12 milliliters ordered, [MEDICATION NAME] 2 ml given); d. Wrong route of administration (e.g. ear drops given in eye); e. Wrong dosage form (e.g. liquid ordered, capsule given); f. Wrong drug (e.g. [MEDICATION NAME] ordered, [MEDICATION NAME] given); g. Wrong time; and /or. During an interview the Director of Nursing (DON), on (MONTH) 7, 2020, at 8:52 AM, he confirmed, the nurses did not follow policy and procedures regarding medication administration. An immediate jeopardy (IJ-a situation that has threatened or is likely to threaten the health and safety of a resident) was called under 483.45(f)(2) Residents are free of any significant medication errors on (MONTH) 6, 2020, at 5:30 PM, in presence of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON). The Administrator, DON, ADON, were informed of the IJ involving a medication error when Resident 250 received twice the dose of [MEDICATION NAME] different from what the physician had ordered on (MONTH) 27, 2019. The wrong dosage was administered on six different occasions, from (MONTH) 27, 2019 through (MONTH) 3, 2020, by five different licensed nurses. An IJ removal corrective action plan was requested and accepted on (MONTH) 7, 2020, at 4:54 PM. The plan included the following: 1. In- service will be conducted to all licensed nurses on medication administration prior to their shifts. The Director of Staff Development (DSD), Director of Nursing (DON), Nurse Consultant 1 (NC 1) will in-service LN regarding; medication administration which will include, observing five rights prior to administering medication, triple checking the medication before giving, discontinuation of regular medications and narcotics, and proper storage and labeling of medications. 2. The ADON called the pharmacy and faxed the physician's orders [REDACTED]. 3. The staff immediately audited and checked Resident 250's Medication Administration Record [REDACTED]. The IJ was lifted on (MONTH) 7, 2020 at 4:54 PM, in the presence of the Administrator, DON, and ADON.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was transferred in a safe manner when Certified Nurse Assistant 1 (CNA 1) failed to use a gait belt (a safety device to assist with transfer) or one-person pivot transfer (resident assist with transfer and is able to bear weight on at least one leg) during one-person physical assist transfer. This failure resulted in Resident 1 falling to the floor, sustaining a fracture to the left tibia bone (breakage to the main weight bearing bone of the lower leg) and left fibular bone (bone located on the outside of the leg) causing physical pain (unable to straightened left leg, left leg throbbing, swelling, achy), head discomfort, hospitalization and open reduction internal fixation (surgery to reposition and stabilize the bone with a plate and screws). Findings: A review of Resident 1's Face Sheet (demographic and medical information) indicated Resident 1 was readmitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 1's General Acute Care Hospital (GACH) Diagnostic Radiology Report dated (MONTH) 6, (YEAR), at 9:18 AM, indicated Left Tibia-Fibula series: Fracture to the proximal tibia and Fracture to the proximal fibular head. A review of Resident 1's GACH Operation/Procedure dated (MONTH) 7, (YEAR), indicated Resident 1 required surgery. The surgical procedure included open reduction internal fixation of left proximal tibia fracture. A review of Resident 1's GACH Discharge Documentation dated (MONTH) 9, (YEAR), indicated Resident 1 was admitted to the hospital on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED].{Hbg-protein in red blood cells that carries oxygen throughout the body}), fall, and leg pain-swelling. During an observation on (MONTH) 15, (YEAR), at 2:20 PM, in Resident 1's room, Resident 1 was lying in bed with a cast which covered Resident 1's left foot, ankle, and lower leg ending below the knee. Resident 1's left leg was elevated on one pillow. Resident 1's toes were red and swollen. During an interview with Resident 1, on (MONTH) 15, (YEAR), at 2:23 PM, Resident 1 stated, The CNA dropped me between my bed and the wall when she was transferring me to my wheelchair. Resident 1 stated the gait belt was not in use at the time of the fall. Resident 1 stated she had surgery on the left leg and a blood transfusion due to blood loss. Resident 1 stated her left leg was very painful and she was taking pain medication every six hours. Resident 1 stated she could not sleep at night due to leg pain. Resident 1 described the leg pain as throbbing and achy. During a concurrent interview and review of Resident 1's Hospital Course Record dated (MONTH) 9, (YEAR), with the Director of Nursing (DON), on (MONTH) 15, (YEAR), at 2:52 PM, the DON reviewed Resident 1's Hospital Course Record and stated Resident 1 developed further [MEDICAL CONDITION] during the hospital admission. A further review of Resident 1's Hbg results indicated the diagnostic reference range (normal range) was 12 grams per deciliter (g/dl-unit of measurement) to 15.1 g/dl (below 12 g/dl indicated [MEDICAL CONDITION]). Resident 1's daily blood Hbg results were as follows: (MONTH) 6, (YEAR) (10.9 g/dl); (MONTH) 7, (YEAR) (8.6 g/dl); (MONTH) 8, (YEAR) (8.6 g/dl); and (MONTH) 9, 2019 (7.7 g/dl). The DON stated Resident 1 had experienced blood loss and required a blood transfusion prior to returning back to the facility. During a telephone interview with CNA 1, on (MONTH) 15, (YEAR), at 3:10 PM, CNA 1 stated she had been assigned to Resident 1 for the night shift of (MONTH) 5, (YEAR). CNA 1 stated on (MONTH) 6, (YEAR), at 6:00 AM, she was transferring Resident 1 from bed to wheelchair and Resident 1 fell to the floor during transfer. CNA 1 stated she had tried to hold Resident 1 up to prevent the fall but she could no longer hold Resident 1 without falling herself. CNA 1 stated Resident 1 started crying and screaming stating her head hurt. CNA 1 stated Resident 1 left leg was bent at the knee and Resident 1 was not able to straighten (extend) the left leg upon the Charge Nurse's request. CNA 1 stated she did not use a gait belt or one-person pivot transfer for Resident 1 to transfer from bed to wheelchair. CNA 1 stated a gait belt was not readily available in Resident 1's room and she thought she could transfer Resident 1 from bed to wheelchair without a gait belt. CNA 1 stated she should have used a gait belt. On (MONTH) 15, (YEAR) at 3:20 PM, a concurrent interview and review of Resident 1's Minimum Data Set (MDS- a comprehensive resident assessment and screening tool) dated (MONTH) 2, (YEAR), was conducted with the Director of Nursing (DON). The DON stated Resident 1's Minimum Data Set under section G Functional Status (activities of daily living and assistance), indicated Resident 1's balance for standing and walking was not steady and required one-person physical assistance for transfer between surfaces including from bed to wheelchair. The DON stated a gait belt should have been used for transfer. The DON stated CNA 1 had not followed the facility's policy and procedure for safe transfer when CNA 1 did not use a gait belt to transfer Resident 1 from bed to wheelchair. During an interview with the Administrator, on (MONTH) 15, (YEAR), at 3:45 PM, the Administrator stated a gait belt should have been used when CNA 1 transferred Resident 1 to the wheelchair. The Administrator stated the training for safe transfers titled, Assisted Transfer: The Pivot Method indicated CNA 1 should have used a gait belt. The Administrator stated facility's staff are expected to use safety equipment (such as a gait belt) at all times for a one-person physical assist to decrease the risk of accidents for residents. During a concurrent interview and review of Resident 1's Medication Administration Record [REDACTED]. The DON stated Resident 1 had experienced moderate to severe pain and had received 15 doses of pain medication from (MONTH) 10, (YEAR) through (MONTH) 15, (YEAR). The DON stated Resident 1 had complained of leg pain and confirmed Resident 1 received pain medication on the following nights: (MONTH) 10, (YEAR), at 12:00 AM, (MONTH) 11, (YEAR), at 2:30 AM, (MONTH) 12, (YEAR), at 3:30 AM, and (MONTH) 15, (YEAR), at 2:00 AM. During a follow-up interview and concurrent review of Resident 1's MDS, dated (MONTH) 2, (YEAR), with the DON, on (MONTH) 15, (YEAR), at 4:20 PM, the DON stated the MDS assessment for Resident 1 indicated one staff member was required to physically assist with Resident 1's transfer and mobility. The DON reviewed Resident 1's care plan titled, Risk for Falls revised (MONTH) 4, (YEAR), and stated the plan of care did not address the use of a gait belt, one-person pivot transfers, or one-person physical assist for safe transfers. The DON stated the plan of care should have reflected MDS findings including one-person physical assist. The DON reviewed the policy and procedure for Transfer of Resident From/To Bed revised on (MONTH) (YEAR), and stated safe transfer techniques included one-person pivot transfers and gait belt use for transferring residents requiring one-person physical assist from bed to wheelchair. During a concurrent interview and review of Resident 1's Accident/Incident Report dated (MONTH) 6, (YEAR), with the DON, on (MONTH) 15, (YEAR), at 5:30 PM, the DON stated the Charge Nurse heard Resident 1 screaming and viewed Resident 1 on the floor with both knees bent. The DON stated the report indicated, Resident was crying and complaining her head hurt and she was unable to straighten her left leg. The DON stated the plan of care should have included a person-centered plan of care for safe transfer. During a telephone interview with the Administrator, on (MONTH) 16, (YEAR), at 11:05 AM, the Administrator stated the facility did not need a physician order to use a gait belt for transferring residents from bed to wheelchair. The Administrator stated, Nursing should have included a plan of care for safe transfers to address one-person physical assist including one-person transfer technique and gait belt use to ensure consistent use of the safety (gait) belt. A review of the facility policy and procedure titled, Transfer of Resident From/To Bed revised (MONTH) (YEAR), indicated Purpose: To assess the resident's capabilities and provide the form of transfer best suited to his needs and to maintain residents' safety during the procedure. Policy: It is the policy of this facility to assess and provide appropriate and safe transfer techniques for each resident based on individual needs. Procedure: Assisting to chair: 1. One Person Pivot Transfer (resident must be able to bear weight) .b. Place the chair on the convenient side of the bed with the back of the chair parallel to the foot of the bed and facing the head of the bed. C. If using wheelchair, ensure foot rests are not in the way and the and wheels are locked . f. turn resident on his side and pivot him to a sitting position, with legs dangling over side of bed .h. Apply gait belt (unless contraindicated) around resident's waist securely enough to prevent sliding up over the ribs. i. Make sure resident's feet are flat on the floor. j. Facing resident, establish broad base with feet spread and one foot slightly in front of the other and grasp the gait belt with thumbs down on either side of the resident and slightly to the back. Pull the resident to a standing position, bracing the knees with yours, if necessary, to prevent buckling. k. Turn or pivot resident around with his back to the chair. Flex your knees and lower resident into chair. Remove gait belt. A review of the facility policy and procedure titled, Resident Assessment and Care Planning revised (MONTH) (YEAR), indicated . Policy: .The development of both the Baseline Care Plan and the Compressive Resident Care Plan are aim to assist the resident to reach his/her highest practicable level of physical, mental, and psychosocial functioning . Procedure: .G. Problems include currently existing difficulties as well as problems identified in the MDS .M. Actions and approaches must be clearly stated and be specific .P. When re-evaluating and reassessing the plan of care, the following will be considered: 1. Problems are current. All new problems are identified 3. Approaches are appropriate and effective.

Based on interview and record review, the facility failed to ensure the hoyer lift sling (a supportive device that is used with a mechanical lift) is safe to use to transfer the residents from bed to and from wheelchair for one of two sampled residents (Resident A). This failure resulted in Resident A falling from the hoyer lift sling onto the floor, sustaining hip and pelvis fractures and requiring hospitalization . Finding: An unannounced visit was made to the facility on [DATE] at 3:15 PM to investigate a complaint regarding quality of care. A review of Resident A's clinical record, reflected Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the history and physical, completed by the physician on April 22, 2016, indicated Resident A does not have the capacity to understand and make her own decision. A review of the Resident Assessment Instrument (RAI-a facility comprehensive assessment tool) functional status (the measure of a person's ability to perform activities of Daily Living (ADL's) dated November 1, 2016, indicated Resident A required staff assistance with all her ADLs. Resident A was non ambulatory. A review of the licensed nurse's progress notes, dated November 24, 2016 at 10:15 PM, reflected Resident A was noted to be grimacing and crying after the fall. Resident (A) was being transferred from the wheelchair to the bed via hoyer lift .both CNA (Certified Nursing Assistant) state that the sling broke from one support loop supporting the lower extremities. Resident (A) ascended down on both legs and rested onto the left side Nurse contacted 911 immediately .Resident (A) transported to hospital. Resident A was not in the facility during the investigation. During an interview with the Licensed Vocational Nurse (LVN 1) on December 6, 2016 at 4:45 PM, he stated after the incident on November 24, 2016 every hoyer lift sling in the facility were checked and found 4 (Four) slings were torn after tugging the straps and the support loops. They were all removed from the floor. During an interview with CNA 2 on December 6, 2016 at 5:30 PM, she stated on November 24, 2016 she assisted CNA 1 to transfer Resident A from the wheelchair to the bed using the hoyer lift. CNA 2 stated during the transfer she heard a tear from the hoyer sling. She had noticed the hoyer lift sling was torn. Resident A fell hard on the left side landing on the metal support base of the hoyer lift. During an interview with the Administrator on December 6, 2016 at 6 PM, she stated prior to the incident the facility did not have any policy in place on how to ensure the hoyer lift slings are safe to use to transfer the residents using the hoyer lift. During an interview with the Certified Nursing Assistant (CNA 1) on December 7, 2016 at 6:30 PM, she stated on November 24, 2016, she was assigned to take care of Resident A. She stated at approximately 7 PM, Resident A was up in the wheelchair with a hoyer lift sling underneath her. Resident A was put on the wheelchair by CNA 3. CNA 1 stated she asked CNA 2 to help transfer Resident A from the wheelchair to the bed with the hoyer lift. CNA 1 stated while she was lifting Resident A from the wheelchair to the bed using a hoyer lift, she heard a tear from the hoyer lift sling. CNA 1 stated she noticed the hoyer lift sling tore from the strap loops from the hoyer lift. Resident A fell out of the sling onto the floor. CNA 1 was asked if she had checked the straps and the strap loops prior to transfer the resident, she responded No. The sling was worn out, it looks old. We kept using it over and over again. I assumed the sling was safe. CNA 1 stated she should have checked the sling straps and strap loops prior to transfer the resident. CNA 1 stated prior to the incident she had not been inserviced on how to inspect the hoyerlift sling that included checking the straps and the support loops. CNA 1 stated Resident A required a hoyer lift transfer. CNA 3 was not available to be interviewed during the investigation. During an interview with the Director of Nursing (DON) on December 7, 2016 at 6:50 PM, she stated there was no system in place on how to check the hoyer lift sling strap and strap loops to ensure the hoyer lift slings are safe to use to transfer the residents using the hoyer lift prior to the incident on November 24, 2016. During a review of the inservice record on December 7, 2016 at 7 PM, at the Director of Staff Development's office, showed there was no record of inservice had been provided to the staff on how to inspect the hoyer lift sling prior to the incident. The DON verified the finding at the time of document review. A review of the hoyer lift sling manufacture Instruction Manual indicated Carefully inspect the sling before each use for wear and damage to seams, fabric, straps and strap loops .Use only slings that are in good condition. Discard and destroy old .slings During an interview with the complainant on December 8, 2016 at 3:45 PM, the complainant stated Resident A had fallen from the hoyer lift sling at the facility on November 24, 2016 at approximately 7:30 PM. Resident A was sent to the acute hospital where Resident A was found to have hip and pelvis fractures. A review of the x-ray result from the acute hospital, dated November 24, 2016, indicated Resident A sustained left hip and pelvis fractures.