Every finding on record at Rock Creek Care Center

Based on interview and record review, the facility failed to ensure the transfer and discharge was appropriate for one of three sampled residents (Resident 1), when the resident was not provided with the required discharge notices when transferred to the hospital and was not permitted to return to the facility.This failure resulted in Resident 1's unnecessary admission in the hospital with no information on resident rights or how to file an appeal to remain in the skilled nursing facility (SNF), and had the potential risk of not attaining Resident 1's highest practicable physical, mental and psychosocial well-being.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in March 2026 with diagnoses which included unspecified sequelae of cerebral infarction (long-term complications that persist after a stroke which include cognitive challenges and emotional changes) and anxiety disorder (persistent, excessive fear or worry that interferes with daily life, functioning, and relationships).A review of the facility's Bed Hold Policy and Notification (BHPN), provided to Resident 1 upon admission, dated on 3/28/26, indicated, It is the policy of this facility to provide any resident that is transferred to a general acute care hospital the right to exercise the bed hold provision.A review of Resident 1's Minimum Data Set (MDS - Federally mandated resident assessment tool), dated 3/29/26, the MDS indicated Resident 1 had mild memory impairment and had not exhibited physical behavioral symptoms directed towards others.During a review of Resident 1's Baseline Care Plan (BCP, instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care), dated 3/29/26, the Social Services Director (SSD) documented Resident 1's psychosocial (psych) goals which included, The recognition and management of depression, anxiety, fear, developmental problems, disability, pain and limitations in daily living. These factors all contribute to resident psych well-being.During a review of the Social Service Note (SSN), dated 3/29/26 at 11:13 a.m., the SSD indicated Resident 1 will be sent out for further evaluation.During a review of the SNF/NF [SNF/nursing facility] to Hospital Transfer Form, dated 3/29/26 at 11:30 a.m., the form indicated, [Resident 1] was being transferred to the hospital for behavioral symptoms (e.g. agitation, psychosis), and the behavioral issues and interventions indicated, .restlessness, irritability, verbal/combative behavior and refusal of care.During a review of the Nurse's Notes (NN), dated 3/29/26 at 12:30 p.m., the NN indicated Resident 1 had been transferred to the (hospital name] emergency department (ED) for further evaluation and treatment.During a review of the Case Management Notes (CMN), dated 3/29/26 at 8:55 p.m., the CMN indicated Resident 1 was transferred directly from the facility to the ED by non-emergent transportation without paperwork or notification of the direct transfer. The CMN indicated during a phone call with the facility's admission Coordinator (AC), the AC stated the facility transferred Resident 1 to the ED because Resident 1 was aggressive and combative. The AC was notified that Resident 1 was agreeable to return to the facility. The AC stated the facility was at capacity and unable to place Resident 1 in a single room.A review of the facility census on 3/29/26 indicated there were four empty beds.During a review of the CMN, dated 3/30/26 at 8:43 a.m., the CMN indicated the facility was notified Resident 1 was ready to return to the facility.A review of the facility census on 3/30/26 indicated there were five empty beds.During a review of the CMN, dated 3/30/26 at 10 a.m., the CMN indicated the AC refused to readmit Resident 1.During a review of Resident 1's Notice of Proposed Transfer/Discharge (NPTD), dated 3/30/26 at 10:40 a.m., the NPTD indicated Resident 1 was discharged and not expected to return.A review of the facility census on 3/31/26 indicated there were four empty beds.A review of the fax confirmation of the NPTD to the Long Term Care Ombudsman (LTCO) dated 3/31/26, the NPTD indicated the facility notified the LTCO office of the proposed transfer/discharge for Resident 1 on 3/31/26 at 1:03 p.m.A review of the CMN, dated 3/31/26 at 2:22 p.m., the CMN indicated the facility had been notified that Resident 1 was ready to return to the facility. The facility indicated they would file an exchange of care for Resident 1 to be transferred to a different facility.A review of the CMN, dated 4/2/26 at 1:39 p.m., the CMN indicated the facility was notified that Resident 1 was ready to return to the facility. Resident 1 had been taking all of his medications, was calm and cooperative and family had been involved in his care and at his bedside. The CMN indicated the facility was notified to either readmit Resident 1 or notify Resident 1's insurance of non-readmittance and cancel the authorization for skilled care. The facility indicated they would not readmit Resident 1 and would cancel the authorization.During a telephone interview on 4/14/26 at 4:57 p.m. with the Case Manager (CM) 1, CM 1 stated Resident 1 was a direct transfer from the facility to the ED on 3/29/26. CM 1 stated Resident 1 sat in the ED waiting room without paperwork or information from the facility regarding the reason for Resident 1's direct transfer. CM 1 stated when the facility was notified of Resident 1's return, the facility refused to readmit Resident 1 because they did not feel comfortable having him return to a three-person room.During a telephone interview on 4/14/26 at 5:25 p.m. with the Transportation Company Manager (TCM), the TCM stated, We typically don't transport to the ER (emergency room) since we are a non-emergent transportation company. The TCM stated the majority of facilities provide a transfer packet or paperwork for a resident who is transferred to the ER or medical appointment. The TCM confirmed the facility did not provide transfer documents or instructions at the time of Resident 1's transfer. During a concurrent interview and record review on 4/15/26 at 12:12 p.m. with the DON and Assistant Director of Nursing (ADON), Resident 1's medical record was reviewed. The DON acknowledged the documentation in Resident 1's chart and did not support Resident 1's transfer to the ER and confirmed there was no documentation that indicated the facility had contacted Resident 1's family, emergency contacts or physician prior to transferring Resident 1 to the ER. The DON stated the Business Office Manager (BOM) or AC should have contacted the resident or resident's responsible party to inquire if Resident 1 would like a bed hold and documented the conversation in Resident 1's medical record. The DON and ADON confirmed there was no documentation to indicate Resident 1 had been offered a bed hold. The DON stated the facility did not readmit Resident 1 due to concerns over his behaviors and an assessment of Resident 1's status and needs at the time of the proposed return to the facility from the ER had not been completed. The DON confirmed the required documentation, transfer or discharge notices and bed hold policy prior to the transfer, and the subsequent discharge from the facility had not been provided to Resident 1.During a concurrent telephone interview and record review on 4/16/26 at 2:19 p.m. with the LTCO, the LTCO reviewed Resident 1's NPTD received on 3/31/26 and indicated the notice should be provided at the time of the transfer or discharge. The LTCO stated, The facility should have accepted this resident back at the facility.A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge revised October 2025, the P&P indicated, Once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record.3. Each resident is permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility; c. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. the health of individuals in the facility would otherwise be endangered.Transfer or Discharge Documentation in the Medical Record: 1. When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: a. The basis for the transfer or discharge; b. That an appropriate notice was provided to the resident and/or legal representative; c. The date and time of the transfer or discharge; d. The new location of the resident; e. The mode of transportation; f. A summary of the resident's overall medical, physical, and mental condition; g. Disposition of personal effects; h. Disposition of medications; i. Others as appropriate or as necessary; and j. The signature of the person recording the data in the medical record. 2. If the basis for the transfer or discharge is that the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility, the resident's physician (or provider) documents: a. the specific resident needs that cannot be met; b. this facility's attempt to meet those needs; and c. the receiving facility's service(s) that are available to meet those needs.4. In situations where the facility determines the resident's clinical or behavioral status endangers the safety or health of individuals in the facility, the documentation regarding the reason for the transfer or discharge is provided by a physician or provider (but not necessarily the resident's physician or provider). Resident Refusal of Treatment as a Basis for discharge: 5. A resident's refusal of treatment is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. a. If a resident's refusal of care poses a risk to the health or safety of the resident or others in the facility, the administrator, director of nursing, and the medical director may choose to conduct an ethics review with legal consultation to determine whether discharge is appropriate. b. Documentation includes that the resident or, if applicable, resident representative, received information regarding the risks of refusal of treatment and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident needs or protect the health and safety of others. Transfer or Discharge Appeals: 1. Upon notice of transfer or discharge, the resident is provided with a statement of his or her right to appeal the transfer or discharge, including: a.The name, address, email, and telephone number of the entity which receives such requests; b. information about how to obtain, complete, and submit an appeal form; c. how to get assistance completing the appeal process; and d. the facility bed-hold policy.

Based on observation, interview, and facility document review, the facility failed to store cookware pans and utensils in accordance with professional standards for food service safety when:2 steam table pans were found wet while stored away2 spatulas, 1 whisk were found wet while stored in the dry storage area1 steam table lid was found with dried food debris at the dry storage area1 gray scoop, and 1green serving spoon found with dry food debris in the dry storage area.These failures had potential to cause food-borne illnesses in a highly susceptible population of 80 residents who received food from the kitchen.Findings:During a concurrent initial tour observation and interview on 1/20/26 at 9 a.m. at the kitchen with the Certified Dietary Manager (CDM), two wet steam tables pans, and several cooking utensils were stacked wet. Additionally, there were cooking utensils found to have dried food debris stored at the clean and ready-to-use storage areas. The following were the findings during the initial visit:2 steam table pans wet at dry storage area2 spatulas, 1 whisk were found wet1 steam table lid cover with dry food particles1 gray scoop and 1 green serving spoons found with dry food particlesThe CDM confirmed that the 2 steam table pans, 2 spatulas and 1 whisk were wet. CDM confirmed 1 steam table lid, 1 gray color scoop, 1 green colored serving spoon had dried food particles and were stored in the ready to use storage area. CDM stated, the steam table pans, spatulas and whisk must be fully dried before storage. CDM further stated, the steam table lid cover, scoop and serving spoon must be fully cleaned without any food particles before stored away.During an interview on 1/23/26 at 10 a.m. with Registered Dietician (RD), the RD stated, the expectation was: all cookware and utensils must be fully cleaned and completely air dried before storage.During a review of the facility's policy and procedure titled, Dishwashing, undated, indicated, .gross food particles shall be removed by careful scraping and pre -rinsing in running water.dishes are to be air dried in racks before stacking and storing .

Based on observation, interview and record review the facility failed to ensure activities of daily living (ADLs) were provided to one of 19 sampled residents when Resident 82 was not provided with a shower for a week.This failure had the potential to further negatively impact Resident 82's psychosocial well-being and carried a risk for skin breakdown, leading to infection.A review of Resident 82's admission Record indicated Resident 82 is a [AGE] year old female who was admitted in January of 2026 with multiple diagnoses including radiculopathy (a pinch nerve in the spine causing symptoms like pain, numbness, tingling, or weakness that can radiate from the back into the arms or legs), difficulty walking and muscle weakness.A review of Resident 82's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 1/17/26, indicated Resident 82 had no cognitive impairment.A review of Resident 82's Care Plan dated 1/14/26 titled Skin, indicated, . [Resident 82] is at risk for skin breakdown related to activity intolerance, impaired AOL [activities of living] ability . Intervention: Keep skin clean and dry to the extent possible .A review of Resident 82's Care Plan dated 1/14/26 titled AOL/Mobility, indicated, . [Resident 82] . is at risk for AOL/mobility decline and requires assistance related to fluctuating ADLs, pain, recent hospitalization, weakness . Intervention: Will have have needs anticipated and met by staff. Bathing Assistance: Mod A [Moderate Assistance] .During an observation and interview on 1/20/26 at 2:58 p.m., in Resident 82's room, Resident 82 was observed lying in bed. Resident 82 stated she had some skin breakdown on her thighs and required staff assistance with ADLs. When asked about frequency of showering/bathing, the resident became teary eyed and stated that she had not received a shower for a week, despite requesting assistance from multiple staff. During a concurrent interview and record review on 1/21/26 at 11:08 a.m., with the Director of Staff Development (DSD), Resident 82's medical chart was reviewed and indicated Resident 82 received a shower on 1/20/26 at 1:18 p.m. DSD confirmed certified nursing assistant (CNA) 2 was scheduled to shower Resident 82 on 1/21/26, during the morning shift. DSD stated CNAs are scheduled to offer showers to all residents two times a week. DSD also stated Resident 82 is scheduled to receive showers on Tuesdays and Fridays. DSD stated that it was her expectation that CNAs offer all residents showers two times a week in order to allow for inspection of the residents' skin integrity, to honor and maintain the residents' dignity, and maintain personal hygiene. During a concurrent observation and interview on 1/21/26 at 11:30 a.m., with the DSD and Resident 82 in Resident 82's room, Resident 82 explained she had not received a shower in a week. Resident 82 stated to the DSD that she did not receive a shower on 1/21/26 at 1:18 p.m. Resident 82 became teary eyed and stated, I feel less than human . I have asked multiple staff to help me . no one comes . its embarrassing as a woman to not shower and feel like you smell like this .During a interview on 1/21/26 at 11:40 a.m., with the DSD and CNA 2, CNA 2 admitted he charted that a shower was provided for Resident 82, but that he did not actually assist Resident 82 with a shower.During an interview on 1/21/26 at 3:03 p.m., with the Assistant Director of Nursing (ADON), ADON stated his expectation was that all residents are offered shower two times a week. The ADON stated it was important to provide showers to residents in order to maintain proper personal hygiene and monitor for skin breakdown.A review of the facility's Policy and Procedure (P&P) titled Activities of Daily Living (ADLs), Supporting, revised October 2024, indicated, . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .A review of the facility's Policy and Procedure (P&P) titled Shower and Bathing, revised October 2024, indicated, . The purpose of this policy is to promote self-determination and facilitate resident choice regarding shower and bathing to ensure cleanliness, provide comfort, observe the overall condition of the resident and skin integrity .

Based on observation, interview, and facility document review, the facility failed to provide 80 square feet of space per resident in rooms 1-8, 11, 12, 17, 18, 19, 21, and 23-36. This failure decreased the facility's potential to provide adequate personal space for the residents in these rooms for a census of 77. Findings: During concurrent observations and interviews conducted on 1/20/26 beginning at 3:32 p.m., room numbers 1, 2, 3, 4, 5, 6, 12 and 24 were observed to be uncluttered with sufficient space for the personal effects of residents. There was enough room for entrance, egress (going out), and maneuvering of equipment in and out of the rooms and access to the bathrooms. There were no validated issues or safety concerns regarding lack of space for the delivery of care verbalized by any of the residents in these rooms.During an interview on 1/21/26 at 9:05 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 indicated that she has enough space in the facility rooms to perform resident care, maneuver, and transfer residents. During an interview on 1/23/26 at 9:25 a.m. with the Maintenance Director (MD), the MD indicated no alterations had been made to any room in the facility. During a concurrent observation and interview on 1/23/26 at 10:01 a.m. Licensed Nurse 1 (LN 1) and Resident 47, LN 1 indicated that she has no problems performing resident care in the rooms. LN 1 was observed transferring Resident 47 out of her bed and into her wheelchair and wheeled her out of the room. During a review of a facility letter addressed to the Department, rooms 1-8, 11, 12, 17, 18, 19, 21, and 23-36 were noted to not meet the minimum space requirements of 80 square feet per resident. Double occupancy rooms provided 142.8-157.3 square feet of living space and 71.4-78.65 square feet per resident. Triple occupancy rooms provided 211.4-229.6 square feet of living space and 70.4-76.5 square feet per resident. The letter also indicated that the Administrator (ADM) requested a continuance of the room size waiver for the specified rooms.The Department recommends continuing the room size waiver for rooms 1-8, 11, 12, 17, 18, 19, 21, and 23-36.

Based on observation, interview, and record review, the facility failed to safely store food for a census of 84 residents, when unlabeled and expired food items were stored in the facility ' s kitchen. This failure had the potential to lead to foodborne illness among residents. Findings: During a concurrent observation and interview on [DATE] at 11:10 a.m. with the Dietary Services Supervisor (DSS) in the kitchen walk-in refrigerator and freezer units, DSS confirmed the following unlabeled and expired food items were stored: In the walk-in refrigerator: 1. A storage container of cooked tomato sauce with expiration date [DATE]; 2. A storage container of fresh parsley with expiration date [DATE]; 3. Three five pounds bags of raw chicken pieces with expiration date [DATE]; 4. Three unlabeled meat packages of five pounds chubs of raw hamburger; 5. An unlabeled package of shredded red cabbage; and 6. Two packages of fresh spinach with expiration dates of [DATE] and [DATE]. In the freezer: - One opened, unsealed, unlabeled, and undated package of veggie burgers. DSS stated she was not sure for how many days the hamburger and chicken had been sitting in the refrigerator to thaw. DSS further stated kitchen staff should not serve any of the expired and unlabeled food because eating these items could potentially make the residents sick. During a concurrent observation and interview on [DATE] at 11:32 a.m. with the [NAME] and DSS in the Dry Goods Storage area, both the [NAME] and DSS confirmed an unlabeled bread storage bin was found with two bags of hamburger buns, one dated [DATE], the other one open and unlabeled, and four unlabeled bags of cinnamon bread. The [NAME] stated the bread was supposed to be labeled. DSS stated the bread was inedible and should have not been placed in the dry storage area. During an interview on [DATE] at 1 p.m. with Administrator (ADM), ADM stated kitchen staff should not store unlabeled and expired food items. A review of the facility ' s procedure titled, Refrigerated Storage, dated 2023, indicated, Food items should be arranged so that older items will be used first. Dating the packages or containers will facilitate this practice. The procedure further indicated, Individual packages of refrigerated or frozen taken from the original packing box need to be labeled and dated. A review of the facility ' s document titled, Refrigerated Storage Guide, dated 2023, indicated, Meat taken from freezer to thaw [poultry . ground meat]: Maximum refrigeration time once meat has thawed: 2 days. A review of the facility ' s document titled, Produce Storage Guidelines, dated 2023, indicated greens such as spinach are to be stored in the refrigerator for three to five days before removal. The document further indicated fresh parsley was to be stored two to three days in the refrigerator before disposal. A review of the facility ' s procedure titled, Freezer Storage, dated 2023, indicated, All frozen food should be labeled and dated. A review of the facility ' s document titled, Dry Good Storage Guidelines, dated 2023, indicated bread, opened or unopened on the shelf was recommended to be stored for five to seven days before discarding unused bread. A review of the facility ' s policy and procedure titled, Storage of [Dry] Food and Supplies, dated 2023, indicated, Labels should be visible . All food will be dated - month, day, year . No food will be kept longer than the expiration date on the product.

Based on observation, interview, and record review, the facility failed to ensure that the menu was being following for the therapeutic diet for lunch on 10/9/24 when: 1.Three residents (Resident 30, 49, and 64) were on modified texture diets, Dysphagia Mechanical (diet is for people with mild to moderate chewing and/or swallowing difficulty) and Pureed (diet is for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) who received no wheat roll for bread instead of receiving pureed roll (for Pureed diet) or chopped and milk-soaked wheat roll (for Dysphagia Mechanical diet) as indicated on the menu; 2. Two residents (Resident 18 and 23) with NCS (No Concentrated Sweets)/CCHO (Consistent or Controlled Carbohydrate) diet (diet is for people that need to control their blood sugar or diabetes) received wheat roll for bread instead of no roll as indicated on the menu; 3. Two residents (Resident 15 and 39) with 60 grams (g) Protein Renal diet (diet is for people to manage chronic kidney disease) received vanilla wafers as dessert instead of a cookie as indicated on the menu; 4. Three residents (Resident 31, 60, and 63) received mashed potato and green beans for vegetables instead of rice and carrot as indicated on the menu; 5. Resident 64 with Dysphagia Mechanical diet received mousse with chocolate chips for dessert instead of mousse without chocolate chips as indicated on the menu; 6. Resident 71 with 60 g Protein Renal, NCS/CCHO diet received mousse without chocolate chips for dessert instead of diet cookie as indicated on the menu; and 7. 75 out 75 meals were served without garnish instead of receiving garnish as indicated on the menu. These failures had the potential to result in compromising the medical and nutrition status of those 75 residents. Findings: During an observation of lunch meal service on 10/9/24 beginning at 12:05 p.m., it was noted as followed: 1. Residents 30, 49, and 64 who were on dysphagia mechanical and pureed diets did not receive chopped and milk-soaked wheat roll and puree wheat roll respectively. A concurrent review of the facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, Fall Menus, Week 2 Wednesday, indicated that dysphagia mechanical diet should have received wheat roll as chop 1/2, mashable, soak and drain and pureed diet should receive wheat roll as P (Pureed) #16 (1/4 cup). 2. Residents 18 and 23 who were on NCS/CCHO diet received wheat roll instead of no roll. A concurrent review of the facility spreadsheet titled, Fall Menus, Week 2 Wednesday, indicated that CCHO diet should have received no wheat roll. A review of the facility document titled, Diet Manual for Long Term Care and Residential Facilities, dated 2020, it indicated, .CCHO diet .carbohydrates are controlled through portion control and avoiding some concentrated sweets . 3. Residents 15 and 39 who were on 60 g Protein Renal diet received six pieces of vanilla wafers instead of a cookie. A concurrent review of the facility spreadsheet titled, Fall Menus, Week 2 Wednesday, it indicated 60 g Protein Renal diet should have received two small sugar cookies or one large sugar cookie for dessert. A review of the facility document titled, Diet Manual for Long Term Care and Residential Facilities, dated 2020, it indicated, .Protein Restricted Diet .a diet high in simple sugars and fat is used to spare protein .desserts: one serving = 2 small sugar cookies . 4. Residents 31, 60, and 63 received mashed potatoes and green beans instead of carrots and rice. A concurrent review of the facility spreadsheet titled, Fall Menus, Week 2 Wednesday, it indicated regular diet should have received brown rice and carrots. 5. Resident 64 who was on a Dysphagia Mechanical diet received mousse with chocolate chips instead of mousse without chocolate chips. A concurrent review of the facility spreadsheet titled, Fall Menus, Week 2 Wednesday, indicated Dysphagia Mechanical diet should have received mousse dessert with no chocolate chips. A review of the facility document titled, Diet Manual for Long Term Care and Residential Facilities, dated 2020, it indicated, .Dysphagia Mechanical .this diet consists of foods that are moist, mechanically altered, or easily mashed .foods must not be sticky or bulky increasing the risk of airway obstruction . 6. Resident 71 who was on a 60 g Protein Renal diet and NCS/CCHO diet received mousse with no chocolate chips instead of a diet cookie. A concurrent review of the facility spreadsheet titled, Fall Menus, Week 2 Wednesday, it indicated Renal CCHO diet should have received two small diet sugar cookies. 7. All meals delivered did not have parsley garnish. A concurrent review of the facility spreadsheet titled, Fall Menus, Week 2 Wednesday, it indicated all diets should have received a parsley garnish. During an interview with the DS (Dietary Supervisor) on 10/9/24 at 1:56 p.m., the DS acknowledged and confirmed the observation findings during lunch meal service. The DS stated that some puree and dysphagia mechanical diet trays did not get the wheat roll. The DS further stated the vanilla wafers for the 60 g Protein Renal diet with and without NCS/CCHO was used because the kitchen did not prepare the cookies. The DS further stated the last few meals were served with mashed potato and green beans because they were running out of rice and carrots. DS further stated the Registered Dietitian (RD) approved the substitution of mashed potatoes and green beans during meal service, but residents had not been notified of the changes. The DS further stated all meals should have garnish with parsley. The DS stated the menu and spreadsheet should be followed. During an interview with the RD on 10/10/24 at 11:29 a.m., the RD acknowledged issues that were found during meal service. The RD stated residents should receive the food items that were reflected on the menu. The RD further stated the kitchen did not prepare enough rice and carrots because the cook did not follow the standardized recipe. The RD further stated the substitute for rice and carrots needed to be approved by the RD and the residents should be informed of the change. The RD further stated, kitchen staff needed to follow the menu and spreadsheet. During a review the facility's policy and procedure (P&P) titled, Menu Planning dated 2023, indicated, .menu changes should be noted on menus on the consumers board and any other menus which may be posted .menus are planned to meet nutritional needs of residents in accordance with established national guidelines .the facility's diet manual and diets are ordered by the physician should mirror the nutritional care provided by the facility .menus are written for regular and therapeutic diets in compliance with the diet manual .standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation . During a review of facility document, titled Job Description: Cook, dated 2/2024, it indicated, .essential duties .ability to follow prepared menus and portion control guides .ability to prepare special diets accurately .

Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Several various metal sheet pans in clean and ready-to-use storage areas: a. Were stacked wet while stored away b. Had food debris; 2. There were opened bags of food items in dry storage and freezer with issues: a. One opened bag of elbow noodles was not tightly closed b. One opened bag of croutons was not labeled with an open or use by date c. One opened package of hamburger meat patties was not labeled with an open or use by date; 3. The thawing process system did not effectively identify when food was pulled from the freezer and used by date; 4. The ice machine was not clean; 5. The hot food cool down was not practiced correctly; 6. Two dietary aides were not able to verbalize the process of manual dishwashing by using the 3-compartment sinks correctly; 7. One dietary aide was not able to verbalize the concentration of the sanitizer solution for the sanitation (red) bucket (a color coded bucket contain sanitizer for the food service staff to sanitize the food-contact surfaces); and, 8. The microwave for resident's food located in dining room was not clean. These failures had potential to cause food-borne illness in a highly susceptible population of 75 out of 75 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with Dietary Supervisor (DS) and Registered Dietician (RD) on 10/8/24 at 9:40 a.m. at the kitchen's initial tour, several metal sheet pans stored at the clean and ready-to-use storage areas were observed stacked wet and had food debris. The metal pans included: -9 of full sheet pans (wet) -5 of full sheet pans (food debris inside) -4 of 1/4 sheet pans (wet) -10 of 1/6 sheet pans (wet) -1 of 1/6 sheet pan (food debris inside) The DS confirmed the metal sheet pans were wet and had food debris inside. The DS stated the dishes, pans and pots needed to be completely air-dried and clean before stored away. The RD stated dishes, pans and pots should be dried before being stored away to prevent mold and bacteria growth. During a review of the facility's policy and procedure (P&P) titled, Dishwashing, dated 2023, it indicated, .dishes are to be air dried in racks before stacking and storing . During a review of the facility's P&P titled, Sanitation dated 2023, it indicated, .All utensils .shall be kept clean . 2. During a concurrent observation and interview with the DS on 10/8/24 at 9:52 a.m. at the kitchen's initial tour, one opened bag of elbow pasta was not tightly closed, and one opened bag of croutons did not have an opened or used by date. The DS confirmed and stated opened packages of food should be wrapped and closed tightly. The DS further stated opened packages of food need to have labels with opened or used by dates. During a concurrent observation and interview with the DS on 10/8/24 at 10:06 a.m., at the kitchen's initial tour, one opened package of hamburger meat patties was not tightly closed and did not have and open or use by date. The DS confirmed and stated the opened package should have been wrapped tightly and labeled with opened or used by dates. During a review of the facility's P&P titled, Storage of Food and Supplies dated 2023, it indicated, .dry food items which have been opened .will be tightly closed, labeled, and dated . During a review of the facility's P&P titled, Labeling and Dating of Foods dated 2023, it indicated, .newly opened food items will need to be closed and labeled with an open date and used by date . 3. During a concurrent observation and interview with DS on 10/8/24 at 10:16 a.m., at the kitchen's initial tour, two boxes of fish and one box of chicken were sitting on the bottom rack in the refrigerator for thawing. The boxes of fish and chicken were not labeled with a pulled or used by date. The DS confirmed the thawing boxes of fish and chicken did not have labels indicating when the food was pulled from the freezer and when the food should be used by date. The DS stated she pulled the two boxes of fish from the freezer yesterday. The DS further stated she did not know when the box of chicken was pulled from the freezer. The DS further stated verbal communication was used to indicate when the meat items were being thawed. The DS further stated verbal communication was not effective. During a review of the facility's P&P titled, Thawing of Meats dated 2023, it indicated, .label defrosting meat with pull and use by date . 4. During a concurrent observation and interview with the DS and the RD on 10/8/24 at 10:35 a.m., at the kitchen's initial tour, an orange slimy substance was on the ice chute (the passageway that allows ice to fall into an ice storage bin) inside the top machinery part of the ice machine. Also observed the water was dripping through the orange slimy substance onto the ice in the ice storage bin. The DS and the RD confirmed the ice machine chute had an orange slimy substance. The DS stated an outside vendor was responsible for deep cleaning the ice machine every three months. During a review of the outside vendor invoice, it indicated the last deep cleaning service was on 5/31/24 and it had passed the three month mark as stated. During a review of the facility's P&P titled, Ice Machine Cleaning Procedures dated 2023, it indicated, .ice machine needs to be cleaned and sanitized monthly .clean inside of ice machine .per manufacturer's instructions . During a review of the ice machine's service manual, dated 12/8/2021, the service manual indicated the icemaker should be cleaned every 6 months and .more frequent maintenance may be required depending on water quality and appliance's environment . According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae). 5. During a concurrent interview and record review with the DS on 10/8/24 at 10:47 a.m., at the kitchen's initial tour, the DS stated hot and ambient foods were documented on the same log. A review of the October 2024 cooling log indicated the last cooling temperature was not documented for all foods on the log. A review of the September 2024 cooling log indicated there was a hot food item that went through the cool down process for more than six hours. A review of the September 2024 and October 2024 cooling logs indicated several hot foods on the log started cool down above 140 degrees Fahrenheit (F). DS confirmed staff were not practicing cool down processes correctly. During a review of the facility's P&P titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023, it indicated cooked food that is not served right away will be cooled using the two-stage method. The P&P further indicated, .cool cooked from 140 degrees F to 70 degrees F within two hours .then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours .when cooling down food, use the Cool Down Log .to document with proper procedure . 6. During a concurrent interview and review of manual dishwashing directions on 10/8/24 at 11:00 a.m. with the Dietary Aide 1 (DA 1), DA 2 and DS, The DA 1 stated they would switch to manual dishwashing with 3-compartment sink if dishwashing machine was not working. The DA 1 was not able to provide sanitizer immersion time for dishes. The DA 2 stated an incorrect immersion time of 20 seconds for the dishes. A review of the directions for sanitizer (Quat) indicated immersion time was 60 seconds. The DS confirmed the immersion time should be 60 seconds for dishes during the sanitizing process for the manual dishwashing procedure. During a review of the facility P&P titled, 3-Compartment Procedure for Manual Dishwashing dated 2023, it indicated, .the third compartment is for sanitizing .immerse all washed items for 60 sec . During a review of the facility's Job Description for Dietary Aide dated 9/1/16, the Job Description indicated the Dietary Aide job functions include, .clean food preparation utensils, dishes .practice infection control . 7. During a concurrent interview and review of red bucket sanitizer directions on 10/8/24 at 11:06 a.m. with the DA 2 and the DS, the DA 2 stated she did not know the right concentration range for red bucket sanitizer. The DS confirmed the DA 2 was not able to state correct concentration range. The DS further stated the concentration range for red bucket sanitizer should be 200-400 ppm (part per million - a measurement of concentration for the sanitizer). During an interview on 10/10/24, at 11:29 a.m. with the RD, the RD stated the staff should have good knowledge about how to test the concentration range for the sanitizer solution, and that would minimize the risk for the residents to get food-borne illness. During a review of the facility's P&P titled, Quaternary Ammonium Log Policy dated 2023 it indicated, .the quaternary solution, use for sanitizing clean work surfaces in the kitchen, will be made according to the instructions .the solution will be replaced when the reading is below 200 ppm . 8. During a concurrent observation and interview on 10/10/24 at 9:36 a.m. with the Director of Staff Development (DSD), noted the interior part of the microwave for resident's food in the dining room had black dry food splashes. The DSD confirmed the microwave was dirty and needed to be cleaned. During a review of the facility's P&P titled, Sanitation dated 2023, it indicated, .all equipment shall be kept clean .

Based on interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when: 1. Dietary Aides (DA) 1 and DA 2, were unable verbalized the process of manual dishwashing by using three-compartment sinks correctly (cross refer to F812, #6), and 2. DA 2 was unable to verbalize the concentration of sanitizer solution for the sanitation (red) bucket (a red color-coded bucket with sanitizer solution for food service staff to sanitize food contact surfaces) (cross refer to F812, #7). These failures had the potential to place 75 out of 75 highly susceptible residents who received food from the kitchen at risk for food-borne illness. Findings: 1. During an interview on 10/8/24, at 11 a.m. with DA 1, DA 1 verbalized the process of manual dishwashing by using the three-compartment sink. She was not able to verbalize the immersion time of the dishes for the sanitizing step with the sanitizer. DA 2 joined the interview and stated the immersion time should be 20 seconds. A concurrent review of the directions for the sanitizer (Quaternary Ammonium - a sanitizer agent) indicated the immersion time was 60 seconds. Dietary Supervisor (DS) confirmed and stated the immersion time should be 60 seconds. During an interview with Registered Dietitian (RD) on 10/10/24, at 11:29 a.m., she acknowledged the issue and stated the staff should know the correct procedure of the manual dishwashing, if not may put the residents at risk for food-borne illness. A review of the facility policy and procedure (P&P), titled 3-Compartment Procedure for Manual Dishwashing, dated 2023, it indicated, the third compartment is for sanitizing .immerse all washed items for 60 sec . A review of DA 1's employee file with hire date of 7/18/19, and a competency audit of DA 1, titled Verification of Job Competency Demonstration & Equipment Competency, completed on 9/20/24 and checked off by DS, indicated DA 1 was competent in the procedure of three-compartment sink manual dishwashing by demonstration. A review of DA 2's employee file with hire date on 9/11/24, showed there was no competency audit completed due to DA 2 did not work at facility for a year per DS. A review of facility document, titled Food & Nutrition Services In-Service, Topic: Sanitation, completed on 6/11/24 by the pervious DS, it indicated DA 1 attended the in-service which included the procedure of three-compartment sink dishwashing. A review of the facility document titled, Job Description: Dietary Aide, dated 9/1/16, it indicated the dietary aide job functions include, .clean food preparation utensils, dishes .practice infection control policies and procedures . 2. During an interview regarding the sanitation (red) bucket on 10/8/24, at 11:06 a.m. with DA 2 and DS, DA 2 was not able to verbalize the correct concentration range for the sanitizer solution (Quaternary Ammonium - a chemical agent for sanitation). DS confirmed and stated the concentration range should be at 200-400 ppm (part per million - a measurement of concentration). During an interview with RD on 10/10/24, at 11:29 a.m., she stated the staff needed to have a good knowledge how to test and the correct concentration range for the sanitizer solution. If not may put the residents at risk for food-borne illness. A review of the facility P&P titled, Quaternary Ammonium Log Policy dated 2023, it indicated, .the quaternary solution, use for sanitizing clean work surfaces in the kitchen, will be made according to the instructions .the solution will be replaced when the reading is below 200 ppm . A review of DA 2's employee file with hire date of 9/11/24, there was no competency audit completed due to DA 2 did not work at facility for a year per DS. There was no indication of DA 2 attended any in-service for sanitation. A review of the facility document titled, Job Description: Dietary Aide, dated 9/1/16, it indicated the dietary aide job functions include, .clean food preparation utensils, dishes .practice infection control policies and procedures of the department .practice infection control .attend in-service education . A review of facility document titled, Job Description: Dietary Manager, dated 2/2024, it indicated, .primary purpose .provide supervision for the Dietary Department .monitor work assignments, provide feedback, evaluate performance .conduct .training, in-service education activities .

Based on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for two of 25 sampled residents (Resident 17 and Resident 25), when the call light was not within reach. This failure had the potential to result in the residents not attaining their highest practicable physical, psychosocial, and emotional well-being. Findings: A review of an Admission Record indicated Resident 17 was admitted to the facility in late 2024 with multiple diagnosis of Parkinson's disease (a brain disease marked by tremor, muscular rigidity, and slow, imprecise movements) and muscle weakness. A review of Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/28/24, indicated Resident 17 had severely impaired cognition. Further review of the MDS indicated that Resident 17 required a helper to lift trunk or limbs during activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 10/8/24 at 1:43 p.m., Resident 17 was in bed and call light was not within reach. Licensed Nurse 1 (LN 1) searched the bed and could not find the call light. LN 1 confirmed that Resident 17 will use the call light if it was available and in their hand. LN 1 acknowledged call light should be within reach. A review of Resident 17's Care Plan, dated 9/9/24, indicated as interventions .Call light in reach and answered timely. A review of an Admission Record indicated Resident 25 was admitted to the facility in August 2024 with multiple diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side (loss of muscle function of the body after blood flow to the brain is reduced or blocked). A review of MDS, dated [DATE], indicated Resident 25 had severely impaired cognition. Further review of the MDS indicated that Resident 25 required substantial/maximal assistance (requires a helper) with activities of daily living. During a concurrent observation and interview on 10/8/24 at 10:16 a.m., Resident 25 was in bed laying on left side. Call light was located behind Resident 25 wrapped around side rail. Resident 25 stated he could not turn and wanted to use the call light to ask for coffee. Director of Staff Development (DSD) came into room and confirmed and acknowledged that Resident 25's call light was not within reach. During a concurrent observation and interview on 10/8/24 at 1:00 p.m. Resident 25 was sitting in a reclining seat next to the left side of the bed. Resident 25's call light was on the opposite side wrapped around siderail of bed. Resident 25 was unable to reach the call light. LN 2 confirmed call light was not within reach and near the resident. A review of Resident 25's fall risk Care Plan, revised 9/26/24, indicated as interventions .Keep call light within reach. During an interview on 10/11/24 at 10:30 a.m., with Director of Nursing (DON), the DON stated her expectation was to have all call lights within reach of the residents. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light revised May 2024, the P&P indicated .When the resident is in bed or confined to a chair be sure the light is within easy reach of the resident .

Based on observation, interview, and record review, the facility failed to ensure accurate assessment was performed for one resident (Resident 22) of 25 sampled residents when Resident 22's dental/oral assessment was inaccurate. This failure resulted in Resident 22 not receiving care reflective of the residents' status and needs. Findings: A review of Resident 22's ADMISSION RECORD indicated an admitted to the facility of 4/4/24 with multiple diagnoses which included adult failure to thrive (significant weight loss, functional decline, and an inability to maintain adequte nutrition and physical health), and malnutrition. Resident 22's Minimum Data Set (MDS, a comprehensive assessment tool) dated 4/10/24, indicated no memory problem. During an observation on 10/9/24 at 10:25 a.m., in Resident 22's room, Resident 22 was observed with all teeth missing. During an interview on 10/10/24 at 3:31 p.m., Resident 22 stated she has no teeth at all, both top and bottom. During an interview on 10/10/24, at 3:45 p.m., Resident 22 stated she had all her teeth pulled before being admitted to the facility. A review of Resident 22's MDS, dated [DATE], indicated, .No natural teeth or tooth fragment(s) (edentulous) [all teeth missing] . was not marked. During an interview on 10/11/24 at 8:23 a.m., with MDSLN (MDS Licensed Vocational Nurse), the MDSLN confirmed Resident 22's MDS was inaccurate. The MDSLN stated, It was a mistake. I should have checked [marked] that one (edentulous) . During an interview on 10/11/24 at 8:47 a.m., Resident 22 stated her responsible party informed the staff during admission about her need for dentures. The facility was asked for policies on accuracy of assessment but none were provided.

Based on observation, interview and record review, the facility failed to ensure that nursing staff had the necessary competencies and skill sets to meet the care and services for one of 25 sampled residents (Resident 378) when one Certified Nursing Assistant (CNA) transferred Resident 378 by herself using a Hoyer lift (an electronically operated mechanical lift used to transfer a patient from place to place). This failure had the potential for Resident 378 to receive unsafe care. Findings: Review of Resident 378's Admission Record, indicated, Resident 378 was admitted to the facility on [DATE], with diagnoses that included fracture of upper end of right leg, muscle weakness, abnormalities in gait and mobility, and hemiplegia and hemiparesis following cerebral infarction (paralysis and weakness on one side of the body after stroke.) During a review of Resident 378's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/7/24, the MDS indicated, Resident 378 needed the assistance of two or more staff for chair/bed-to-chair transfer (transfer to and from a bed to a chair or wheelchair.) During a review of Resident 378's Order Summary Report (OSR), dated 10/10/24, the OSR indicated Resident 378 is non-weight bearing (NWB-can't put any weight or pressure) on his right lower extremity (entire right leg.) During a review of Resident 378's Physical Therapy Evaluation & Plan of Treatment (PT Eval) dated 10/2/24, the PT Eval indicated, Resident 378 is NWB on his right leg and needed total assist with mechanical lift for transfers. During an observation on 10/8/24 at 10:56 a.m. in Resident 378's room, Resident 378 was in bed and a Hoyer lift sling was on the bed. CNA 1 was providing care to Resident 378 by herself. During a concurrent observation and interview on 10/8/24 at 11:12 a.m. in Resident 378's room, Resident 378 was observed to be on his motorized wheelchair. CNA 1 confirmed that she did the transfer by herself without additional staff assistance using the Hoyer lift. CNA 1 stated that Hoyer lift transfers should be done by two persons. During an interview on 10/10/24 at 3:04 p.m. with Director of Staff Development (DSD), DSD stated, Hoyer lift transfers were always done by 2 persons, it was part of training and what was taught in school. DSD stated that 2 persons were needed for the safety of the residents. During a review of the facility's policy and procedure (P&P) titled, Lifting Machine, Using a Mechanical, dated, May 2024, the P&P indicated, .At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.

Based on observation, interview, and record review the facility failed to implement infection prevention and control practices for one of 25 sampled residents (Resident 379) when the Certified Nursing Assistant (CNA 2) did not wear the proper Personal Protective Equipment (PPE-gown, eye protection or face shield and gloves) upon entering Resident 379's room with an isolation precaution sign. This failure put the residents at increased risk for the spread of infection. Findings: During a review of Resident 379's Admission Record, the Admission Record indicated, Resident 379 was admitted on [DATE], with diagnoses that included but is not limited to COVID-19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus), moderate protein-calorie malnutrition, and muscle weakness. During a review of Resident 379's Result Details, dated 10/2/24, the Result Details indicated a positive result for COVID-19. During a review of Resident 379's Order Summary Report (OSR), dated 10/10/24, the OSR indicated Resident 379 had an order for Droplet Precaution in Place: Dx [diagnosis] covid positive until 10/12/24. During an observation on 10/8/24 at 12:43 p.m., outside Resident 379's room, there was a signage that indicated Resident 379 is on droplet precaution (a set of measures used to prevent the spread of organisms that cause disease through respiratory secretions.) During an observation on 10/8/24 at 12:48 p.m., inside Resident 379's room, the CNA 1 brought in the lunch tray, and asked the CNA 2 to help her reposition Resident 379. At 12:51 p.m. the CNA went in the room with gown, gloves, and a yellow surgical mask (disposable loose-fitting mask that covers the user's nose and mouth). During a concurrent observation and interview on 10/8/24 at 12:56 p.m., with the CNA 2, the CNA 2 confirmed wearing the yellow surgical mask inside Resident 379's room. The CNA 2 looked at the signage posted at the door and stated, I'm sorry, I'm sorry. During a review of the facility's P&P titled Categories of Transmission Based Precautions, dated May 2024, the P&P indicated, Droplet Precautions .masks are worn when entering the room. During a concurrent interview and record review on 10/11/24 at 10:59 a.m. with Infection Preventionist (IP), IP stated that for Covid-19 isolation staff should be wearing an N95 mask (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air). IP stated that a sign was placed on the door indicating that staff should be wearing N95. The 'Droplet Precautions' signage at Resident 379's door was reviewed, and IP nurse confirmed that the picture 'Respiratory Protection' in that signage was the indicator that staff should be wearing N95.

Based on observation, interview and record review, the facility failed to ensure 28 multiple-resident rooms (rooms 1-8, 11, 12, 17-19, 21, 23-36) met the required 80 square feet (sq. ft.) per resident when the following rooms were measured as: room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 71.45 sq. ft. per person room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 75.5 sq. ft. per person room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 74.5 sq. ft. per person room [ROOM NUMBER] at 74.5 sq. ft. per person room [ROOM NUMBER] at 76.9 sq. ft. per person room [ROOM NUMBER] at 74.67 sq. ft. per person room [ROOM NUMBER] at 72.1 sq. ft. per person room [ROOM NUMBER] at 74.67 sq. ft. per person room [ROOM NUMBER] at 73.83 sq. ft. per person room [ROOM NUMBER] at 78.93 sq. ft. per person room [ROOM NUMBER] at 70.47 sq. ft. per person room [ROOM NUMBER] at 70.8 sq. ft. per person room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 70.47 sq. ft. per person room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 70.8 sq. ft. per person room [ROOM NUMBER] at 71.9 sq. ft. per person room [ROOM NUMBER] at 70.8 sq. ft. per person room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 70.8 sq. ft. per person room [ROOM NUMBER] at 71.4 sq. ft. per person room [ROOM NUMBER] at 70.8 sq. ft. per person room [ROOM NUMBER] at 75.64 sq. ft. per person room [ROOM NUMBER] at 70.8 sq. ft. per person room [ROOM NUMBER] at 70.8 sq. ft. per person This failure had the potential to negatively affect the residents' quality of life and result in inadequate space for the provision of care. Findings: During observations made throughout the survey in the rooms with two and three resident occupancies, the space was adequate to store assistive devices in the rooms (such a wheelchair and/or walkers) and to facilitate provision of care and needs. During an interview on 10/8/24 at 10:19 a.m., a resident in room [ROOM NUMBER] stated, he did not have many things, so he had enough space in the room. During an interview on 10/8/24 at 10:16 a.m., Residents in room [ROOM NUMBER] stated they had no concerns or issues with the size of the room. During an interview on 10/8/24 at 12:29 p.m., a resident in room [ROOM NUMBER] stated he had no issues with the space in the room. During an interview on 10/9/24 at 11:13 a.m. a resident in room [ROOM NUMBER] stated there was not enough space in her room for assistance in getting out of bed. She had a Hoyer lift, and stated the Certified Nursing Assistants (CNAs) had a difficult time and sometimes had to maneuver furniture, such as her bedside table and items on her nightstand. Her roommate stated the CNAs often moved items past the dividing curtain into her space when they were transferring Resident 22 via the Hoyer lift, but she lets them do it because she wanted to respect her roommate's needs. The Department recommends continuation of the waiver for the above-mentioned rooms.

Based on observation, interview, and record review the facility failed to provide food that was palatable when three of seven sampled residents (Resident 3, Resident 4, and Resident 7) had food that was served cold. This failure had the potential for Resident 3, Resident 4, and Resident 7 to experience dissatisfaction with meals leading to decreased intake with possible weight loss. Findings: A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility in March 2023 with multiple diagnoses including hemiparesis (weakness on one side of the body) and hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke- lack of blood flow to the brain) and moderate protein calorie malnutrition (inadequate intake of protein, calories, and nutrients). A review of Resident 3's MDS (Minimum Data Set- a federally mandated assessement tool), Cognitive Patterns, dated 9/18/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 3 was cognitively intact. A review of Resident 4's Admission Record indicated Resident 4 was admitted to the facility in October 2021 with multiple diagnoses including osteoarthritis (type of arthritis caused by the wearing down of cartilage that lines the joints) of left knee and moderate protein calorie malnutrition. A review of Resident 4's Minimum Data Set MDS, Cognitive Patterns, dated 8/2/24, indicated Resident 4 had a BIMS score of 14 out of 15 that indicated Resident 4 was cognitively intact. A review of Resident 7's Admission Record indicated Resident 7 was admitted to the facility in September 2024 with multiple diagnoses including hemiparesis and hemiplegia following cerebral infarction and diabetes (too much sugar in the blood). A review of Resident 7's MDS, Cognitive Patterns, dated 9/12/24, indicated Resident 7 had a BIMS score of 13 out of 15 that indicated Resident 7 was cognitively intact. A review of Resident 7's Resident Grievance Form, dated 9/18/24, indicated .Resident verbalized concerns about the food. She states food tray comes to her cold. Last night dinner looks like dog food, fried eggs cold for breakfast .Investigation Findings: Counseled staff on making sure food is covered so that it stays hot. Also counseled on plating/ presentation . A review of Summer and Fall Menus, from 8/5/24 to 10/1/24, with site for temperature entries of menu items, indicated multiple missing temperature entries including: 8/5/24, 8/8/24, 8/9/24, 8/14/24, and 8/17/24, the dinner temperature entries were missing, 8/6/24, 8/11/24, 8/12/24, and 8/13/24, menu items including rice, zucchini, sweet potato fries, and breakfast meat, were missing temperature entries. Menu spreadsheets for 8/15/24 and 8/18/24 did not have temperature entries, and there were no menu spreadsheets for 9/2/24 to 9/5/24 and 9/13/24 to 9/30/24. During an interview on 10/1/24 at 12:20 p.m. with the Dietary Manager (DM), the DM stated she recently started working at facility and has not heard any complaints about food temperature, but has heard complaints about how food looks. The DM stated she checked food temperatures today at point of service from kitchen but did not check temperature of food when served to residents. The DM stated the Certified Nursing Assistants (CNAs) pass out meal trays to the residents. During an interview on 10/1/24 at 1:28 pm. with Resident 3, Resident 3 stated her breakfast yesterday was cold. Resident 3 stated she asked to have it reheated but was told it could not be reheated. Resident stated food is cold off and on. During an interview on 10/1/24 at 1:34 p.m. with Resident 4, Resident 4 stated food is always cold. Resident stated the vegetables are cold. Resident 4 stated she is not eating well. During a joint interview on 10/1/24 at 2:10 p.m. with the Director of Nursing (DON) and the Social Services Director (SSD), the DON stated if resident complains of cold food will have the kitchen make a new tray. The CNAs deliver the food to the residents and are to close the cart door each time trays are pulled out. The DON stated the Registered Dietitian (RD) performs test tray temperature checks. Requested documentation of test tray temperature checks. During an interview on 10/1/24 at 2:12 p.m. with Licensed Nurse (LN) 1, LN 1 stated, Cold food has been an issue. LN 1 stated for the past couple of weeks residents have complained of the protein being cold. During an interview on 10/1/24 at 2:18 p.m. with the DM, the DM stated the cook takes the temperature of food on the steam table and records it on the menu. The DM provided menus for 8/5/24 to 8/17/24, and acknowledged that temperature recordings were incomplete. The DM stated she was unable to locate the menus for 8/18/24 to 9/30/24 but will check with the cook. The DM stated the prior cook was not recording the temperatures on the menus. During a subsequent interview on 10/1/24 at 2:36 p.m. with the DM, the DM stated that there is not a test tray temperature log and did not know to maintain one. The DM stated she had been testing temperatures at time of the cart fill in the kitchen but not at time of distribution to residents. The DM stated she was only managing temperatures in the kitchen. During an interview on 10/1/24 at 3:31 p.m. with Resident 7, Resident 7 stated the food is not good and is cold all the time. Resident 7 stated the chicken and corn served at lunch today was cold. Resident 7 stated she has lost a few pounds because the food is not good. During an interview on 10/1/24 at 3:37 p.m. with the Administrator (ADM) and the DON, the ADM acknowledged that cold food has come up. Reviewed menus for 8/5/24 to 8/18/24, and additional menus provided with temperatures entered for 8/19/24 to 9/12/24. The ADM acknowledged that temperature monitoring was incomplete, and the prior cook was not documenting food temperatures. The ADM acknowledged that a test tray temperature log was not found. A review of the facility's Policy and Procedure (P&P) titled Meal Service, dated 2023, .Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures The Food and Nutrition Services staff member will take the food temperatures prior to service of the meal .The food will be served on trayline at the recommended temperatures .and recorded on the daily therapeutic menu in the temperature column of the regular food and next to the food item under the therapeutic diet column of each food served .The temperatures of the foods should be periodically monitored throughout meal service to ensure proper hot or cold holding temperature .Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot . A review of the facility's P&P titled Covered Food During Transport, dated 2023, indicated .All hot food will be covered to maintain the proper temperature .

Based on observation, interview, and record review, the facility failed to ensure resident needs were accommodated for one of six sampled residents (Resident 3), when Resident 3's call light was not within reach. The failure had the potential to result in the resident not attaining her highest practicable physical, psychosocial, and emotional well-being. Findings: Resident 3 was admitted to the facility in June 2024 with multiple diagnoses that included osteoarthritis (deterioration of tissue that lines the joints) and muscle weakness. A review of Minimum Data Set (MDS, and assessment tool), dated 6/11/23, indicated Resident 3 had moderately impaired cognition. During an interview on 7/3/24, at 11 a.m., with Resident 2, Resident 2 stated that her roommate, Resident 3 was unable to push the call light. Resident 2 further stated that she had to push the call light for Resident 3 on multiple occasions. Resident 2 further stated that Resident 3 also had to call out for help when she is unable to push the call light. During a concurrent observation and interview on 7/3/24, at 11:15 a.m., with Resident 3, Resident 3 was lying in bed on her right side facing the wall. Resident 3's call light was wrapped the left side rail and not within reach. Resident 3 stated that she was unable to reach the call light because it was difficult for her to turn side to side. During an interview on 7/3/24, at 11:17 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 confirmed that Resident 3 was unable to reach her call light. CNA 1 stated that, If the resident can't use the call light, they can fall if trying to use the bathroom or get a drink. During an interview on 7/3/24, at 11:50 a.m., with the Infection Preventionist (IP), the IP stated that a resident's needs may not be met if call lights are not within their reach. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light dated 12/23, the P&P indicated .when the resident is in bed or confined to a chair be sure the light is within easy reach of the resident . During a review of the facility's P&P titled, Accommodation of Needs, revised 12/22, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning .The resident's individual needs and preferences shall be accommodated to the extent possible .shall be evaluated upon admission and reviewed on an ongoing basis .adaptations may be made to the physical environment .providing access to assistive devices .assisting residents in maintaining independence, dignity and well-being.

Based on interview and record review, the facility failed to follow physician orders to ensure professional standards of quality were maintained for one of six sampled residents (Resident 1), when Resident 1's surgical staples were not removed on the date ordered by the physician. This failure had the potential to cause an infection in Resident 1's wound. Findings: Resident 1 was admitted to the facility in April 2024 with multiple diagnoses that included a fracture of the right lower leg and rhabdomyolysis (a breakdown of muscle tissue). A review of the Minimum Data Set (MDS, and assessment tool), dated 4/24/24, indicated Resident 1 was cognitively intact. During a review of Resident 1's Admission Summary Note dated 4/18/24, the Admission Summary Note indicated, .Skin/Head to toe assessment .laceration to right side of forehead, 5 staples in place (Remove in 10-14 days, 4/24-4/28) . During a review of Resident 1's Order Summary dated 4/18/24, the Order Summary indicated, Laceration upper right forehead- 5 staples in place (Remove in 10-14 days, 4/24-4/28). During a review of Resident 1's Care Plan (CP) dated 4/19/24, the CP indicated, .Surgical incision: Resident has a surgical incision laceration to right forehead, and is at risk for dehiscence, delayed healing, infection . During a review Resident 1's Skin/Wound Note dated 5/3/24, the Skin/Wound Note indicated, .5 staples removed from right forehead surgical site . During an interview on 7/3/24, at 11:50 a.m., with the Infection Preventionist (IP), the IP stated that staples are removed by the treatment nurse. The IP further stated that physician orders should be followed. During an interview on 7/3/24, at 1:15 p.m., with the Treatment Nurse (TN), the TN confirmed that there was a physician's order to remove Resident 1's forehead staples between 4/24/24-4/28/24. The TN stated that Resident 1's forehead staples were removed on 5/3/24. The TN further stated that there is a risk for infection if staples are not removed as ordered. During a review of the facility's policy and procedure (P&P) titled, Physician Orders,dated 10/23, the P&P indicated, . the licensed staff shall carry out physician/nurse practitioners' orders as prescribed . During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: (1) Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing- Stated of California Department of Consumer Affairs).rvices that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing- Stated of California Department of Consumer Affairs).

Based on interview and record review, the facility failed to ensure pharmacy services were maintained for one of six sampled residents (Resident 2), when Resident 2 did not receive chlordiazepoxide (a medication used to treat alcohol withdrawal symptoms) according to physician orders. This failure resulted in Resident 2 to have experienced uncomfortable symptoms and had the potential to cause Resident 2 to relapse during alcohol detoxification. Findings: Resident 2 was admitted to the facility June 2024 with multiple diagnoses that included fibromyalgia (a chronic condition involving widespread body pain and tiredness) and alcohol abuse. A review of Minimum Data Set (MDS, an assessment tool), dated 6/28/24, indicated Resident 2 was cognitively intact. During an interview on 7/3/24 at 11 a.m. with Resident 2, Resident 2 stated that chlordiazepoxide was ordered when she was admitted to the facility. Resident 2 further stated that she did not receive the medication until three days later. Resident 2 further stated, It was not cool; I had a concern there. I needed it (chlordiazepoxide) to detox. It was hard when I didn't get that medication. They had a doctor's order, so it didn't make sense that they didn't have the medication. During an interview on 7/3/24 at 11:50 a.m. with the Infection Preventionist (IP), the IP stated that three days is an unacceptable time frame to receive medications after being ordered. The IP further stated that residents can have side effects if they do not receive medications when ordered. During a review of Resident 2's Interdisciplinary (IDT) Note dated 6/25/24, the IDT indicated, .Psychotherapeutic Med: Chlordiazepoxide . During a review of Resident 2's Order Summary dated 6/25/24, Resident 2 had an order for Chlordiazepoxide Hcl (hydrochloride) oral capsule 5 mg (mg, a unit of measurement) Give 1 capsule by mouth every 24 hours as needed . During a review of Resident 2's Medication Administration Note (MAR) dated 6/26/24, the MAR indicated, .chlordiazepoxide .awaiting delivery from pharmacy, not in E-kit (emergency kit that contains small quantity of medication that can be dispensed when pharmacy services are not available) . During a review of Resident 2's MAR dated 6/27/24, the MAR indicated, . chlordiazepoxide .delivery from the pharmacy waiting . During a review of the facility's policy and procedure (P&P) titled, Physician Orders, dated 10/23, the P&P indicated, .the licensed staff shall carry out physician/nurse practitioners' orders as prescribed .

Based on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when ready to use dishware was found dirty and in uncleanable condition. These failures had the potential to cause food-borne illnesses (an illness caused by food or water contaminated with bacteria, viruses, parasites or toxins) to all residents. Findings: During a concurrent observation and interview on 6/27/24 at 10:55 a.m. with the Activities Assistant (AA) in the main dining room, eight residents with beverage mugs were in the dining room playing a game and there was a cart with urns of coffee and mugs available for residents to use. The AA confirmed three of the mugs available for residents to use had brown and white residue stuck to the inside of the mugs. The AA stated the mugs were not clean, should not be used for residents, and she would take them back to the kitchen to be cleaned. During a concurrent observation and interview on 6/27/24 at 10:59 a.m. with the Certified Dietary Manager (CDM) in the kitchen, the CDM stated clean, ready to use dishware was stored on a rack next to the dishwashing machine. The CDM confirmed on the rack of ready to use dishware was the presence of a plastic cup with yellow residue and bowl with white residue and stated they were not clean and needed to be rewashed. The CDM confirmed the presence of a plastic cup with brown residue, two bowls that had rough surfaces inside and stated all three items needed to be thrown out because they were uncleanable due to staining and rough surfaces. The CDM acknowledged dishwashing staff should be checking dishware for cleanliness prior to putting them on the ready to use rack and, if unclean, they could cause food borne illness to the residents. During a concurrent observation and interview on 6/27/24 at 1:39 p.m. with the Dietary Aide (DA) in the kitchen, the DA was putting dishware that came out of the dishwashing machine on to the ready to use storage rack. The DA stated when she is putting away dishware she was expected to check for cleanliness. The DA added if the dishware is no longer cleanable, they should be thrown out. The DA stated dishware that is still dirty but cleanable will be sent back to the dishwasher to be cleaned. The DA stated if residents were served food and beverages in dirty dishes, they could get sick from food borne illness. A review of the facility's policy and procedure titled, Sanitation, dated 2023, indicated, .the FNS [Food and Nutritional Services] Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques .plastic ware, china, and glassware that becomes unsightly, unsanitary or hazardous because of chips, cracks, or loss of glaze shall be discarded . Based on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when ready to use dishware was found dirty and in uncleanable condition. These failures had the potential to cause food-borne illnesses (an illness caused by food or water contaminated with bacteria, viruses, parasites or toxins) to all residents. Findings During a concurrent observation and interview on 6/27/24 at 10:55 a.m. with the Activities Assistant (AA) in the main dining room, eight residents with beverage mugs were in the dining room playing a game and there was a cart with urns of coffee and mugs available for residents to use. The AA confirmed three of the mugs available for residents to use had brown and white residue stuck to the inside of the mugs. The AA stated the mugs were not clean, should not be used for residents, and she would take them back to the kitchen to be cleaned. During a concurrent observation and interview on 6/27/24 at 10:59 a.m. with the Certified Dietary Manager (CDM) in the kitchen, the CDM stated clean, ready to use dishware was stored on a rack next to the dishwashing machine. The CDM confirmed on the rack of ready to use dishware was the presence of a plastic cup with yellow residue and bowl with white residue and stated they were not clean and needed to be rewashed. The CDM confirmed the presence of a plastic cup with brown residue, two bowls that had rough surfaces inside and stated all three items needed to be thrown out because they were uncleanable due to staining and rough surfaces. The CDM acknowledged dishwashing staff should be checking dishware for cleanliness prior to putting them on the ready to use rack and if unclean, they could cause food borne illness to the residents. During a concurrent observation and interview on 6/27/24 at 1:39 p.m. with the Dietary Aide (DA) in the kitchen, the DA was putting dishware that came out of the dishwashing machine on to the ready to use storage rack. The DA stated when she is putting away dishware she was expected to check for cleanliness. The DA added if the dishware is no longer cleanable, they should be thrown out. The DA stated dishware that is still dirty but cleanable will be sent back to the dishwasher to be cleaned. The DA stated if residents were served food and beverages in dirty dishes, they could get sick from food borne illness. A review of the facility's policy and procedure titled, Sanitation, dated 2023, indicated, .the FNS [Food and Nutritional Services] Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques .plastic ware, china, and glassware that becomes unsightly, unsanitary or hazardous because of chips, cracks, or loss of glaze shall be discarded .

Based on interview and record review the facility failed to ensure appropriate treatment and services were provided to two of four sampled residents (Resident 1 and Resident 2) when the Restorative Nursing Assistant program (RNA program: provides residents with exercises to improve or maintain mobility and strength) services were not implemented per the physician's order. This deficient practice had the potential to result in Resident 1 and Resident 2 experiencing declines in range of motion and strength. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in September of 2023 with diagnoses which included muscular dystrophy (weakness and loss of muscle mass) and multiple sclerosis (causes muscle stiffness and weakness). A review of Resident 1's Minimum Data Set (MDS: an assessment tool), dated 3/28/24, indicated Resident 1 had moderate memory impairment and had no rejection of care behaviors. An interview on 6/27/24 at 11:41 a.m., Resident 1 stated he was supposed to be getting assistance in the RNA program to help with exercises three times a week but stated he had not been provided the assistance consistently. Resident 1 added he worried he would lose the strength he worked to achieve in physical therapy (PT: focuses on the resident's ability to move their body). A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in November of 2021 with diagnoses which included generalized muscle weakness and abnormalities of gait (manner of walking) and mobility. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had no memory impairments. During an interview on 6/27/24 at 12:33 p.m., Resident 2 stated he was supposed to be getting assistance with RNA program to help with getting out of bed and upper body exercises. Resident 2 added he was not sure how often he was supposed to be getting RNA sessions but stated he doesn't get them very often and wanted more assistance than he had been getting. During a concurrent interview and record review on 6/27/24 at 1:05 p.m. with Director of Rehabilitation (DOR), Resident 1's and Resident 2's PT discharge summaries were reviewed. The DOR stated Resident 1's and Resident 2's PT discharge summaries both indicated they were referred for RNA program after they completed their PT program. The DOR stated the Director of Nursing (DON) and Director of Staff Development (DSD) oversaw the RNA program. During an interview on 6/27/24 at 3:13 p.m., the DON stated she expected RNA program staff to document the days RNA assistance was provided, time spent on RNA exercises, and if the resident refused to participate in the RNA program. The DON stated the DSD would be the best to discuss the RNA program documentation. During a concurrent interview and record review on 6/27/24 at 3:20 p.m., with the DSD, Resident 1's and Resident 2's order summary report (OSR: report indicating physician prescribed treatments and services) and RNA Range of Motion (ROM) program task sheets (RNATS) for date ranges 5/29/24-6/27/24 were reviewed. The DSD stated she expected residents with orders for RNA program to get the services as ordered and she expected the RNATS to indicate when the resident was helped with the RNA program, what exercises were performed, and how long the RNA exercises were performed. The DSD confirmed both Resident 1 and Resident 2 had orders to receive RNA program three times a week. Upon reviewing Resident 1's RNATS the DSD confirmed Resident 1 did not have any documented refusals for RNA program and did not receive RNA assistance three times a week when it was documented as given on 6/1/24, 6/3/24, and not again until 6/19/24. Upon reviewing Resident 2's RNATS the DSD confirmed Resident 2 did not have any documented refusals of RNA program and did not receive RNA assistance three times a week when it was documented as given on 6/2/24, 6/3/24, 6/9/24, 6/10/24, and 6/17/24. The DSD acknowledged that a lack of documentation means it was not done. An interview on 6/27/24 at 4:18 p.m., the Restorative Nursing Assistant 1 (RNA 1) stated he assisted residents with their RNA program and was trained to document the date RNA assistance was offered, any refusals, what exercises were performed, and how much time was spent on RNA program exercises. The RNA 1 stated if it was not documented it means it was not done. A review of facility policy and procedure titled, RNA program, revised 8/14/23, indicated, .Facility should have designated certified and trained RNA staff to fully provide the RNA treatment as recommended for each resident . provide per physician's order . Based on interview and record review the facility failed to ensure appropriate treatment and services were provided to two of four sampled residents (Resident 1 and Resident 2) when the Restorative Nursing Assistant program (RNA program: provides residents with exercises to improve or maintain mobility and strength) services were not implemented per the physician's order. This deficient practice had the potential to result in Resident 1 and Resident 2 experiencing declines in range of motion and strength. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in September of 2023 with diagnoses which included muscular dystrophy (weakness and loss of muscle mass) and multiple sclerosis (causes muscle stiffness and weakness). A review of Resident 1's Minimum Data Set (MDS: an assessment tool), dated 3/28/24, indicated Resident 1 had moderate memory impairment and had no rejection of care behaviors. An interview on 6/27/24 at 11:41 a.m., Resident 1 stated he was supposed to be getting assistance in the RNA program to help with exercises three times a week but stated he had not been provided the assistance consistently. Resident 1 added he worried he would lose the strength he worked to achieve in physical therapy (PT: focuses on the resident's ability to move their body). A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in November of 2021 with diagnosis which included generalized muscle weakness and abnormalities of gait (manner of walking) and mobility. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had no memory impairments. During an interview on 6/27/24 at 12:33 p.m., Resident 2 stated he was supposed to be getting assistance with RNA program to help with getting out of bed and upper body exercises. Resident 2 added he was not sure how often he was supposed to be getting RNA sessions but stated he doesn't get them very often and wanted more assistance than he had been getting. During a concurrent interview and record review on 6/27/24 at 1:05 p.m. with Director of Rehabilitation (DOR), Resident 1's and Resident 2's PT discharge summaries were reviewed. The DOR stated Resident 1's and Resident 2's PT discharge summaries both indicated they were referred for RNA program after they completed their PT program. The DOR stated the Director of Nursing (DON) and Director of Staff Development (DSD) oversaw the RNA program. During an interview on 6/27/24 at 3:13 p.m., the DON stated she expected RNA program staff to document the days RNA assistance was provided, time spent on RNA exercises, and if the resident refused to participate in the RNA program. The DON stated the DSD would be the best to discuss the RNA program documentation. During a concurrent interview and record review on 6/27/24 at 3:20 p.m., with the DSD, Resident 1's and Resident 2's order summary report (OSR: report indicating physician prescribed treatments and services) and RNA Range of Motion (ROM) program task sheets (RNATS) for date ranges 5/29/24-6/27/24 were reviewed. The DSD stated she expected residents with orders for RNA program to get the services as ordered and she expected the RNATS to indicate when the resident was helped with RNA program, what exercises were performed, and how long the RNA exercises were performed. The DSD confirmed both Resident 1 and Resident 2 had orders to receive RNA program three times a week. Upon reviewing Resident 1's RNATS the DSD confirmed Resident 1 did not have any documented refusals for RNA program and did not receive RNA assistance three times a week when it was documented as given on 6/1/24, 6/3/24, and not again until 6/19/24. Upon reviewing Resident 2's RNATS the DSD confirmed Resident 2 did not have any documented refusals of RNA program and did not receive RNA assistance three times a week when it was documented as given on 6/2/24, 6/3/24, 6/9/24, 6/10/24, and 6/17/24. The DSD acknowledged that a lack of documentation means it was not done. An interview on 6/27/24 at 4:18 p.m., the Restorative Nursing Assistant 1 (RNA 1) stated he assisted residents with their RNA program and was trained to document the date RNA assistance was offered, any refusals, what exercises were performed, and how much time was spent on RNA program exercises. The RNA 1 stated if it was not documented it means it was not done. A review of facility policy and procedure titled, RNA program, revised 8/14/23, indicated, .Facility should have designated certified and trained RNA staff to fully provide the RNA treatment as recommended for each resident . provide per physician's order .

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene was performed for a census of 75, when the policy for handwashing was not followed during a gastroenteritis (an intestinal infection marked by diarrhea, cramps, nausea, and vomiting) outbreak. This failure had the potential to increase the spread of infection. Findings: During an observation on 4/25/23, at 11:08 a.m., of signage taped to the front door of the facility entrance, the sign indicated the facility was experiencing a gastroenteritis/Norovirus outbreak. During a review of facility document titled, Resident Outbreak Line List, the document listed residents who experienced symptoms which included nausea, vomiting, and diarrhea. On 4/22/23, there were five residents with symptoms. On 4/23/23, there an additional three residents with symptoms. On 4/24/23, there were eight additional residents with symptoms. On 4/25/23, there were an additional three residents with symptoms. During an observation on 4/25/23, at 12:53 p.m., in the hallway, multiple staff members entered and exited isolation rooms having used alcohol-based hand sanitizer (ABHS) to clean their hands. During an interview on 4/25/23, at 2:26 p.m., with the Infection Preventionist (IP, nurse responsible for infection prevention education and policy adherence), the IP stated, Until we know what the pathogen is, handwashing is the most preventative, especially loose stools, but hand sanitizer is ok. When the policy was reviewed with the IP, the IP indicated she would expect staff to wash hands with soap and water per the policy. During a concurrent observation and interview on 4/25/23, at 3:02 p.m., outside an isolation room, with Certified Nursing Assistant 3 (CNA 3), CNA 3 was observed leaving the room. CNA 3 removed her gown, gloves and used ABHS to clean her hands. Confirmed with CNA 3 she used ABHS to clean her hands. CNA 3 stated, I will wash my hands in a few minutes, before I go into the next room. During a review of the facility's policy and procedure (P&P) titled, Norovirus/Gastroenteritis Prevention and Control, revised March 2022, the P&P indicated, During outbreaks, use soap and water for hand hygiene after providing care or having contact with residents suspected or confirmed with norovirus/gastroenteritis.

Based on observations, interviews, clinical record reviews, and facility policy reviews, the facility failed to ensure Resident 1 received adequate care to promote the highest practicable physical, mental, and psychosocial well-being in accordance with a comprehensive assessment and plan of care to prevent the development of a Stage III pressure ulcer (Full thickness tissue loss). These failures were a direct result of a significant decline in Resident 1's condition. Findings: On 4/18/12 at 7:25 a.m., an unannounced visit was conducted at the facility to investigate a complaint related to quality of care/treatment. The Director of Nurses (DON) was made aware of the complaint and the facility was toured. Resident 1 was observed in bed, lying on her back with one blanket partially covering her stomach, both legs were exposed and she was fully dressed. Resident 1 had no socks on her feet and an eschar (skin breakdown) was noted on each of her heels. No pressure relief devices were on the bed or on Resident 1's heels. Licensed Nurse (LN) 1 assisted with Resident 1's wound observation on 4/18/12 at 8:10 a.m. LN 1 exposed Resident 1's coccyx (tail bone area) where there was a Stage III pressure ulcer (Full thickness tissue loss, extends into underlying subcutaneous tissue layer). The wound had minimal, thready slough tissue in the center of the wound with boggy white tissue (skin that appears to have been in water for a long period of time-whitish appearance) on the outer edges of the wound. The intact tissue surrounding the wound was observed to be deep red and was blanchable (skin turns white and then red when pressure is applied). During the observation, Resident 1 complained of pain and stated, "I just want to die." When questioned about the pressure ulcer and when it had occurred, LN 1 stated he worked part-time and was unaware of when Resident 1's pressure ulcer began. He further stated, "Yes, the wound is a Stage III pressure ulcer." When questioned about the Stage II pressure ulcers (superficial open sore in the upper layer of skin. The sore may look like a blister, abrasion (scrape), or shallow crater) to Resident 1's right and left heels, LN 1 said, "Yes, I see them." No heel protectors or pressure relieving devices were observed. An interview with Certified Nurse Assistant (CNA) 1 was conducted on 4/18/12 at 8:35 a.m. When questioned about the pressure ulcers on Resident 1, CNA 1 said, "Resident 1 has been in the facility for two years and never had any wounds on her... one of the CNAs noticed redness on her tailbone area in February and told the charge nurse and nothing was done. Now, there is a large wound. CNA 1 further stated "sometimes we report to the nurses and nothing gets done" and now "Resident 1 complains of pain. It's terrible". CNA 2 was interviewed on 4/18/12 at 8:42 a.m. When questioned about what he knew about Resident 1, CNA 2 said, "She has pressure ulcers. Resident 1 has been in the facility for two years with no skin problems (pressure sores). One of the CNAs noticed redness and reported to the licensed nurse and nothing was done. We (CNAs) told the nursing staff something needed to be put on the coccyx and the heels to prevent it from opening and nothing was done. The residents seem to need more care, but the staff aren't responding, especially the licensed staff." An interview with an anonymous staff person on 4/18/12 at 10:05 a.m. was conducted. The anonymous staff stated a reddened area on the coccyx was noticed in February after providing pericare. The redness was reported to the licensed nurse. The following day the same situation occurred. After providing pericare, the redness on the coccyx area was reported to the licensed nurse. The anonymous staff stated these requests for treatment to the reddened coccyx of Resident 1 went on for three weeks and no interventions were implemented. Resident 1's skin opened as a Stage III pressure ulcer in March and the wound consultant was notified April 6, 2012. The Anonymous staff further stated, "Resident 1 never had any skin problems and now she has a Stage III pressure ulcer and Stage II pressure ulcers on her heels." An interview was conducted on 4/18/12 with the DON at 8:48 a.m. When questioned about Resident 1's pressure ulcer on the coccyx and the pressure ulcers on each heel, the DON said, "I wasn't aware it was that bad." When questioned about the sequence of events leading to the open wound on Resident 1's coccyx, the DON stated she was notified on or about 3/25/12. DON further stated "the facility system failed". The skin checks are reported on an "Event Report" and should be submitted to the DON. Review of the document titled, Event Report and dated 2/16/12 indicated the following information: > "Blanchable redness on coccyx > activity level- locomotion, walking/wheeling in wheelchair" Event Report dated 3/22/12 indicated the following information: > "Coccyx ulcer (tailbone sore) > length x width x depth measures- 4.0 cm (centimeters) x 4.0 cm x 0 cm > character of wound bed- purplish discoloration > surrounding tissue is red > nutrition/hydration intervention to manage skin problems" Event Report dated 3/24/12 indicated the following information: > "Right and left heel blisters- measurements right heel 3 cm x 3 cm, left heel 1 cm x 1 cm (Stage II pressure ulcers to each heel) > Resident complains of pain to both heels > no environmental changes" An interview with LN 2 was conducted on 4/18/12 at 10:10 a.m. When questioned about reporting to the DON or the wound physician, LN 2 stated she didn't know. When questioned about the wound and what signs of the wound would indicate she contact the DON or the wound physician, she stated she really didn't know. When questioned about the training LN 2 had in wound care, she stated none. She further stated she had been a nurse for two years and her experience was working in the office of a plastic surgeon. A review of documents titled, Physician Communication by Fax and dated 3/22/12, 3/24/12, 4/1/12, 4/6/12, and 4/12/12 indicated the following information: > "3/22/12- 1. Resident noted to have coccyx stageable deep tissue injury (Deeper, full-thickness damage to underlying tissue which may appear as purple areas or dark necrotic/dead tissue) ... 2. APP (alternating pressure relieving) Mattress... 3. Turn and reposition every 2 hours. > 3/24/12-...Resident 1 was noted to have Stage II pressure ulcers on both heels...right heel measures 3.0 cm x 3.0 cm x 0.8 cm, left heel measures 1.0 cm x 1.0 cm x 0.3 cm... > 4/1/12- Resident noted to have coccyx pressure ulcer 4.5 cm x 4.0 cm x 0.5 cm...mattress? (no evidence of a pressure relieving mattress ordered)... > 4/6/12- Increased needs for wound healing... 1. recommend add fortified to diet order (Physician agreed with request on 4/10/12) (First Registered Dietician Consult on 4/6/12) > 4/12/12- 1. coccyx pressure ulcer... 3. Bilateral heel blisters Stage II..." An interview with MD 1 was conducted on 4/18/12 at 1:05 p.m. MD 1 stated he was notified of Resident 1's wound and a consult was requested by the facility on 4/6/12. When questioned about the wound and whether this was avoidable vs unavoidable, MD 1 stated with the age of Resident 1, she was high risk for wounds but since she hadn't had a wound in the past two years in the facility, this may have been avoidable. MD 1 further stated he was unaware the skin had been reddened and blanchable for three weeks prior to opening into a Stage III pressure ulcer. MD 1 stated "In this case, the wound may have been avoidable". A continued interview with MD 1 indicated he was unaware Resident 1 had redness of the coccyx area since 2/12/12. MD 1 stated his consultation was requested on 4/6/12 when the coccyx wound was a Stage III pressure ulcer. A review of the facility's policy titled, Pressure Ulcer Risk Assessment and dated 2001 with revision of October 2010 indicated the following information: "Purpose: ...provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. General Guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure of decrease of circulation (blood flow) to that area, which destroys the tissues. 4. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. 10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment: 1. Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes. 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring. a. Staff will maintain a "skin alert", performing routine skin inspections daily... b. Nurses are to be notified to inspect the skin if skin changes are identified... 4. ...a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers." A facility's policy titled Prevention of Pressure Ulcers and dated 2001 with a revision of October 2010 indicated the following information: "General Guidelines: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. 4. Pressure ulcers are often made worse by continual pressure... 5. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, family, and addressed. General Preventive Measures: 1. Identify risk factors for pressure ulcer development. 3. For a person in a chair: a. Change position at least every hour; b. Use foam, gel or air cushion as indicated to relieve pressure. 10. Immediately report any signs of a developing pressure ulcer to the supervisor. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions..." An interview with CNA 3 was conducted on 4/18/12 at 8:48 a.m. When questioned about Resident 1, CNA 3 stated the pressure sore on Resident 1 should have never happened. CNA 3 further stated Resident 1 was so active. When questioned about Resident 1's activity, CNA 3 stated Resident 1 would self-propel her wheelchair all over the facility during the day and she loved to play the piano for the other residents in the facility. When the redness was noticed on Resident 1's bottom, we (CNAs) all were aware and the licensed nurses were alerted but there was nothing done (no treatment) to prevent the pressure sore. CNA 3 further stated Resident 1 had developed pneumonia sometime (approximately) around the end of February or first part of March and Resident 1 was in bed more. CNA 3 further stated these changes all happened around the time her skin was red and we (CNAs) had reported to the licensed staff and nothing was done to help Resident 1. When questioned about the response from the licensed staff, CNA 3 stated they (licensed staff) would say they "would take care of it", (but nothing was done). An interview with LN 3 was conducted on 4/18/12 at 3:10 p.m. When questioned about Resident 1, LN 3 stated she had provided direct care to Resident 1 and was familiar with her. LN 3 stated, "She never had skin problems when I had her on my hall." LN 3 further stated Resident 1 was active as she would self-propel in her wheelchair up and down the hallways and she loved to play the piano for the other residents.