Every finding on record at Redwood Healthcare Center LLC

Based on interviews and record reviews, the facility failed to ensure that one of five sampled residents (Resident 1) received scheduled pain medications as prescribed by the physician when Resident 1 did not receive Hydromorphone (brand name Dilaudid, a strong pain medication) and Lidocaine Patch (a topical patch used to relieve localized pain) as ordered for multiple days, from 3/20/26 to 3/29/26.This failure to administer the prescribed pain medications resulted to Resident 1 experienced uncontrolled pain and was sent back to the hospital on 3/29/26 for pain evaluation and management.During a review of Resident 1's admission Record (AR), printed on 6/15/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of spinal cord (a long, tubular bundle of nervous tissue that runs from the brainstem down to the lower back) injury.A review of Resident 1's facility document After Visit Summary, printed on 3/20/26, indicated Resident 1 underwent a cervical (neck area) spinal fusion (a surgical intervention involving the spinal cord).During a review of Resident 1's facility document Medication Administration Record (MAR) for March, MAR indicated a physician order for Dilaudid 2 milligrams (mg), three tablets to be taken orally three times daily at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The MAR indicated Resident 1 did not receive the prescribed Dilaudid doses from 2:00 p.m. on 3/24/26 through 3/25, 3/26, 3/27, 3/28 and 3/29.A review of Resident 1 's facility document Progress Notes (PN) dated from 3/24/26 to 3/29/26, the PN indicated Dilaudid was unavailable during this period.During a review of Resident 1's facility document MAR for March, the MAR indicated a physician order for Lidocaine patch 4% to be applied topically to the pain area once daily in the morning, with removal in the evening. The MAR indicated Resident 1 did not receive the Lidocaine patch on 3/21/26, 3/22, 3/23, 3/25, 3/26, 3/27, 3/28, and 3/29.A review of Resident 1's facility document PN from 3/21/26 through 3/28/26 indicated the Lidocaine Patch was not available for Resident 1 during this period.During a review of Resident 1's facility documents MAR for March and PN on 3/29/26, both facility documents indicated Resident 1 was transferred to the hospital on 3/29/26 for pain management.During an interview on 6/15/26 at 2:00 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that the pharmacy supplied Dilaudid 2 mg for a duration of three days. Subsequently, they contacted UCSF Hospital to request a triplicate order for refill but did not receive a response. LVN 1 stated nursing staff administered Tylenol to Resident 1 on an as-needed basis for pain management; however, Tylenol did not adequately control Resident 1's pain. LVN 1 stated the facility's pharmacy E-kit (emergency kit containing select medications) contains Dilaudid and confirmed nursing staff are responsible for administering Dilaudid to Resident 1.During a concurrent interview and record review on 6/15/26 at 2:29 p.m. with Director of Nursing (DON), MAR for March was reviewed. The DON confirmed Resident 1's Dilaudid and Lidocaine Patch were not given for multiple days. The DON stated the facility was responsible for clarifying orders, coordinating with physician and pharmacy, and ensuring prescribed medications were administered to Resident 1. The DON was unable to provide information regarding the availability of Dilaudid and Lidocaine for Resident 1.During a review of the facility's Policy and Procedure (P&P) titled Administering Medications, revised in April 2019, the P&P indicated medications are administered in a safe and timely manner, and as prescribed.

Based on interviews and record reviews, the facility failed to ensure one of five sampled residents (Resident 1), was provided physician-ordered physical therapy (PT) five times per week. Multiple PT sessions were not provided to Resident 1 during the first three weeks of admission from 3/20/26 through 4/9/26.This failure to provide PT sessions to Resident 1 had a potential risk for delayed recovery following a spinal cord surgery. During a review of Resident 1's facility document admission Record (AR) printed on 6/15/26, AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of spinal cord (a long, tubular bundle of nervous tissue that runs from the brainstem down to the lower back) injury.A review of Resident 1's facility document After Visit Summary (AVS) printed on 3/20/26, AVS indicated Resident 1 underwent a cervical (neck area) spinal fusion, a surgical intervention involving the spinal cord.During a review of facility document Order Listing Report (OLR) printed on 6/15/26, OLR indicated an order for skilled PT services five times a week for four weeks to address muscle weaknesses to include therapeutic exercises, therapeutic activities, neuromuscular education, wheelchair mobility training and patient/caregiver education. During a concurrent interview and record review on 6/15/26, at 11:53 p.m., with Director of Rehabilitation (DOR), Resident 1's Net Health Therapy (NHT, a cloud-based Electronic Health Record) and Physical Therapy Treatment Encounter Notes (PTTEN) from 3/20/26 through 4/9/26 were reviewed. The NHT indicated Resident 1 received PT four times during week one: 3/20, 3/22, 3/24, and 3/26. During week two, PT was provided two times: 3/29 and 4/2. During week three, Resident 1 received four PT sessions: 4/3, 4/4, 4/6, and 4/8. The DOR stated the lack of therapist availability might have contributed to missed scheduled sessions but could not confirm this definitively.During an interview on 6/15/26 at 2:50 p.m. with the Director of Nursing (DON), the DON stated it is the facility's responsibility to provide therapy for residents according to the physician order. During a review of the facility's policy and procedure (P&P) titled Scheduling Therapy Services, revised in 7/2013, the P&P indicated therapy is scheduled in coordination with nursing service and is documented in the resident's medical records.During a review of the facility's P&P, titled Referral for physical, occupational, and speech therapy services, no revision date, the P&P indicated it is the policy of the skilled nursing facility to ensure that all residents who demonstrate a need for rehabilitation services, including PT, occupational therapy (OT), and speech-language pathology (SLP), are promptly identified and appropriately referred. The interdisciplinary team (IDT) and nursing staff are responsible for recognizing changes in resident conditions and initiating timely referrals to promote optimal functional outcomes, safety, and quality of care.

Based on interview, and record review, the facility failed to provide adequate supervision to reduce the risk of elopement (leaving the facility unauthorized, without notifying staff), for three out of three sampled residents, when their wander guards (electronic monitoring devices, usually worn as a bracelet or anklet) were not being consistently monitored for functioning (performance of the system).1. For Resident 1, there was no documented evidence that the wander guard was monitored for functioning, every shift, from 12/15/25 until 4/17/26 (approximately four months).2. For Resident 2, there was no documented evidence that the wander guard was monitored for functioning, every shift, from 3/13/26 until 3/17/26 (13 days).3. For Resident 3, there was no documented evidence that the wander guard was monitored for functioning, multiple times on various days, in September 2025, and on 8/8/25 for functioning and placement of the wander guard.These deficient practices had the potential to place the residents at risk of elopement, which could lead to harm.Findings:1.During a review of Resident 1's admission Record (AR) printed on 4/16/26, the AR indicated, Resident 1 was admitted on [DATE] and originally admitted on [DATE], with diagnoses that included vascular Dementia and Adult failure to thrive.A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool to direct care), dated 12/1/25 indicated a Brief Interview for Mental Status (BIMS, an assessment to detect cognitive impairment) score of 9, indicating moderate cognitive impairment.A review of Resident 1's elopement evaluation dated 12/4/25, indicated, Resident 1 had a history of elopement or an attempted elopement while at home, and also had a history of elopement or attempted leaving the facility without informing staff, and that Resident 1 did wander in the past.A review of Resident 1's progress note (PN) dated 12/4/25, indicated, Resident 1 eloped from the facility during the early morning of 12/4/25, and two police officers brought him back to the facility after he was found at a gas station. The PN indicated, Resident 1 did not have his wander guard on when he returned, and that Resident 1's wander guard was found on his bed.A review of Resident 1's care plan, initiated 12/4/25, revised date 3/6/26, indicated, Resident 1 had Exit seeking behavior or elopement related to: Alzheimer's disease, dementia, history of elopement. The goal indicated, resident will have no episode or attempting to go out of the facility. Further review of the care plan also indicated, interventions initiated 12/4/25 that included .Monitor functioning of wander guard every shift.Monitor Placement of Wander guard every shift on left arm wrist .Monitor skin for any discoloration or skin issues around the wander guard on left arm.During an interview on 4/16/26 at 3:45 pm, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated they do check the wander guard for residents on wander guard at least once a shift and they document in the progress report.During an interview on 4/16/26 at 5:15 p.m., with the Regional Nursing Home Administrator (RNHA), RNHA stated the facility does not have a wander guard policy. RNHA stated it is just an added measure to the elopement and wandering policy.A review of Resident 1's physician orders details provided on 4/16/26, included: A prescriber written Physician order (PO) dated 12/3/25 indicated, Monitor functioning of wander guard every shift. A phone PO, dated 12/3/25 ,indicated, Monitor placement of wander guard every shift on right arm wrist every shift Another phone PO, dated 12/3/25, indicated, Monitor placement of wander guard on left arm/wrist. A phone PO, dated 12/3/25, indicated, Monitor functioning of wander guard on left wrist/arm. A phone PO, dated 12/4/25, indicated, Monitor placement of wander guard on right arm/wrist every shift. The prescriber written PO, dated 3/17/26, indicated, Monitor placement of wander guard on left arm/wrist every shift and another PO dated, 3/17/26, indicated, Monitor skin for any discoloration or skin issues around the wander guard on left arm/wrist every shift.A review of the Resident 1's Medication Administration Record (MAR), dated December 2025, indicated, Monitor functioning of wander guard on left wrist/arm start date 12/3/25 D/C (discontinue) date 12/15/25. A review of Resident 1's January 2026 MAR and February 2026 MAR, both with start date 12/4/25 and D/C date 3/17/25 also indicated, monitoring placement of the wander guard and monitoring skin for any discoloration or skin issues around the wander guard on right arm/wrist were all with checkmarks and initials every shift. However, there was no indication or documented evidence that the functioning of the wander guard was monitored.A review of Resident 1's MAR dated March 2026, indicated, placement of the wander guard was monitored, on Right arm/wrist from 3/1/26 every shift to 3/17/26 on day shift as there were checkmarks and initials by nurses. Resident 1's March MAR also indicated, from night shift of 3/17/26 to 3/31/26, placement of the wander guard on the left arm/wrist and skin was monitored and signed by staff. There was no indication on Resident 1's MAR for March 2026, that staff monitored the functioning of the wander guard.During an interview on 4/17/26 at 11a.m., with the Maintenance Supervisor (MS), MS stated he was responsible for wander guard adjustment from his end and the nurses were responsible for checking battery life using the detector device. MS stated the nurses also register the number in order to know the number on the alarm door wander guard pad.During a telephone interview on 4/20/26 at 10 a.m., with the Director of Nursing (DON), DON stated wander guard is part of the elopement care plan interventions.During a concurrent interview and record review on 4/21/26 at 5:05 p.m., with DON, Resident 1's order summary report dated 3/17/26 was reviewed. The report indicated, Monitor placement of Wander Guard on left arm/wrist every shift active order prescriber written; the report also indicated, Monitor skin for any discoloration or skin issues around the Wander Guard on left arm/Wrist every shift. No order indicated for monitoring functioning of the wander guard and no documented evidence it was being monitored for Resident 1. DON stated the order for monitor functioning of Resident 1's wander guard was not there and DON did not have the answer.During a concurrent interview and record review on 4/21/26 at 5:20 p.m., with the DON, DON confirmed the wander guard for Resident 1 was not monitored for functioning on every shift, from 12/15/25 to 4/17/26 (approximately four months). DON stated they were supposed to check the wander guard with the wander guard device to make sure it was ringing. DON stated, if it is not documented, it means it was not done.2. During a review of Resident 2's admission Record (AR) printed on 4/16/26, the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included cognitive communication deficits, and other psychoactive substance dependence.A review of Resident 2's MDS dated [DATE], indicated, Resident 2's Brief Interview for Mental Status (BIMS, an assessment to detect cognitive impairment) score was 8, indicating moderate cognitive impairment.A review of Resident's 2 elopement evaluation, dated 3/13/26, indicated Resident 2 had a history of elopement or attempted leaving the facility without informing staff.A review of Resident 2's care plan, initiated 3/13/26, revised date 4/2/26, indicated, Resident 2 had Exit seeking behavior or elopement . The care plan goal, indicated, resident will have no episode or attempting to go out of the facility. Further review of the care plan also indicated, .Monitor functioning (performance of the system) of Wander guard every shift.Monitor Placement of Wander guard every shift on left arm wrist.During an observation on 4/16/26 at around 11:55 a.m., Resident 2 was at the front exit door, and wanted to leave and the staff ran after the resident to redirect him, but the resident still would not leave the area despite redirection. During a concurrent telephone interview and record review on 4/20/26 at 11:09 a.m., with DON, Resident 2's MAR for March 2026 was reviewed. DON confirmed that there was no monitoring for functioning of the wander guard for Resident 2 for 13 days, from 3/13/26 to 3/26/26. DON stated it was important to monitor the wander guard functioning because they want to make sure that it was working well to eliminate elopement and safety of the patient.3. During a review of Resident 3's admission Record (AR) printed on 4/16/26, the AR indicated, Resident 3 was admitted to the facility on [DATE] with original admission on [DATE], with diagnoses that included dementia, multiple fractures of ribs, right side, and fracture of one rib, left side.A review of Resident 3's MDS, dated [DATE], indicated, Resident 3 had short-term and long-term memory problem. A review of Resident 3's elopement evaluation, dated 1/12/26, indicated, Resident 3 had a history of elopement or attempted leaving the facility without informing staff and the resident did wander in the past.A review of Resident 3's care plan, initiated 10/1/24, revised date 4/4/25, indicated, Resident 2 had Exit seeking behavior or elopement related to.: Alzheimer's disease, dementia, history of elopement. The care plan goal, indicated, resident will have no episode or attempting to go out of the facility. Further review of the care plan also indicated, interventions initiated 9/5/25, included .Monitor functioning wander guard every shift.Monitor Placement of Wander guard every shift on left arm wrist.Monitor skin for any discoloration or skin issues around the wander guard on left arm.During an observation on 4/16/26 at 1:05 p.m., Resident 3 was standing close to the back exit door, looking outside through the glass door. Staff went after him when they heard the wander alarm beeped.During a concurrent interview and record review on 4/21/26 at 3:30 p.m., with DON, Resident 3's MAR for August 2025 and September 2025 were reviewed. Multiple days and shifts were not signed by staff for monitoring the functioning of Resident 3's wander guard, placement, and monitoring skin for any skin issues, discoloration around the wander guard. DON confirmed the days and shifts without check marks and initials and blank were: 8/8/25 evening shift, 9/1/25 evening shift, 9/13/25 night shift, 9/20/25 day shift, and 9/29/25 evening shift for Monitor functioning of wander guard; and missing checkmarks and initials on 8/8/25 evening shift, for Monitor placement of wander guard on left arm wrist Monitor skin for any discoloration or skin issues around the wander guard on left arm every shift. DON stated the nurses forgot to sign and would check if they have documented it in the progress notes.During an interview on 4/21/26 at 4:35 p.m. with DON, DON stated it seemed like the staff didn't do it [monitoring functioning and placement of wander guard and monitoring skin around the wander guard for Resident 3]. DON stated she could not find staff documentation in the progress notes or anywhere else.During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, revised date March 2019, the P&P indicated, If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised date March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.During a review of the wander guard manual, titled, [NAME] Healthcare Data sheet WanderGuard BLUE Detector, undated, the manual indicated, .The detector is used to detect and activate Tags and check their battery level. It also enables Tags to be visible in the WanderGuard BLUE Manager.Any staff member can quickly and easily verify Tag battery status without disturbing residents or forcing them to walk to a door monitored by a WanderGuard BLUE controller.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool used to direct care) for one of three sampled residents (Resident 2) was completed and coded accurately for wander guard [an electronic monitoring device, usually worn as a bracelet or anklet]. This failure placed Resident 2 at risk of not receiving the care and services appropriate to his needs, due to an inaccurate reflection of Resident 2's clinical status on the MDS assessment.Findings:During a review of Resident 2's admission Record (AR) printed on 4/16/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficits, and other psychoactive substance dependence.A review of Resident 2's MDS dated [DATE], indicated, Resident 2's Brief Interview for Mental Status (BIMS, an assessment to detect cognitive impairment) score of 8, indicating moderate cognitive impairment. The MDS also indicated, code '0' for Wander/Elopement alarm indicating not used.A review of Resident's 2 elopement (leaving the facility unauthorized, without notifying staff) evaluation, dated 3/13/26, indicated, Resident 2 had a history of elopement or attempted leaving the facility without informing staff.A review of Resident 2's care plan, initiated 3/13/26, revised date 4/2/26, indicated, Resident 2 had Exit seeking behavior or elopement . The goal indicated, resident will have no episode or attempting to go out of the facility. Further review of the care plan also indicated .Monitor functioning (performance of the system) of Wander guard every shift.Monitor Placement of Wander guard every shift on left arm wrist.During a concurrent telephone interview and record review on 4/20/25, at 11:30 a.m., with the Director of Nursing (DON), Resident 2's MDS section P, dated 3/16/26, was reviewed and indicated 0 meaning it was not used. DON stated Resident 2's MDS was an inaccurate assessment. DON stated the MDS coordinator (MDSC) coded the assessment and that the MDSC was currently not available. DON stated Resident 2 had the wander guard on March 16. DON stated it was important to ensure staff put the correct documentation for patient safety that coincides with their needs.A review of the facility's policy and procedure (P&P) titled, Resident Assessments, revised date March 2022 indicated, .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.admission Assessment (Comprehensive).A comprehensive assessment include: .development of the comprehensive care plan.A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised date March 2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure fall risk care plan interventions were implemented for two out of two sampled residents (Residents 1 and 2) who were at risk for falls, when their call lights were not within reach.This deficient practice had the potential to result in falls, injury, and harm to the residents.1.A review of Resident 1's admission record, undated, indicated Resident 1 had diagnoses that included compression fracture of the vertebra (a break in a vertebra - a bone in the spine, which may be caused by a fall or accident), and repeated falls.During an observation on 3/16/26 at 11:55 a.m. in Resident 1' room, Resident 1 was observed from the hallway. Resident 1 stood up from her bed, grabbed her walker, held onto it, and went to the bathroom unassisted. Resident 1 appeared unsteady on her feet.During concurrent observation and interview on 3/16/26 at 12:03 p.m. in Resident 1's room, Certified Nursing Assistant (CNA) 1 stated Resident 1 needed staff assistance to the bathroom as she was at risk of falling. She stated sometimes Resident 1 was steady and sometimes she was not. CNA 1 stated CNA 2 was Resident 1's assigned CNA was on lunch break and would be back soon. CNA 1 stated she would go and assist Resident 1. CNA 1 assisted Resident 1 back to her bed. Resident 1 was now lying in bed, alert. CNA 1 stated Resident 1 was hard of hearing. Resident 1 stated she could hear better in her left ear. CNA 1 then spoke to her in her left ear. CNA 1 stated Resident 1 was supposed to call for assistance. When asked for her call light, Resident did not understand or hear well. CNA searched for Resident 1's call light and she found Resident 1's call light on the floor somewhere behind Resident 1's nightstand. The nightstand was not very close to Resident 1's bed. CNA 1 then pinned the call light to Resident 1's bed, showed it to her and instructed her how to use it, then Resident 1 pressed the call light button.During an interview on 3/16/26 at 12:40 p.m. with CNA 1, CNA 1 stated the call light should be attached, snapped on the pillow or bed, or blanket where the residents can reach it.During an interview on 3/16/26 at 1:55 p.m. with CNA 1, CNA 1 stated the call light should be next to the residents because it is a means of communication to call staff.A review of Resident 1's care plan initiated 2/1/26 indicated, Risk for falls, fall related injury secondary to Gait/bal (balance), cognitive problem, unaware of safety. with interventions including, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.2. A review of Resident 2's admission record, undated, indicated Resident 2 had diagnoses that include seizures, and benign prostatic hyperplasia (a condition in which the prostate gland grows larger than normal, but the growth is not caused by cancer) with lower urinary tract symptoms.During a concurrent observation and interview on 3/16/26 at 12:20 p.m. in Resident 2's room, Resident 2 was lying on his bed, sleeping. CNA 3 stated Resident 2 is a fall risk and he had a weak right side. When asked, CNA 2 stated Resident 2 had not called today. When asked about Resident 2's call light, CNA 3 looked around for it and found it on the floor, picked it up, and attached it to Resident 2's pillow. CNA 3 stated the call light was not supposed to be on the floor. She stated the call light needs to be reachable by the resident so that he can call if he needs anything. When asked, CNA 3 stated in her last round, she did not check if Resident 2's call light was within reach. CNA 3 stated the call light should be attached, snapped in the pillow or bed, blanket where they can reach it.During an interview on 3/16/26 at 2:18 p.m. with CNA 3, CNA 3 stated it is important to have the call light within residents' reach in case they need help.for safety, to prevent falls or accidents.During a review of Resident 2's progress note (PN) dated 2/18/26, the PN indicated Resident 2 had an unwitnessed fall in his room. The PN indicated, reason for fall: resident was self-transferring from bed to his wheelchair.During a review of Resident 2's care plan dated and initiated on 2/18/26 it indicated: Risk for injury: Fall occurred. Goal - Resident will be free of further falls.During an interview on 3/16/26 at 3:05 p.m. with Licensed vocational nurse (LVN) 1, LVN 1 stated call lights should be within arm's reach of the resident. During an interview on 3/16/26 at 3:20 p.m. with the Director of Nursing (DON), DON stated the call lights should always be close to the residents at all times and should be at arm's reach of the resident per their preference whether they want it pinned on the bed or pillow. During an interview on 3/16/26 at 5 p.m. DON stated as she stated before, the call light should be within reach of the residents all the time considering their preference as long as it is reachable for the resident. DON acknowledged it should not be on the floor.During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, dated September 2022, the P&P indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.During a review of the facility's P&P titled, Fall and Fall Risk, Managing, revised March 2018, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to minimize complications.

Based on interview and record review, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietician and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full-time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 43 residents eating facility prepared foods. Findings: According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes the following: The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). During an interview on 8/19/24 at 9:10 a.m. with Dietary Supervisor (DS), DS stated she was the supervisor for the kitchen and worked with the facility as a supervisor for a year. During an interview on 8/19/24 at 9:30 a.m. with Registered Dietician Nutritionist (RDN), RDN stated she worked at the facility part time, once a week for 8 hours. During an interview on 8/22/24 at 10:00 a.m. with DS, DS stated she did not have a Dietary Manager Certification. DS also stated that she was currently enrolled and working on courses to obtain her certificate. During a review of facility's job description titled Dietary Supervisor revised 03/17/21, the job description indicated, Position Summary .Responsible for assisting in planning, organizing, developing and directing overall operation of Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations.

Based on observation, interview, and record review, the facility failed to trim and clean fingernails for three out of four sampled residents when Residents 30, 32, and 33 had long fingernails with dirty substances underneath them. This failure had the potential to result in Resident 30, Resident 32, and Resident 33's poor personal hygiene and risk for infection. FINDINGS: 1a. During a review of Resident 30's Face Sheet, dated August 2024, the Face Sheet indicated, Resident 30 was admitted on [DATE] with diagnosis that includes Hemiplegia (the loss of muscle function on one side of the body) and Hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) and Diabetes (a long-term chronic disease in which the body cannot regulate the amount of sugar in the blood). During a review of Resident 30's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated July 2024, the MDS indicated, Resident 30's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 15 out of 15, indicating cognitively intact mental status. The MDS assessment also indicated, Resident 30 was dependent with personal hygiene. During a review of Resident 30's care plan titled Activities of Daily Living (ADL-are those needed for self-care and mobility and include activities such as grooming), dated October 2023, the care plan indicated, Resident had an ADL deficit related to Cerebrovascular Accident (CVA-also called a stroke, occurs when blood flow to a part of the brain stops) with hemiplegia .personal hygiene: dependent .groomed daily .adl needs will be met daily .assist with ADL as needed. During a concurrent observation and interview on 8/19/24 at 8:38 a.m. with Resident 30 in her room, Resident 30's fingernails were about 1/2 inch long with brown matter underneath her fingernails. Resident 30 stated she preferred short nails and clean, but no staff assist her in trimming her fingernails. During a concurrent observation and interview on 8/19/24 at 8:45 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 30's room, Resident 30's fingernails were observed. CNA 1 stated, Resident 30's fingernails were long and dirty. CNA 1 also stated Resident 30 had a diagnosis of Diabetes and licensed nurses (LN) were responsible to trim her fingernails. During a concurrent observation and interview on 8/19/24 at 10:05 a.m. with Registered Nurse (RN) 2 in Resident 30's room. RN 2 stated he worked at the facility as a treatment nurse and could also provide fingernail trimming to diabetic residents. RN 2 stated Resident 30's fingernails were long and dirty. RN 2 also stated fingernails should be trimmed and cleaned. 1b. During a review of Resident 32's Face sheet, dated August 2024, the face sheet indicated, Resident was admitted on [DATE] with diagnosis of Disease of Spinal Cord (condition that cause damage and deterioration to the spinal cord. Spinal cord is a tubelike structure that consist of a bundle of nerves that extends from base of the brain and down the back that carries messages from the brain to the rest of the body). During a review of Resident 32's MDS dated [DATE], the MDS indicated, Resident 30's BIMS was 10 out of 15, indicating moderate impairment in mental status. During a review of Resident 32's care plan titled Activities of Daily Living (ADL), dated November 2023, the care plan indicated, Resident had an ADL deficit related to Spinal Cord Disease .personal hygiene: dependent .groomed daily .ADL needs will be met daily .assist with ADL as needed. During an observation on 8/19/24 at 7:54 a.m. in Resident 32's room, Resident 32's fingernails were 1/4 inch long with black colored matter embedded underneath his fingernails. During a concurrent observation and interview on 8/19/24 at 8:20 a.m. with CNA 1 in Resident 32's room, CNA 1 stated that Resident 30's fingernails were long and dirty. CNA 1 also stated Resident 32's fingernails should be trimmed and cleaned. During an interview on 8/19/24 at 10:20 a.m. with RN 1, RN 1 stated Resident 32's hands should be clean every day and fingernails should be trimmed as the need arises. 1c. During a review of Resident 33's Face sheet, dated August 2024, the Face sheet indicated, Resident was admitted on [DATE] with diagnosis of Cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During a review of Resident 33's MDS dated [DATE] , the MDS indicated, Resident 33's BIMS was 5 out of 15, indicating severe impairment in mental status. The MDS assessment also indicated, Resident 33 required a maximum assist in personal hygiene. During a review of Resident 33's care plan titled Activities of Daily Living (ADL) dated May 2023, the care plan indicated, Resident 33 had an ADL deficit .groomed daily .ADL needs will be met daily .assist with ADL as needed. During an observation on 8/19/24 at 8:10 a.m. in Resident 33's room, Resident 33's fingernails were 1/4 inch long with black colored matter embedded underneath his fingernails. During a concurrent observation and interview on 8/19/24 at 8:15 a.m. with CNA 1, CNA 1 stated, Resident 33's fingernails were long and dirty. CNA 1 stated fingernails should be trimmed and cleaned when noted. During an interview on 8/22/24 at 9:06 a.m. with DON, DON stated she expected CNAs and LNs to check residents' fingernails during morning rounds. CNAs should provide nail care to non-diabetic residents and licensed nurses to diabetic residents if fingernails were long and dirty. DON stated that Residents fingernails should be trimmed and cleaned. DON also stated fingernails that left untrimmed and dirty could lead to infection when residents placed their hands in their mouth and skin breaks when residents scratched themselves. During a review of the facility's Policy and Procedures (P&P) titled, CARE OF FINGERNAILS/TOENAILS revised February 2018 was reviewed, the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .nail care includes daily cleaning and regular trimming. During a review of the facility's Policy and Procedures (P&P) titled, Activities of Daily Living (ADL), Supporting revised March 2018 was reviewed, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene.

Based on observation, interview, and record review, the facility failed to ensure safe storage of drugs and biologicals when: 1. Outdated or expired medications were stored in the medication room 2. A discontinued medication, including food items were stored in the medication cart These failed practices could contribute to unsafe medication use and storage in the facility. Findings: 1. During a concurrent observation and interview on 8/19/24 at 11:24 a.m., with the Infection Preventionist (IP) present, in the facility's medication room, the IP stated that the following items should have been discarded or placed in the designated discontinued or discard box next to sink inside the medication room: 1 Tube Feeding Formula, use by date 3/23/24 1 Box of COVID-19 Test Kit containing 34 test cards, kit lot number 192047, expiry date 4/30/23 3 Boxes of Sample Specimen Collection Kits containing individually packaged tubes and swabs, expiry dates 11/9/22 1 first aid kit, expiry date 1/31/22 27 Dextrose 5% Injection Bags 250 ml (milliliter), expiry dates 1/1/24 6 Normal Saline Pre-filled Flush Syringes 10 ml, expiry dates 8/31/22 2 Normal Saline Pre-filled Flush Syringes 10 ml, expiry dates 9/30/22 1 Normal Saline Pre-filled Flush Syringes10 ml, expiry date 11/30/23 2. During a concurrent observation and interview on 8/19/24 at 2:18 p.m., with Registered Nurse (RN) 1 present, the following items were stored on the third drawer, left hand side, of Medication Cart 1: 1 opened cough syrup bottle with no open date, name, or room number of resident 1 raspberry flavored yogurt cup 1 sugar free pudding cup During an interview with RN 1 on 8/19/24 at 2:20 p.m., RN 1 stated the cough syrup bottle was for Resident 11, which was no longer used. RN 1 stated, the medication should be labeled with an open date, including name and room number of Resident 11. RN 1 stated the medication had to be labeled to ensure it belonged to Resident 11 and not given to another resident. During an interview with RN 1 on 8/19/24 at 2:24 p.m., RN 1 stated the yogurt and pudding cups should not be kept inside the medication cart and should have been discarded. Review of the facility's Policy and Procedures (P&P), titled, Storage of Medications, revision dated 4/2019, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to provide 27 of 43 residents in resident Rooms A, B, C, D, E, F, G, H, and I with at least 80 square (sq) feet (ft) of living space per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and lack of sufficient space for residents to have personal belongings at the bedside. Findings: During a record review of the Client Accommodations Analysis, dated 8/19/24, the following resident rooms and corresponding square footage were identified: Room A was a total of 216.2 sq. ft. and had three beds making 72 sq. ft. of space per resident. Room B was a total of 214.28 sq. ft. and had three beds making 71.42 sq. ft. of space per resident. Room C was a total of 216.04 sq. ft. and had three beds making 72 sq. ft. of space per resident. Room D was a total of 217.04 sq. ft. and had three beds making 72.34 sq. ft. of space per resident. Room E was a total of 217.88 sq. ft. and had three beds making 72.62 sq. ft. of space per resident. Room F was a total of 215.19 sq. ft. and had three beds making 71.73 sq. ft. of space per resident. Room G was a total of 218.18 sq. ft. and had three beds making 72.72 sq. ft. of space per resident. Room H was a total of 218.57 sq. ft. and had three beds making 72.85 sq. ft. of space per resident. Room I was a total of 220.96 sq. ft. and had three beds making 73.65 sq. ft. of space per resident. During random observations of care and services from 8/19/2024-8/22/2024, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the 9 rooms. Recommend granting room size waiver.

Based on observation, interview and record review the facility failed to meet food safety requirements for food storage and kitchen sanitation when multiple surfaces had dust, food particles and/or granular particles, two cans were dented, two items were missing use by dates, and one bag potatoes contained potatoes with roots. These failures has the potential to compromise the safety of the food served through cross contamination and cause illness or hospitalization to residents who consume it. Findings: During the initial tour of the kitchen on 8/8/22 at 10:15 a.m. with Dietary Manager 1, (DM 1), the following was observed: 1. The cart used to transport various food products to residents was observed to have a granular substance on the shelves and imbedded in the grip on the handle of the cart. 2. The stainless-steel lip on the walls surrounding the dishwasher area was observed to have substantial dust over the length of the wall mounted lip. 3. The stainless-steel counter on the dirty side of the dishwasher was observed to be very wet with food particles on the surface. 4. The dishwasher was observed to have dry particles stuck to the exterior sides of the dishwasher and granulated particles on top of the dishwasher. 5. The tray rack used to store clean dishes was observed to have dust and dirt on each of the tray support lips inside the rack. 6. The drying pads used for drying clean dishes were observed to be worn to the point of leaving granular particulates on the trays underneath on three trays in the tray rack. 7. Three trays underneath the drying mats were observed to have granular particulates and a dried substance on the trays under the mats. 8. The countertop on the left side of the sink was tacky to the touch. 9. The drawers holding clean cooking utensils were observed to have granular particles on the inside of the drawers. 10. The shelf storing dry seasonings was observed to have a granular particles and dust underneath the bottles of dry seasoning. 11. The wall surface between the counter and stove on both sides of the stove was observed to have stains and dried substances splattered across the surface. 12. The floor between the counter and both sides of the stove were observed to have stains, splattered dried substances, and dust. 13. One can of tuna located in the dry storage area was observed to be dented. 14. One can of baked beans located in the dry storage area was observed to be dented. 15. A storage bin holding 17 soft and rooted potatoes was observed to be in the dry storage area labeled with a preparation date, (date placed in storage), of 7/12/22 and use by date (UBD), of 8/12/22. 16. A storage bin containing packaged dry pasta was observed to have white powder on the outside of pasta bags. 17. A one-gallon container of classic buttermilk dressing located in Refrigerator 1 was observed to be missing an opened on or a UBD on the container. 18. A one-gallon container of pickle relish was observed to be missing an opened on or a UBD on the container. During an interview with the DM1, on 8/8/22 at 11:15 a.m. DM1 stated it is the responsibility of the dietary aid to clean kitchen surfaces. DM1 stated the drying matts under the clean dishes on the trays in the rack were not changed appropriately and the trays were unclean. During an interview with the Dietary Assistant, (DA), on 8/8/22 at 11:30 a.m. DA stated keeping the surfaces in the kitchen clean is her responsibility. She stated she gets very busy and cannot get to cleaning kitchen surfaces. During an interview with Dietary Manager 2, (DM2), on 8/16/22 at 2:30 DM2 stated the kitchen follows the sanitation and storage standards set forth by RDs for Healthcare. During a review of a facility document titled, General Appearance of Food and Nutrition Department from RDs for Healthcare dated 2018, indicated Floors, floor mats and walls must be scheduled for routine cleaning and maintained in good condition, .Walls and ceilings must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently as necessary, .Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), and availability of routine and emergency drugs when: 1. Two out of 2 medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift; 2. There was no record of controlled drug destruction available upon request; 3. One out of 5 emergency kits (e-kit, a kit containing medications and supplies for immediate use during a medical emergency) was not replaced in a timely manner in accordance with the facility policy and procedures (P&P); 4. Two out of 5 e-kits expired; and 5. Expired and discontinued medications were not removed from active stock These failures had the potential for the facility to not have accurate accountability of controlled medications, abuse or misuse of these medications, use of ineffective medications or those with reduced potency, and medications being unavailable for use during an emergency. Findings: 1. On [DATE] at 12:50 p.m., a review of the controlled drug sign-in/sign-out for Medication Cart 2 alongside Licensed Vocational Nurse 1 (LVN 1) identified missing signatures by the outgoing and incoming nurse for each shift (7 a.m., 3 p.m., and 11 p.m.). LVN 1 acknowledged the record was missing signatures between nursing shift changes and stated, I think everyone knows to sign the narcotic book. A review of the controlled drug sign-in/sign-out sheet, dated [DATE] to [DATE], indicated 46 missing signatures (for the dates indicated) between nursing shift changes. On [DATE] at 11:13 a.m., a review of the controlled drug sign-in/sign-out for Medication Cart 1 alongside LVN 1 identified and confirmed multiple missing signatures by the outgoing and incoming nurse for each shift. A review of the controlled drug sign-in/sign-out sheet, dated [DATE] to [DATE], indicated 98 missing signatures (for the dates indicated) between nursing shift changes. During an interview on [DATE], at 11:58 a.m., with Director of Nursing (DON), when asked if nurses were expected to sign the controlled drug sign-in/sign out sheet between shift changes, DON stated, I believe so . let me get one of my nurses. During an interview on [DATE], at 12:01 p.m., with Infection Preventionist (IP) and DON, IP verified and stated the incoming and outgoing nurse were to count controlled medications together, and both sign the sheet between each shift change. The DON then stated, Looks like we need to practice. During an interview on [DATE], at 12:58 p.m., with Consultant Pharmacist (CP), CP confirmed the controlled sign-in/sign-out sheet had to be signed between shift changes to acknowledge a count of controlled drugs in the medication cart matched the controlled drug record. A review of the facility's policy and procedure titled, Medication Storage in the Facility, dated [DATE], indicated, At each shift change, a physical inventory of all controlled medications . is conducted by two licensed nurses and is documented on the controlled medication accountability record. 2. The controlled drug destruction log was requested for review during the survey. During an interview on [DATE], at approximately 1 p.m., with DON, DON was unable to locate the narcotic destruction log and stated he would try to find it. During an interview on [DATE], at 1:10 p.m., with CP, CP stated the narcotic destruction log stayed with the DON. During an interview on [DATE], at 11:16 a.m., with DON, DON confirmed he was not able to find or locate the narcotic destruction log. A review of the facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies, dated [DATE], indicated, The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the medication disposition form. 1. Date of destruction 2. Resident's name 3. Name and strength of medication 4. Prescription number 5. Amount of medication destroyed 6. Signatures of witnesses . The medication disposition form is kept on file in the facility for 3 years. 3. On [DATE] at 1:47 p.m., an inspection of the medication storage room with IP identified and confirmed an opened e-kit. Review of the drug removal records indicated medications were removed from the e-kit on [DATE], [DATE] and [DATE]. IP stated as soon as an e-kit was opened, it was to be reordered from the pharmacy and replaced immediately. She agreed that if this process was not followed, medications would potentially not be available when needed in an emergency. During an interview on [DATE], at 12:03 p.m., with DON, DON verified when an e-kit was opened it was to be reordered from the pharmacy and agreed the. He acknowledged and agreed the e-kit should have been reordered after it was first opened, more than 2 months prior. During an interview on [DATE], at 1:06 p.m., with CP, CP stated the opened e-kit should have been replaced after it was opened so emergency medications would be available when and if needed. A review of the facility's policy and procedure titled Medication Ordering and Receiving from Pharmacy, dated [DATE], indicated, . the nurse . notifies the pharmacy for replacement of the emergency drugs supply . used sealed kits are replaced with the new sealed kits within 72 hours of opening. 4. On [DATE] at 11:43 a.m., a concurrent interview and inspection of Medication Cart 2 with LVN 1 identified and confirmed a controlled medication e-kit with expiration date of [DATE]. Inside the e-kit LVN 1 verified four 0.5 milliliter (ml, a unit of measure) prefilled syringes of [MEDICATION(S)] 10 milligram/0.5 milliliter (mg/ml, a measurement) expired [DATE], and three 1 ml vials [MEDICATION(S)] 2 mg/ml (a pain medication) expired [DATE]. LVN 1 stated the staff should have replaced the e-kit the month prior to it expiring. During a concurrent interview and record review on [DATE], at 12:44 p.m., with LVN 1, all e-kit replacement fax requests to the pharmacy were reviewed from [DATE] to [DATE]. There were no requests submitted to the pharmacy to replace the expired e-kits. During an inspection of the medication storage room on [DATE], at 1:51 p.m., alongside IP, an expired intravenous (IV) antibiotic e-kit with expiration date [DATE] was identified and confirmed. During an interview on [DATE], at 12:03 p.m., with DON, DON acknowledged the controlled drug e-kit and IV antibiotic e-kit were expired. He confirmed they should have been replaced prior to their expiration. During an interview on [DATE], at 1:02 p.m., with CP, CP stated the facility was notified in [DATE] of the two e-kits due to expire on [DATE]. He stated the facility was responsible for ensuring the kits were replaced prior to their expiration dates. 5. On [DATE] at 10:40 a.m., an inspection of the medication storage room with DON identified five oyster shell calcium 250 mg plus vitamin D expired on ,d+[DATE] and three bottles sevelamer 800 mg tablets (a medication used to treat [CONDITION(S)]) for a resident that had been discharged . DON confirmed expired, discontinued and medications for residents who were no longer at the facility were to be removed from the active supply and destructed. A review of the facility's policy and procedure titled Medication Storage in the Facility, dated [DATE], indicated, Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal . A review of the facility's policy and procedure titled Disposal of Medications and Medication-Related Supplies, dated [DATE], indicated, Discontinued medications and medications left in the facility after a resident's discharge . are destroyed.

Based on observation, interview, and record review, the facility had a 6.9% error rate when two medication errors out of 29 opportunities were observed during a medication pass for two of seven Residents (Residents 1 and 30). These failures resulted in medications not given in accordance with the prescriber's orders and may affect the resident's clinical condition. Findings: 1. During a medication pass observation on 8/8/22, at 10:39 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed preparing five medications, including aspirin 81 milligrams (mg, a measurement) tablet for Resident 30. A review of Resident 30's medical record indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .C., a coating formulation that allows aspirin to pass through the stomach to the small intestine before dissolving) 81 mg one tablet daily. During an interview on 8/9/22, at 12:36 p.m., with LVN 1, LVN 1 confirmed the order was for aspirin E.C. and stated she could not recall whether or not she administered the correct aspirin formulation. During an interview on 8/10/22, at 1:44 p.m., with Director of Nursing (DON), DON confirmed any medication given to a resident must be given as ordered by a physician. During a review of the facility's policy and procedure titled, IIA2: Medication Administration- General Guidelines, dated October 2017, indicated, Medications are administered in accordance with written orders of the attending physician. 2. During a medication pass observation on 8/8/22, at 11:14 a.m., with LVN 1, LVN 1 was observed preparing five medications, including Senna 8.6 mg (a medication for constipation) for Resident 1. LVN 1 was unable to locate Senna 8.6 mg tablets in the medication cart and stated she would notify the physician. A review of Resident 1's physician's telephone orders, dated 8/8/22 at 3 p.m., indicated, D/C [discontinue] previous Senna orders [for] residents who has Senna. Change to Senna 8.6 mg [with] [MEDICATION(S)] sodium 50 mg 2 tabs [tablets] orally every morning. During an interview on 8/9/22, at 11:06 a.m., with LVN 1, LVN 1 verified the Resident 1's medication order for Senna was not updated to reflect the physician's telephone order. She stated Resident 1's Senna order was, still the same and I don't see any notes. During an interview on 8/9/22, at 12:05 p.m., with DON, DON stated it was the nurse's responsibility to communicate with the physician anytime a medication was not available for administration. During an interview on 8/9/22, at 12:08 p.m., with Infection Preventionist (IP), IP verified Resident 1's medication order for Senna was not updated to reflect the physician's telephone order given at 3 p.m. on 8/8/22. IP confirmed the Senna with [MEDICATION(S)] tablet was not administered to Resident 1 on 8/8/22, as ordered by the physician. A review of Resident 1's medical record indicated the order for Senna 8.6 mg tablets was not discontinued until 8/9/22, an entire day after the physician ordered for it to be discontinued. The medical record indicated Senna 8.6 mg with [MEDICATION(S)] 50 mg tablet, 2 tablets orally once daily for constipation, started 8/9/22. During an interview on 8/10/22, at 1:44 pm., with DON, DON confirmed medications should be administered as ordered by the physician. During an interview on 8/11/22, at 11:43 a.m., with DON, DON stated in his previous experience he would ensure telephone orders for medications were updated in a resident's record, within an hour. During a review of the facility's policy and procedure titled, Telephone orders, dated February 2014, indicated, Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record.

Based on observation, interview and record review, the facility failed to ensure proper storage of medications when: 1. Medications and biologicals requiring refrigeration were not stored within manufacturer's specifications; and 2. Medication storage room and medication refrigerator temperatures were not monitored routinely per facility policy and procedure (P&P) The deficient practices had a potential for improperly stored and inadequately monitored medications, which could lead to unsafe and ineffective medication use for residents. Findings: 1. On 8/10/22 at 2:16 p.m., an inspection of the medication refrigerator with Infection Preventionist (IP) identified an internal thermometer with a temperature that measured 25 degrees Fahrenheit. Inside the refrigerator were various types of resident insulins (medication to treat elevated blood sugar) and six vials of [MEDICATION(S)] (an injectable used to test for [CONDITION(S)]). When asked if 25 degrees Fahrenheit was a safe temperature to store [MEDICATION(S)] at, IP stated she did not know. She then looked at the manufacturer's box which indicated the product was to be stored between 36 to 46 degrees Fahrenheit and stated, No. During a separate inspection of the medication refrigerator on 8/11/22 at 10:36 a.m., with Director of Nursing (DON), the DON verified the internal thermometer measured 32 degrees Fahrenheit. DON stated he was uncertain if that was a safe temperature to store medications at and would need to check the facility policy. DON verified 32 degrees Fahrenheit was too cold and stated, that is outside the range, so we need to bump that up. DON acknowledged and agreed it was unsafe to administer medications when they were not stored correctly. During an interview on 8/11/22, at 11:23 a.m., with Consultant Pharmacist (CP), CP confirmed medications that required refrigeration should be stored between 36 and 46 degrees Fahrenheit. CP confirmed the facility was to regularly monitor the temperature to ensure it stayed within that range. A review of the facility's policy and procedure titled Medication Storage in the Facility, dated April 2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations . Medications requiring 'refrigeration' or 'temperatures between 2?C [degrees Celsius] (36?F [degrees Fahrenheit]) and 8?C (46?F)' are kept in a refrigerator with a thermometer to allow temperature monitoring . Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified. 2. During a concurrent interview and record review on 8/08/22, at 1:10 p.m., with LVN 1, the medication room temperature log for 5/1/2022 to 8/2/22 were reviewed. The medication temperature log indicated temperature readings were documented in the morning and the evening. A review of the log identified 65 temperature readings that were not completed. LVN 1 acknowledged and confirmed temperatures were not routinely monitored. She stated nurses should check to see if temperatures for the medication room and refrigerator was logged, at least once on your shift. During a concurrent interview and record review on 8/08/22, at 1:13 p.m., with IP, the medication storage room temperature log was reviewed. IP confirmed the temperature monitoring for the medication storage room was not routinely performed. During an interview on 8/08/22, at 1:36 p.m., with DON, DON confirmed the temperature for the storage room and refrigerator should be documented, at least once (daily). DON acknowledged and agreed if there was any deviation from the manufacturer's storage specifications, it would not be possible to confirm whether the medications were still safe and effective for use without routine temperature monitoring. A review of the facility's medication refrigerator temperature log, dated May 2022 to August 2022, indicated a column for morning and evening temperature readings. Review of the document identified 75 temperature readings that were not performed. During an interview on 8/09/22, at 12:58 p.m., with CP, CP stated the medication storage room and refrigerator monitoring, should be done religiously. He agreed and confirmed temperatures for both should have been documented on the respective logs. A review of the facility's policy and procedure titled, Medication Storage in the Facility, dated April 2008, indicated, Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified.

Based on observation, interview, and record review, the facility failed to ensure bowel movements (BMs) were documented for three of 12 sampled residents (Residents 9, 20 and 28), on 8/1/22 through 8/5/22. This failure had the potential to result ineffective bowel management for Residents 9, 20 and 28. Findings: During a concurrent interview and record review on 8/10/22, at 2:33 p.m., with Infection Preventionist (IP), the Bowel and Bladder Log, dated August 2022 was reviewed. The log indicated that BMs were not documented for Residents 9, 20 and 28 on 8/1/22 through 8/5/22, IP stated that their policy was for Certified Nursing Assistants (CNAs) to document BMs for residents every shift in the Bowel and Bladder Log. IP stated that it was important to document resident BMs because staff wouldn't know if residents had a bowel movement, when their last bowel movement was, or if they were constipated. IP stated that resident's may have been restless due to constipation, but they wouldn't have known if their BMs weren't documented. During an interview on 08/11/22, at 8:28 a.m., with CNA 1, CNA 1 stated that she was supposed to document resident BMs in the Bowel and Bladder Log every shift. During a record review of Resident 9's Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/2/22, the MDS indicated resident 9's, Bowel Continence, was Always incontinent. During a record review of Resident 20's MDS, dated [DATE], the MDS indicated resident 20's, Bowel Continence, was Always incontinent. During a record review of Resident 28's MDS, dated [DATE], the MDS indicated resident 28's, Bowel Continence, was Always incontinent. During a review of the facility's policy and procedure (P&P) titled, Bowel (Lower-Gastrointestinal Tract) Disorders - Clinical Protocol, revised September 2017, the P&P indicated, .the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. The P&P indicated, Examples of lower gastrointestinal tract conditions and symptoms include: .fecal incontinence. The P&P indicated, .the nurse shall assess and document/ report the following: .Quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount consistency, etc.). The P&P indicated, The staff and physician will monitor the individual's response to interventions and overall progress; for example, overall degree of comfort or distress, frequency and consistency of bowel movements.

Based on interview and record review, the facility failed to ensure competency skills checks for one of three licensed nursing staff and one of two certified nurse assistants were completed. This failure had the potential for care to be provided by licensed nurses and certified nurse assistant in an unsafe and incompetent manner. Findings: During a concurrent interview and review of employee personnel files, on 8/10/22, at 2:35 p.m., with Director of Staff Development (DSD), the files indicated Licensed Vocational Nurse (LVN) 4 was hired on 5/24/20 and Certified Nurse Assistant (CNA) 2 was hired on 7/9/20. The personnel files also indicated there was no competency skills check done for LVN 4 and CNA 2 at the start of employment. DSD, indicated competency checklist was not in the employee file because it was not done. During an interview on 8/11/22, at 10:29 a.m., with the Infection Preventionist Director of Staff Development Consultant (IPDSDC), the IPDSDC confirmed, competency evaluation for LVN 4 and CNA 2 was not done. During an interview on 8/11/22, at 1:23 p.m., with the Director of Nursing (DON), DON stated, quality of care and safety of residents can be affected when LVN 4 and CNA 2 was not evaluated for competency skills. During a review of facility's policy and procedure (P&P) titled, Competency of Nursing Staff, dated May 2019, the P&P indicated, 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.6. Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.

Based on observation, interview and record review, the facility failed to provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. The facility had nine resident rooms (room A, B, C, D, E, F, G, H, I) with a total of 27 licensed beds that were occupied by 25 residents, that provided less than 80 square feet (sq. ft.) per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and lack of sufficient space for residents to have personal belongings at the bedside. Findings: During observations between 8/8/2022-8/11/2022, the following resident rooms and corresponding square footage were identified: Room A had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. Room B had three beds that measured 17 ft. by 12.6 ft., providing 70.83 sq. ft. per resident. Room C had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. Room D had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. Room E had three beds that measured 17 ft. by 12.8 ft., providing 71.89 sq. ft. per resident. Room F had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. Room G had three beds that measured 17 ft. by 12.8 ft., providing 71.89 sq. ft. per resident. Room H had three beds that measured 17 ft. by 12.8 ft., providing 71.89 sq. ft. per resident. Room I had three beds that measured 17 ft. by 12.10 ft., providing 72.72 sq. ft. per resident. During random observations of care and services from 8/8/2022-8/11/2022, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the nine rooms. Recommend granting room size waiver.

Based on observation, interview, and record review, the facility failed to serve therapeutic diets (diet ordered by a physician for treatment of [REDACTED]. This failure resulted in under and overserved portions of food and meals not served according to the planned menu. This also had the potential for compromised medical and nutritional status for residents. During an observation of the tray line on 2/10/20 at 11:45 a.m., and review of the winter menu for Monday Week 2, showed the following: 1. The menu indicated for 4 ounce (oz) servings. Cook 1 weighed 1 cooked beef patty at 3 oz for the CCHO regular diet. Cook 1 served 3 oz of the meat patty for the CCHO regular diets. 2. There were eight CCHO Regular diets, one 3 oz southern style meat patty and 4 oz of mashed potatoes. The menu planned was for 4 oz beef patty and 2 oz of mashed potatoes. 3. For twelve fortified diets, Cook 1 served 4 oz of melted butter on mashed potatoes. The menu directions specified the amount was supposed to be one-half oz. 4. One puree double portion diet received one 6 oz scoop, plus a little extra pureed meat, as Cook 1 ran out of pureed meat. The Dietary Supervisor Staff (DSS) stated the double should receive two serving of 6 ounces. Cook 1 did not prepare adequate quantities of pureed meat to serve all of the portions required. 5. Four No Added Salt (NAS) diets received regular gravy with beef patty. During an observation and taste sample of the test tray on 2/10/20 at 12:48 p.m., DSS tasted the meat and stated it, tastes salty. During an interview on 2/11/20 at 10:25 a.m., with the Registered Dietician (RD), RD read the gravy mix ingredients and stated, This would be an issue for NAS diets.

Based on observation, interview, and record review, the facility did not notify the physician for changes in condition for four(Residents 24, 28, 194 and 2[AGE]) of nine sampled residents. Resident 2[AGE] had incomplete vital sign (temperature, pulse, respiratory rate, blood pressure) records, and was subsequently sent to the hospital's emergency department (ED). The doctors were not notified when Resident 28 stopped eating, and of Residents 24 and 194's elevated blood pressure (BP). These failures resulted in the staff's failure to identify and monitor for changes in condition which had resulted in, or had the potential, for a decline in the resident's health. Findings 1. A record review of the document, Face Sheet showed Resident 24 had [DIAGNOSES REDACTED]. During an observation of the medication pass, on 2/10/20 at 8:10 a.m., Licensed Vocational Nurse 2 (LVN 2) checked Resident 24's BP, which was 1[AGE]/102 (normal range 120/[AGE]). LVN 2 stated, Oh, that's high, and continued to administer medications to Resident 24 and to other residents. She did not re-check Resident 24's BP or notify the doctor. The record review of Resident 24's Monthly Vital Signs reflected on 1/9/20, the BP was 127/[AGE]. On 2/9/20, the BP was 128/[AGE]. In an interview on 2/10/20 at 1:26 p.m., LVN 2 stated she had Forgotten about Resident 24's elevated BP and did not call the doctor. In a subsequent interview, on 2/11/20 at 10:40 a.m., LVN 2 stated she did not call the doctor about Resident 24's high BP because she had administered [MEDICATION NAME]. According to the food & drug administration (FDA), [MEDICATION NAME] is a blood-thinning medication used to reduce the risk of stroke and blood clots in patients. In an interview on 2/12/20 at 10:41 a.m., the Director of Nursing (DON) stated it was important for staff to monitor Resident 24's BP because of her history of stroke. Furthermore, DON stated staff should have re-checked the BP and, if still high, notify the doctor. 2. The record review of the document, Face Sheet showed Resident 28 had [DIAGNOSES REDACTED]. Further review of the nursing notes showed the following food intake for Resident 28: 12/11/19: 50% of dinner 12/12/19: refused both breakfast and lunch and, Only drank 2 cups of fluids. 12/12/19: 50% of dinner and, Won't open his mouth. 12/14/19: Did not eat breakfast. Consumed 25% of lunch. 12/15/19: .refused breakfast and lunch. The doctor came to visit and ordered IV (intravenous, into the vein) hydration to replenish fluids and 9-1-1 was called. Resident 28's oxygen saturation (percent of oxygen in the blood) was 63% (normal range 90's). In an interview on [DATE] at 12:15 p.m., LVN 1 stated he did not notify the doctor when Resident 28 was refusing his breakfast and lunch on 2/12/20, and had eaten 50% of his dinner the night before. During an interview on [DATE] at 12:41 p.m., the Director of Staff Development (DSD) stated there was no I&O (intake and output) or documented weights for Resident 28. (Note: Monitoring I&O during a 24-hour period is an important aspect of fluid balance assessment. Body weight is an important indicator of fluid status, including fluid loss and potential signs of dehydration). During an interview on [DATE] at 2:38 p.m., DON stated when a resident is showing signs of dehydration , staff should monitor the vital signs, weights, and notify the doctor. A record review of the facility's document, Transfer and Referral Record dated 12/15/19 showed Resident 28 was sent to the hospital with lethargy and weakness. The record review of the document, ED to Hosp (hospital)-admitted d [DATE] showed Resident 28's [DIAGNOSES REDACTED]. 3. A record review of the Face Sheet showed Resident 194 had [DIAGNOSES REDACTED]. The record review of the Physician order [REDACTED]. A record review of Resident 194's, Medication Administration Record [REDACTED] 2/8/20: 158/[AGE] 2/9/20: 166/[AGE] 2/10/20: 1[AGE]/74 In an interview on 2/11/20 at 2:57 p.m., DON stated residents taking BP medications have their BP's checked every day. DON further stated staff are to call the doctor if the readings are outside the established parameters, which are greater than 150/90 or less than 100/50. In a subsequent interview on 2/12/20 at 10:41 a.m., DON confirmed Resident 194 had consistently high BP's and the doctor was not notified. DON further stated the doctor should have been called so the medication dosage could be re-evaluated. During an observation of the medication pass on 2/10/20 at 8:10 a.m., LVN 2 was checking Resident 194's BP and was 1[AGE]/74. LVN 2 did not recheck the BP. In a subsequent interview, on 2/10/20 at 1:26 p.m., LVN 2 stated she had not rechecked the BP or call the doctor because the resident, . gets BP medication. 4. A record review of the document, Face Sheet showed Resident 2[AGE] had [DIAGNOSES REDACTED]. A review of the nursing notes dated, 10/22/29, 10/23/19, 10/24/19, and 11/4/19, showed no documented vital signs. On 11/4/19, the notes indicated Patient 2[AGE] was lethargic and sent to the ED. The record review of the facility's document titled, Transfer and Referral Record dated 11/4/19, reflected the reason for the transfer to the hospital was because Resident 2[AGE] was, Lethargic, with signs and symptoms of dehydration. In an interview on [DATE] at 2:16 p.m., DSD confirmed there was no vital signs taken before Patient 2[AGE] condition changed and was transferred to the hospital's ED on 11/4/19. DSD further stated that tracking (monitoring) Patient 2[AGE]'s BP and heart rate could have shown signs of possible dehydration. The record review of the hospital's, Discharge Summary dated 11/9/19 showed the reason for Resident 2[AGE]'s hospital admission was due to, Lethargy, weakness, poor po (per os, oral) intake. Resident 2[AGE] was treated with IV fluids. A record review of the facility's policy and procedure, Change in a Resident's Condition or Status dated 11/'15 indicated, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .A significant change in the resident's physical/emotional/mental condition; .A need to alter the resident's medical treatment significantly.

Based on interviews and record reviews, the facility failed to provide education to families regarding food brought in from home for the residents. The facility also failed to have a system for staff to ensure food from home was re-heated to a safe temperature. This had the potential to result in burn injuries from hot food. Findings: During an interview on 2/11/20 at 9:16 AM, registered nurse 1 (RN 1) stated nursing staff reheats food in the microwave in the break room, but was not sure what temperature food is supposed to be heated. During an interview with the Dietician on 2/11/20 at 10:25 AM, the Dietician stated she does not train facility staff on the safety of food brought from home for residents. The Dietician further stated she has no involvement with how staff re-heats outside food brought into the facility for residents. She stated a re-heated food temperature of 165 degrees was too hot to eat directly, but staff was probably thinking of temperatures for other food items, such as poultry. The Dietician stated she does not provide education to families regarding food safety and food brought into the facility from home. During an interview on 2/11/20 at 10:30 AM, the certified nursing assistant 2 (CNA 2) stated time frames for reheating a resident's food depends on what type of food is being heated. CNA 2 indicated the staff use the buttons on the microwave to guide re-heating foods and does not check food temperatures. During an interview on 2/11/20 at 10: 38 AM, the Director of Nursing (DON) confirmed staff does not use thermometers for temperature testing during food re-heating but rely on common sense to know when re-heated food is the appropriate temperature for residents to safely consume. During a record review of the facility's policy and procedure titled, Food Preparation: Leftover Foods dated 2018 indicated, Leftover foods will be stored and served in a safe manner .2) Reheat all leftover foods to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds. During a record review of the facility's policy and procedure titled, Foods Brought by Family/Visitors, (undated)indicated, 1. Family members should inform nursing staff of their desire to bring foods into the facility. The Dietician or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan, and 3. The Dietician will counsel residents or families about requests that conflict with resident's dietary restrictions and whenever diets cannot be liberalized.

Based on observation, interview, and record review, the facility failed to ensure that staff performed hand hygiene after contaminating their hands while passing meal trays. This failure resulted in a certified nursing assistant passing meal trays to residents after contaminating her hands by touching her nose and lips. Findings: During an observation on 2/10/2020 at 12:30 p.m. adjacent to the dining room, Certified Nursing Assistant (CNA) 1 touched the underside of her nose and/or her lips with her hand six times while passing trays to residents in the dining room. CNA 1 did not perform hand hygiene after she touched her nose and/or mouth. During an interview on 2/10/2020 at 2:05 p.m., with CNA 1, CNA 1 stated she did not perform hand hygiene each time after she touched her nose and/or mouth with her hand while passing trays. CNA 1 stated she was supposed to perform hand hygiene after each time she touched her nose and/or mouth. During an interview on 2/11/2020 at 2:07 p.m., with Director of Staff Development (DSD), DSD stated that staff are required to do hand hygiene when passing food trays to residents for infection control. DSD stated that staff touching the end of their nose or lips would contaminate the staff's hands and the staff was therefore, required to do hand hygiene after touching their nose or lips before passing a tray. During a review of the facility's policy and procedure titled, Hand Hygiene Program, (undated), indicated hand hygiene should be done before and after serving food to residents and when hands are likely to be contaminated.

Based on interview and record review, the facility failed to provide an environment free of corporal punishment and protection from abuse when Licensed Vocational Nurse (LVN) 1 locked Resident 1 out of the facility for going outside to smoke a cigarette early in the morning (approximately 5 a.m.). LVN 1 refused to open the front door for Resident 1 to enter the facility. Despite pleas from Resident 1, Resident 1 was left outside for one and half hour in a gown. These failures caused emotional distress for Resident 1 when he cried, expressed having ongoing fear of LVN 1 and had the potential for psychological harm. Findings: During an interview on 3/19/19 at 11:00 a.m., Resident 1 stated, he went out of the front door to smoke cigarette on 3/14/19 around 5a.m. and LVN 1 saw him go out and slammed the door after him. Resident 1 stated he knocked the door and asked LVN 1 to open the door and LVN 1 refused to open the door. Resident 1 further stated he stayed outside for about one and half hour when he saw the Dietary Manager (DM) walk by. Resident 1 asked DM to open the door who did not. Resident 1 waited for Certified Nursing Assistant (CNA) 1 to walk by to open the door for him. Resident 1 stated once he was inside, LVN 1 told him that next time he goes outside to smoke at night LVN 1 will make Resident 1 sleep outside. Resident 1 stated it was cold, he wore only gown, and no pants. Resident 1 stated that LVN 1 had locked him outside the facility on two other occasions for going outside to smoke. Resident 1 stated LVN 1 ran the facility like a jail. Resident 1 stated he felt violated, disrespected, and was moved to tears because of this incident. Record review of the Minimum Data Set (MDS - Resident Assessment tool used to guide care), dated 2/7/19, indicated Resident 1 had clear speech was able to express his ideas and wants, and understood what others stated to him. Resident 1 was mobile with a wheelchair. Resident 1 had capacity to make decisions by himself. Record review of the physician order, dated 1/24/19, indicated Resident 1 may go out on pass for four hours. During an interview on 3/19/19 at 11:12 a.m., Dietary Manager (DM), stated he walked by the hallway, heard Resident 1 knocked on the front door. DM stated LVN 1 told him not to open the door for Resident 1 to enter the facility. DM stated LVN 1 told DM that Resident 1 did not listen to instructions not to go outside. And that he did not open the door. Record review of the nurse's notes indicated on 3/12/19 around 4:00 a.m., LVN 1 locked Resident 1 outside when he went outside to smoke cigarette. LVN 1 indicated in the record that she was not going to open the door for Resident 1 to enter the facility. Record review of facility's investigation report, indicated on 3/14/19, LVN 1 locked Resident 1 out and refused to open the door for Resident 1 to enter the facility. During an interview on 3/19/19 at 12:05 p.m., LVN 1 stated she locked Resident 1 out of the facility because Resident 1 did not listen to her instruction not to go outside late at night and during the early morning hours to smoke. LVN 1 stated she saw Resident 1 banging the front door and she refused to open the door. LVN 1 stated DM wanted to open the door for Resident 1 but LVN 1 told DM not to open the door for Resident 1 but to let Resident 1 stay outside. LVN 1 confirmed that on 3/12/19 and 3/14/19 she had locked Resident 1 out of the facility for going outside to smoke. Record review of Resident 1's behavior care plan, dated 11/14/18 and 12/8/18 included the following interventions: provide non-confrontational environment, do not scold or reprimand and do not force resident to comply against their wishes. During an interview on 3/21/19 at 9:56 a.m., CNA 2 stated during the early morning hour of 3/14/19, she heard Resident 1 banging on the front door. CNA 2 stated she opened the door and assisted Resident 1 to his room. CNA 2 stated Resident 1 was upset and cursed at staff. The facility's policy and procedure titled, Abuse-Prevention Program, revised (MONTH) 2006, read, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any individual.

Based on observations, interviews and record review, the facility failed to ensure that food was stored, prepared, distributed and served under sanitary conditions as evidenced by: Not having an operating dish machine and not using manual washing and sanitizing methods correctly, which could lead to food born illness. This resulted in the kitchen staff preparing and serving food on dishes and utensils that were not properly sanitized. Findings: On 5/13/13 at 12:45 p.m. an unannounced visit was made to the facility regarding a complaint that the dishwasher was removed from the facility due to nonpayment. During the onsite visit to the facility on [DATE] at 1:00 p.m. the assistant dietary supervisor was interviewed. She said, when asked, "The dish washer was broke on May 6, 2013. We are going to replace the dishwasher with another company. We are using the three compartment sink to wash the dishes. We were using paper plates, plastic spoons and knives, but ran out of them today." Review of the facility's policy and procedure for three compartment washing read: "Flush, scrape or soak equipment and utensils before washing. Wash items in sink bay 1 in a solution of 3 ounces detergent and hot water. the temperature must be at least 110 degrees. Rinse items thoroughly in sink bay 2 in clean, clear water with a temp of at least 110 degrees. As items are removed allow the excess water to drain. Add 1 ounce of 6% bleach sanitizer per 21/2 gallon of water to sink Bay 3. Check with test strip dipped in sanitizer solution one second. Must read 100-200 PPM (parts per million). Immerse all washed items for 2 minutes." The dietary aide was observed washing the dishes on 5/13/13 at 1:20 p.m. She removed food items from a plate and rinsed it with the water hose, placed the plate in three different containers with clear looking water. She was then asked by the evaluator to test the plate sanitation. The sanitation strips showed that the plate was not sanitized. The dietary aide was then asked how she was sanitizing the dishes. She said, "I use five tablespoon of bleach to seven gallons of water." I follow the policy posted on the wall. The evaluator then asked the dietary aide where the thermometer was to test the water for the dish water. She replied, "I don't know where the thermometer is. I didn't test the water." The evaluator put her hands in the three compartment used to wash the dishes, and the water in the three compartments was cold. During an interview with the Administrator on 5/13/13 at 2:30 p.m. he stated, "I knew that the dish washer was not working, but I thought the staff was using disposable plates and utensils. The contracted company over the dietary department should have made sure that their people was trained on the three compartment washing procedure." A second interview was done concurrently at 2:45 p.m. with the assistant dietary supervisor she said, "I tested the water it should be at 100 degrees. We get the water from the sink. I let the hot water run in the sink and fill the pitcher with water. I fill the three compartment. Then we (sic) aide our self with boiling water from the coffee machine." (Meaning she would heat up the water in the sink with hot water from the coffee machine.) The dietary manager was interviewed during a second visit to the facility on [DATE] at 1:15 p.m. she said, when asked, "The dish machine company came in the kitchen. I didn't ask what he came for because every month they come inspect and check the machine and talk to me when finished. This time when he finished, he showed me an invoice and said that he turned off the dish machine. He left the building really fast. I called my manager and told him my dish machine is not working because they turned it off. He said to use paper plates, plastic forks and knives, and use the three compartment for washing dishes." The administrator was interviewed also on 5/14/13 at 2:45 p.m. he said. "I was told the dishwasher was malfunctioning. I continued to call the dietary manager from (the contracted company) for the dietary department. They are responsible for the dish washer and the chemicals. (The contracted company) insisted that they were changing out the dishwasher to another company. I was waiting for them to put in a new dishwasher. I think it was not professional the way (the contracted company) handled this." During a telephone interview with the regional manager from (the contracted company) on 5/15/13 at 8:30 a.m. He said. "The dishwasher was turned off sometime last week due to nonpayment. The district administrator was responsible. For whatever reason he had not paid the bill. He decided to call another company that we use to cover for him not paying the bill. I had the dishwasher back working after talking to the district manager about what happened."

Based on interview and record review, the facility failed to permit one of two sampled residents (1) to remain in the facility. The resident was discharged from the facility to boarding house for independent living without establishing his level of care needs or readiness for independent living, resulting in Resident 1 leaving the board and care facility twice and was missing for several days. Resident 1 was found in the acute care hospital in city V several miles away from the board and care facility, lost, confused, without identification and mistaken for a homeless man. Findings: Resident 1 was a [AGE] year old male who was admitted to the facility on [DATE] from acute care hospital H where he had undergone surgery to correct a small bowel obstruction and repair to his existing [MEDICAL CONDITION] (surgical construction of an artificial opening from the colon to the outside of the body, permitting passage of intestinal contents). According to a consultation report dated 1/15/12 from the acute care hospital, the resident was unable to provide information due to his dementia and altered state. Review of the facility's initial minimum data set assessment ((MDS) dated [DATE] revealed Resident 1 was not able to recall the year, month or day of the week, nor was he able to recall three words, "sock", "blue", or "bed" that he was told to remember. Additionally, he needed extensive assistance with the physical support of two persons for his personal activities of daily living. According to the care area assessment (CAA) dated 2/3/12, the resident had cognitive deficits due to a [DIAGNOSES REDACTED]. He had no capacity to make decisions per the physician and his sister and family made decisions for him. He was at risk for further decline due to dementia. A review of the quarterly MDS assessment dated [DATE] showed Resident 1 needed limited assistance with the physical help of one person for all his activities of living. This was an improvement from the initial assessment dated [DATE] where he needed extensive assistance. His cognitive condition however, was unchanged. The physician's history and physical dated 1/31/12 revealed that the resident's rehabilitation potential was guarded and that he was not informed of his medical condition and or plan of treatment because of "dementia," and he did not have the capacity to understand and make decisions. Review of the social service progress notes dated 5/1/12 revealed that the social services director (SSD) had a "talk" with the resident and let him know that his health had improved and that they would plan to discharge him soon. A board and care facility was offered and "he agreed." The note indicated that Resident 1's sister was informed via message left on her telephone. The note indicated the SSD contacted a Board and Care operator (Owner 1) to "come see and talk with resident." There were other SSD notes dated 5/4/12, and 5/18/12 which revealed that messages were left for the resident's sister to call back, but she had not called back by 5/18/12. The last physician's progress note dated 5/9/12 indicated that the resident was "Stable, no new problems, physical exam without changes, assessment/plan continue current plan." According to the nurses note dated 5/18/12 at 1:20 p.m. "Resident discharged from facility, transferred to board and care facility..." The physician's orders [REDACTED]. There was no assessment of discharge needs or what indication that Resident 1 was able to care for self in a boarding home environment. On 10/4/12 at 1:25 p.m., the Director of Nurses was asked about Resident 1's discharge. Resident 1's sister was present during the interview. The Director of Nurses (DON) stated that Resident 1 was discharged because he was taking his [MEDICAL CONDITION] bag off and smearing it on the linen cart. She stated he was asking to be discharged . She acknowledged that the facility could not reach the resident's responsible party, his sister. Resident 1's sister stated that she was in the hospital and didn't know that her brother had been discharged until four or five weeks ago (early September 2012) when she called the facility. The sister stated that when her brother went to the Boarding House he found out that Resident one had been missing since 9/7/12. A note written by the social service assistant (SSA 2), dated 9/27/12 at 1 p.m., revealed that the manager (Manager 1) of Owner 1's boarding house stated that Resident 1 had been missing on 9/7/12 and they filed a missing persons report and called a few hospitals and was found at the Acute care Hospital B but was discharged by the hospital and had been missing since. Manager 1 said that he spoke to the family a week ago and informed them. In a telephone interview with manager 1 on 10/5/12 at 9:30 a.m. he stated that they were a "Boarding House," not a Board and Care home. He stated that "we fix three meals a day and Resident 1 would go out and come back. Then he went missing on 9/7/12..." In a telephone interview with Owner 1 on 10/10/12 at 3 p.m. she stated that she got the referral for Resident 1 from the SSD at the facility. She stated that her boarding house was unlicensed and unlike a board and care home. She only provided meals and a clean bed. The residents were independent. She said that Resident 1 left once in June 2012 and was found in the emergency room in acute care hospital B. They discharged him to a nursing home because he couldn't remember where he lived. Owner 1 said she went to the nursing home and retrieved him the same day. Resident 1 left again on 9/7/12 and after searching the local hospitals had not seen him since. In a telephone interview with Resident 1's physician, (MD) on 10/16/12 at 9:20 a.m., he stated that his understanding was that the resident was discharged back to his previous board and care home (G.S. home). He expressed an understanding of the difference between a board and care home and an unlicensed boarding house. He also stated that the did not know what level of care Resident 1 needed when he was discharged and when asked if the resident was capable of independent living including managing his own [MEDICAL CONDITION], he stated, "I couldn't tell you." After contacting several local hospitals Resident 1 was found admitted to acute care hospital K on 10/4/12. According to the history and physical note dated 10/4/12 the resident's chief complaint was "[MEDICAL CONDITION] bag problem, homeless, placement issue, and confusion." The note revealed, "This is a 71 yo (year old) homeless male with PMHx (past medical history) of abdominal trauma, [MEDICAL CONDITION] who presented to the Emergency Department with c/o (complaint of) losing his [MEDICAL CONDITION] bag. As per pt (patient) he lost [MEDICAL CONDITION] bag and feces were leaking, so came to ER (emergency room . Pt's [MEDICAL CONDITION] bag was placed and when shelter staff came to evaluate him for placement, pt was not able to follow instructions, not appropriate for shelter placement as per them..."

Based on observation, interview and record review, the facility failed to provide care for one of 11 sampled residents (1) and six of six residents of the confidential group meeting in a manner and in an environment that maintained or enhanced their dignity and recognized their individuality. This failure resulted in the following: For Resident 1, personal photos were removed from her wall, her bedtime snack was removed and she was asked to throw away food brought by her family, which resulted in her feeling sad and hungry. See F174 for additional information regarding Resident 1. Findings: (1.) Below, is related to complaint number CA 839. 1. The Ombudsman called the Department on 5/9/11 to report that Resident 1 left a message the night before, 5/8/11, stating that the owner of the building came into her room and took all of her family photos off the wall, against her wishes, told her she could not keep the food her family brought from home and took her bedtime snack, which she needed because she was diabetic. Review of Resident 1's admission sheet on 5/10/11 showed she was a [AGE] year old woman who lived at the facility since 4/5/10 and was listed as her own responsible party. She had end stage [MEDICAL CONDITION] (loss of kidney function) and went to [MEDICAL TREATMENT] three times a week. Her other [DIAGNOSES REDACTED]. A review on 5/10/11 of Resident 1's minimum data set (MDS) assessment dated [DATE] showed she had no problems with her memory or cognitive function. Review of Resident 1's care plan, dated 4/5/10 with a goal date of 7/11, addressed a behavioral issue of isolation with suicidal thoughts. The approaches were to give the antidepressant medication [MEDICATION NAME], monitor for side effects, and to encourage relaxation techniques such as writing, reading, peer discussion, one on one with staff or family. During an interview with Resident 1 on 5/10/11 at 9 a.m., in her room, she stated that on 5/8/11 at around 8 p.m., the owner came into her room and took the pictures of her family off of the wall and told her she was not allowed to post any pictures on the wall. Resident 1 stated that owner told her she would put them in a photo album and then took the pictures away. The owner also took the Resident's crackers and jelly given to her by the facility as a bed time snack. Resident 1 said that it made her feel so sad to have her pictures taken away because she looked at her children at night to keep from feeling depressed. She also stated that she was diabetic so she sometimes needed a snack in the middle of the night and felt anxious if she didn ' t have some food at her bedside. On 5/10/11 at 9:30 a.m., the facility owner stated in a telephone interview that she talked to Resident 1 about the pictures "all over the light and surrounding the light (behind her bed) " . The owner said that she talked to Resident 1 and that Resident 1 agreed to their removal. The owner said she felt the pictures on the wall were endangering the area. She also said that she told Resident 1 that the food, which was in plastic containers, should be kept in the refrigerator and raised her concerns that the food had been at room temperature too long. The owner further stated that she did not know where the food came from, and that the Resident threw the food out herself. The owner denied taking Resident 1's crackers and jelly. On 5/10/11 at 9:30 a.m., the Administrator and Director of Nurses (DON) who were present during the telephone interview with the facility owner, both stated that they were aware that the facility Owner came in on 5/8/10 and took the Resident ' s pictures down from her wall. They both stated that they knew it was wrong and that they knew that Resident 1 was upset. The administrator stated he did not know why the owner would do such a thing. The surveyor contacted the Life Safety Code Supervisor (LSC Supv) from the California Department of Public Health, Licensing and Certification on 5/10/11 shortly after 9:30 a.m., by telephone for advice regarding the possibility of any hazards posed by pictures on resident walls or near the light fixtures. He stated that there was no hazard unless the pictures covered more that 75 % of the entire wall. Resident 1's pictures did not cover 75% of the wall. In an interview on 5/11/11 at 8:50 a.m., Resident 1 repeated her complaint about the facility owner. Resident 1 stated the owner went into her room around 8 p.m., on 5/8/11 and started taking down her pictures and then the owner told Resident 1 she couldn't have her (native) food from home, so Resident 1 threw it out. Resident 1 went on to say that the owner took her crackers and jelly. Resident 1 also stated that, "(Resident 9) had pictures on the wall and they didn't take hers down. I feel sad and it was unfair. It was Mother's Day. Why did they do that to me?" The Resident ' s eyes welled with tears as she spoke of her children and her pictures and how much it meant to have them near to her. During an observation of Resident 9's room on 5/12/11 many family pictures were printed on paper and taped to her wall next to her bed. The amount of pictures was similar to or exceeded the size of Resident 1's photo collection. Review of the doctor's orders for Resident 1's current diet included a snack to be given at bedtime. The Registered Dietician (RD) stated in an interview on 5/10/11 at 2 p.m., that the bedtime snack for diabetics consisted of a half sandwich or crackers and jelly. In a telephone interview on 5/18/11 at 1:15 p.m., with the Ombudsman, she read the following from their telephone intake log dated 5/9/11, "(Resident 1) called. Owner of facility took all of her pictures of her children and did not give them back. They also took her food away and she was hungry." The Ombudsman ' s office receptionist stated in a separate telephone interview on 5/18/11 at 11:25 a.m., that when she called Resident 1 back on Monday morning 5/9/11, Resident 1 told her ' they took her children off the wall ' (her pictures) and the Resident was crying. The receptionist stated that she asked Resident 1 if they gave her pictures back and she said ' no. '

Based on observation, interview and record review, the facility failed to provide routine, twice daily, narcotic pain medication for one (3) of 11 sampled residents on two consecutive days. A total of four of four doses were not given by two of two licensed vocational nurses. For Resident 3, who had pain from spinal disc damage of the lumbosacral (low back) area, this failure resulted in Resident 3 having unrelieved severe pain for three days and interfered with Resident 3's enjoyment and ability to participate fully on a Mother's Day outing with her daughter and grandchildren. Findings: Review of Resident 3's admission face sheet on 5/11/11 showed she was a [AGE] year old female, admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Review of Resident 3's admission minimum data set (MDS) assessment ( a tool to assess the Resident strengths and needs) dated 4/1/11, showed Resident 3 had frequent pain that was moderate that rated a 5 on a pain scale of 0 (no pain) to 10 (worst pain you can imagine). Review of a care plan titled " Pain " dated 3/19/11 showed, "Patient is at risk for discomfort due to the following factors below: On [MEDICATION NAME] SO 4 (sulfate) for pain." The goal listed was, "Patient will be free from discomfort and or pain as much as possible." The approaches developed were to "assess signs and symptoms of pain, provide comfort measures and pain meds as ordered." Review of physicians orders dated 3/19/11 showed pain medications listed on admission to the facility: [MEDICATION NAME] sulfate ER (extended release) 60 mg (milligrams), by mouth, twice a day for pain; [MEDICATION NAME] 5/325 mg, one tablet by mouth, as needed every four hours for mild pain and [MEDICATION NAME] 5/325 mg, two tablets by mouth, as needed every four hours for moderate to severe pain. Resident 3 also had an order for [REDACTED]. Physician orders [REDACTED]. During an observation of Resident 3's care on 5/11/11 in the mid-morning, she was up out of bed, dressed in pajamas and a bathrobe. She walked in her room with the use of a front wheel walker, and she was bent over at the waist; she could not stand up straight. She was able to get in and out of bed without assistance. On 5/12/11, at the conclusion of an interview in her room at 1:15 p.m., Resident 3 gave the surveyor a hand written note which read, "I was in SEVERE pain for two nites (sic) someone faild (sic) to order enou (sic) MSO ([MEDICATION NAME] sulfate) for me." On 5/12/11 at 2:30 p.m., Resident 3's daughter was in her mother's room. The daughter stated that she took her mother home for Mother's Day, 5/8/11 and that Resident 3 was in severe pain. Resident 3's daughter also said she didn't know what to do for her mother to help her pain. She said that she didn't get her routine [MEDICATION NAME] and they gave her [MEDICATION NAME] but, "it didn't help." In a follow-up interview with Resident 3 on 5/17/11 at 3 p.m., she was in bed. She stated that she was in so much pain on Sunday (5/8/11). "That was the worst!" she said. Resident 3 went on to say she had unrelieved pain for a couple of days after because, "it takes a while to build back up." She explained that she went to her granddaughter's house on Sunday afternoon with her daughter for Mother's Day that she asked her daughter to bring her back to the facility earlier than planned because she was starting to hurt. Resident 3 said she felt "so bad" because her daughter made a special day for her, but she just couldn't stand the pain.