Every finding on record at Rolling Hills Care Center

Based on observation, staff interviews and review of facility documents, the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards for food service safety when:1. Leftover previously cooked rice was not monitored for cooling;2. One sanitation solution in a red bucket was not the appropriate concentration when the Food Service Worker (FSW 2) sanitized the food preparation counter; and3. The can opener was dirty with a thick black substance on the blade. This had the potential for the growth of microorganisms which can lead to food borne illness for the 31 residents admitted to the facility1. During an observation, in the kitchen, in the reach-in refrigerator, on 5/19/26 at approximately 10:38 a.m., there was a container of cooked rice dated 5/18/26 with a use by date of 5/21/26 that was 43 degrees Fahrenheit (F). During an observation with concurrent interview with the Certified Dietary Manager (CDM) on 5/19/2026 at 2:43 p.m., CDM confirmed the rice in the reach-in refrigerator and stated the cook on the 18th should have cooled it down and wrote it down on the log. CDM showed the surveyor the cooling log and confirmed the log was blank and stated nothing has been recorded for this month. During a review of the facility document titled Food and Nutrition: 2-Stage Cooling Temperature log, undated, indicated food must be cooled from 140 degrees F to 70 degrees F within the first two hours, then from 70 degrees F to 41 degrees F within the next four hours. 2. During an observation and concurrent interview on 5/19/26 at 11:17 a.m., Food service Worker 2 (FSW 2) wiped down the food preparation counter. Surveyor asked FSW 2 to check the concentration of the sanitation bucket. FSW 2 checked the concentration of the sanitizer in the bucket and it was 0 parts per million (ppm). FSW 2 stated that she filled up the bucket 30 minutes ago and was not sure why it was not the proper concentration. FSW 2 filled up the sanitation bucket again and tested the concentration and it was 200 ppm. During a review of the sanitizer bucket log, dated May 2026, showed on 5/19/26 at 11:00 a.m. it was 200 ppm. The log showed the appropriate concentration was 200 to 400 ppm. 3. During a joint observation and concurrent interview with the Certified Dietary Manager (CDM) on 5/19/26 at 9:05 a.m., the can opener had a thick black substance on the blade. The CDM acknowledged the black substance on the blade and stated it was very dirty. The CDM stated it should be cleaned after each use. During an interview with the Dietary Manager (DM) on 5/20/26 at 9:20 a.m., DM stated when they looked at their cleaning log the can opener was not listed on it and they plan to include that piece of equipment on it now. DM stated staff have been in-serviced to clean the can opener after each use. During a review of the of facility weekly cleaning schedule dated 5/18/26, did not show can opener. During a review of the facility policy and procedures titled Sanitation Inspection dated 2026, indicated as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. The facility did not provide a policy or procedure regarding food service equipment that needs to be cleaned. During a review of the United States Food and Drug Food Code, dated 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated (a) equipment food-contact surfaces and utensils shall be clean to sight and touch. And c) nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on interview and record review, the facility failed to promote and implement an antibiotic (ATB) stewardship and surveillance program (ATBS-designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) for the use of antibiotics when the Infection Preventionist (IP) did not ensure the antibiotic surveillance log (chronological record used to continuous monitor antibiotic use) was complete and accurate to identify, track, and monitor resident antibiotic use. This failure had the potential to result in the administration of unnecessary and inappropriate antibiotic use, as well as inaccurate monitoring of antibiotic use which could lead to antibiotic-resistant organisms and inaccurate data monitoring and reporting. During a concurrent interview and record review on 5/21/26 at 3:45 p.m. with the Director of Staff Development/Infection Preventionist (DSD/IP), the DSD/IP stated she started as IP in August 2025 and shared the IP position with the Minimum Data Set Coordinator (MDSC). The DSD/IP stated included in her duty and responsibility as IP was monitoring infections in the facility and keeping track of logs. The DSD/IP reviewed the antibiotic (powerful, life-saving medicines used to treat bacterial infections) surveillance log and stated she did not have a record of the urine analysis (urine test) culture and sensitivity results (C&S-two-part lab procedure used to identify the exact cause of an infection and find the best medication to cure it) of residents who were ordered antibiotics for urinary bladder infection (UTI- bladder infection). The DSD/IP stated she did not have access to (name of company) laboratory to print the results. The DSD/IP stated she was not sure if the antibiotic ordered for residents was appropriate not knowing whether the bacteria was susceptible (vulnerable) or resistant to the medication. The DSD/IP stated she was not sure why the result was needed; residents were already ordered antibiotic medications. The DSD/IP stated she was trying to do her job the best way she can. During an interview on 5/22/26 at 9:25 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated resident's primary doctor usually orders urine test with C&S for residents with signs of bladder infections before ordering antibiotics. LVN 2 stated some primary doctor orders antibiotics before knowing the result of the urine test. LVN 2 stated it was the responsibility of the IP to update the primary doctor of the result of urine test including C&S once completed. LVN 2 stated all licensed nurses have access to the lab results and was not sure why the DSD/IP did not have access. LVN 2 stated C&S result was important to know whether the bacteria were resistant or susceptible to the antibiotic ordered. During an interview on 5/22/26 at 9:50 a.m. with the MDSC, MDSC stated she also shares the IP position, but the DSD/IP was responsible with the antibiotic surveillance log. The MDSC stated C&S result was important, we have to make sure correct antibiotic was ordered. The MDSC stated the C&S result was important to make sure the prescribed antibiotic was appropriate for the type of bacteria causing the infection. The MDSC stated infection will re-occur if bacteria were resistant to the prescribed antibiotic. The MDSC stated all licensed nurses have access to all lab results, if not available they can always call to follow-up to ensure resident was prescribed the appropriate antibiotic. During an interview on 5/22/26 at 11:15 a.m. with the Director of Nursing (DON), the DON stated the DSD/IP was responsible in ensuring the antibiotic surveillance log was accurate and complete to ensure the antibiotic ordered was appropriate to treat the bacteria causing infection. The DON stated the DSD/IP should have made sure she followed up with the C&S results to ensure appropriate antibiotic was ordered and update the primary doctor. The DON stated infections could re-occur if bacteria were resistant to the prescribed antibiotic. The DON stated she was not made aware the DSD/IP did not have access to the lab results. During an interview on 5/22/26 at 11:45 a.m. with the Assistant Administrator (AA), the AA stated he had been in the position for two years and waiting to take his test to be a licensed administrator. The AA stated his expectation was for all staff to have access to all resources they need to do their job. The AA stated, Staff have to let me or the administrator know if they have any concerns or if they need access in order for me to help them find an answer. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, dated 2025, the P&P indicated, .Infection Preventionist-utilizes expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic uses starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms . Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to: a. Action plans and/or work plans . b. Assessment forms. c. Antibiotic use protocols/algorithms. d. Data collection forms for antibiotic use, process, and outcome measures . During a review of facility document titled, Infection Preventionist, Job Description, dated 2023, the document indicated, .Develop and implements an ongoing infection prevention and control program to prevent, recognize, and control onset and spread of infections in order to provide a safe, sanitary, comfortable environment . Oversees the facility's antibiotic stewardship program . Leads the facility's Infection and Prevention Control Committee . Implements an annual infection control risk assessment process . Maintains documentation of infection prevention and control program activities . During a review of the professional reference retrieved from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html titled, The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 9/10/25, the professional reference review from The Centers for Disease Control and Prevention (CDC) stated, .standardize the practices which should be applied during the care of any resident suspected of an infection or started on an antibiotic.perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians.

Based on observation, interview and record review the facility failed to maintain an environment free of accident hazards when: 1. Oxygen safety precautions were not implemented for one of thirty two residents (Resident 36) when oxygen equipment was present in Resident 36's room and oxygen-in-use signage was not posted outside the room.This failure had the potential to expose the residents, staff, visitors and emergency responders to accident hazards, including fire or injury, due to unrecognized oxygen use and exposure to ignition sources. 2. One of seven slings (specialized fabric support used with a patient lift to safely transfer individuals with limited mobility between beds, wheelchairs, and commodes) were found with frayed edges and torn corners in the clean linen closet ready for use. This failure had the potential to cause fall and injury when used on residents requiring the use of mechanical lift for transfers. Findings: 1. During a review of Resident 36's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 36 was admitted to the facility on [DATE] with a diagnosis which included pneumonia (a lung infection that made it harder to breath because the lungs could fill with fluid or pus [a thick liquid made of germs, dead cells and the body's infection-fighting cells]) and chronic respiratory failure with hypoxia (a long term condition where the lungs did not work well enough to get enough oxygen into the body, causing hypoxia [low oxygen levels in the body]). During a review of Resident 36's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 36's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 11 indicated Resident 36 was moderately cognitively impaired. During an observation on 5/19/26 at 9:27 a.m., Resident 36 was observed in her room watching television. Resident 36's bed was in the lowest position. An oxygen concentrator was observed on the floor next to the resident's bed; however, the resident was not observed wearing oxygen at the time of observation. Resident 36 declined to participate in an interview. During an interview on 5/20/26 at 3:17 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it was important to have an oxygen-in use sign posted to alert staff, visitors, and others that oxygen was in use in the area. LVN 1 stated the sign served as a hazard warning to prevent flammable items or ignition sources from being brought into the area. LVN 1 stated if a resident was receiving oxygen, a sign should be posted on the door. LVN 1 stated the risk to the resident was that someone could enter the area, create a spark and ignite the oxygen. During an interview on 5/21/26 at 12:10 p.m. with the Infection Preventionist (IP), the IP stated there should have been an oxygen-in-use sign posted to the residents' door. The IP stated it was important to notify staff, visitors and others that oxygen was in use so appropriate caution could be taken. During a record review of Resident 36's Order Summary Report (OSR), dated 5/22/26, the OSR indicated Resident 36 had an order for nasal cannula oxygen therapy since 5/18/26. During an interview on 5/22/26 at 12:00 p.m. with the Director of Nursing (DON), the DON stated her expectation was that when a resident was receiving oxygen therapy, the resident's room would have necessary oxygen equipment available, including an oxygen concentrator, storage bag, cannula, and an oxygen-in-use sign posted on the door. The DON stated it was staff's responsibility to place the oxygen-in-use signage outside the resident's room. The DON stated the purpose of the sign was to alert staff, visitors, and emergency responders that oxygen was in use, as oxygen presented a fire hazard due to its highly flammable nature. The DON stated it was important for others to be aware of which rooms had oxygen in use in the event of a fire or exposure to an open flame. The DON stated the risk to the resident was potential fire or injury if ignition sources were brought into the area. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 2026 the P&P indicated, oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. 2. During a concurrent observation and interview on 5/21/26 at 9:11 a.m. with Laundry Aide (LA) in the laundry area, LA stated she worked full time in the facility and had been working in the laundry department for three years. LA stated she washed the sling in the washer and dried it in the dryer. The LA stated once the slings are dry she bring them in the clean linen closet ready to be used. In the clean linen closet, one sling was found with frayed edges and torn corners. The LA stated she did not inspect the slings when she placed them in the closet ready for use. The LA stated the sling was not safe for use, the torn corners and frayed edges could get bigger and residents could fall. During an interview on 5/21/26 at 8:29 a.m. with Certified Nurse Assistant (CNA) 3, CNA 3 stated she gets a sling from the clean linen closet when using a mechanical lift to transfer residents. CNA 3 stated slings with frayed edges and torn corners should be taken out of the linen closet and not made available to use. CNA 3 stated the torn corners and frayed edges could get bigger and residents could fall during transfer which could result to injury. During an interview on 5/21/26 at 8:35 a.m. with CNA 5, CNA 5 stated slings are stored in the clean linen closet and ready for use. CNA 5 stated it was important to inspect slings prior to use making sure they were safe to be use. CNA 5 stated slings with a torn corner and frayed edges when used could get bigger causing resident to fall and result in injury. During an interview on 5/21/26 at 3:19 p.m. with Environmental Director (ED), the ED stated he had only been in his position for three months. The ED stated slings after washing are air dried and not placed in the dryer. The ED stated placing the sling in the dryer could cause the sling to shrink and destroy the fabric materials. The ED stated laundry department was responsible for checking slings for any signs of wear and tear before placing them in the clean linen closet available for use. The ED stated slings with frayed edges and torn corners should have been pulled out of circulation because it was not safe to use. During an interview on 5/21/26 at 3:36 p.m. with Director of Staff Development/Infection Preventionist (DSD/IP), the DSD/IP stated staff had to make sure the appropriate sling size are used on residents. The DSD/IP stated her expectation was for staff to inspect slings for any signs of wear and tear prior to use to prevent accidents and falls. The DSD/IP stated slings placed in the linen closet meant they were available for use. The DSD/IP stated the laundry department was responsible in inspecting slings prior to placing them in the clean linen closet. During an interview on 5/22/26 at 11:05 a.m. with the Director of Nursing (DON), the DON stated her expectation was for the laundry department to inspect all the slings for any signs of wear and tear and get rid of slings if found with frayed edges and torn corners. The DON stated nursing staff should be inspecting slings prior to use and making sure sling are safe to use. The DON stated sling with signs of wear and tear like frayed edges and torn corners are not safe for use, resident could fall and sustain injury. During a review of facility's policy and procedure (P&P) titled, Safe Resident Handling/Transfers, dated 2025, the P&P indicated, . The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly . The facility will ensure there are appropriate amounts of varying sizes of slings to accommodate residents . Slings will be laundered according to manufacturer's instructions and any damaged, broken or unsafe slings will be removed from service and replaced . During a review of facility's P&P titled, Fall Prevention Program, dated 2025, the P&P indicated, . Upon admission, the nurse will complete a fall risk assessment . to determine the resident's level of fall risk. The nurse will indicate on the Evaluation the resident's fall risk and initiate interventions .Implement universal interventions that decrease the risk of resident falling, including, but not limited to: . Wheelchairs and assistive devices are in good repair .

Based on observation, interview and record review, the facility failed to post actual direct care staffing hours worked for public review for 30 of 30 residents in the facility, as required, by posting projected DHPPD (Direct Hours Per Patient Day) staffing information instead of actual hours worked for the prior day. This failure had the potential to prevent residents' family members and visitors from having accurate information regarding the actual nursing staffing levels providing care in the facility. During an observation on 5/19/26 at 9:34 a.m. the facilities publicly posted staffing document titled Rolling Hills Care Center Tuesday, May 19th, 2026 was reviewed. The posting reflected a projected census of 30, projected staff hours of 127 and projected Nurse Hours Per Patient Day (NHPPD) of 4.23. Staff were listed by shift (AM, PM and NOC [night shift]) with estimated hours and assigned staff names for licensed nursing and direct care staff. The document identified the staffing information as projected/estimated staffing hours and did not reflect the actual hours worked for the prior day. During a concurrent interview and review of the facility's Rolling Hills Care Center Tuesday, May 19th, 2026 sheet dated 5/19/26 and Appendix PP tag F732, dated 2/3/23, on 5/21/26 at 11:44 a.m. with the Infection Preventionist (IP), the IP stated staffing needs were determined based on the facility census and did not include bed hold residents. The IP stated the facility aimed to maintain Certified Nursing Assistant (CNA) hours at 2.5 or greater and nursing hours at 3.5 or greater. The IP stated she completed the staffing posting each morning, and the hours posted were projected staffing hours. The IP stated the document was prepared each morning and updated as needed, such as when a new admission occurred. The IP stated if no changes occurred, the posting remained in place until a new document was created the following day. The IP stated there was no designated area on the current posting form to reflect the actual hours worked. The IP stated she had used a form at a previous facility that reflected actual hours worked, but this practice was not utilized at the current facility. The IP stated accurate staffing information was important so residents' families and visitors could see that services were being provided appropriately. The IP stated the facility maintained documentation of the actual staffing hours worked; however, the actual staffing hours were maintained internally and were not posted daily for residents, visitors and the public to review. During the interview, Appendix PP, Tag F732, indicating the requirement to post the actual hours worked, was reviewed with the IP. The IP verbalized understanding of the regulation. During a concurrent interview and review of Appendix PP tag F732, dated 2/3/23, on 5/22/26 at 11:47 p.m. with the Director of Nurses (DON), the DON stated the facility posted expected/projected staffing hours rather than the actual hours worked. The DON stated if the facility had a total of 10 CNA's scheduled, the posted staffing reflected the predicted hours those staff were expected to cover. The DON stated the projected staffing hours were intended to meet or exceed the facilities DHPPD. The DON stated it was her expectation that projected/expected hours be included on the publicly posted staffing sheet. The DON stated it was important for residents, visitors and families to have accurate staffing information so they could determine whether sufficient staff were available to meet resident care needs. The DON stated the facility maintained a sperate staffing document where actual hours worked were tallied; however, this information was not publicly visible. During the interview, Appendix PP, Tag F732, requiring the posting of the actual hours worked, was reviewed with the DON, the DON verbalized understanding that the public staffing posting was required to reflect the actual hours worked rather than projected staffing hours. During a review of facilities policy and procedure (P&P) titled, Nurse Staffing Posting Information, dated 2025, the P&P indicated, The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: d. the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses, ii. Licensed Practical Nurses/Licensed Vocational nurses iii. Certified Nurse Aids.3. The information posted will be: b. in a prominent place readily accessible to residents, staff and visitors.

Based on observation, staff interview and review of facility documents, the facility failed to ensure menus were followed for the lunch meal on 5/19/26 when the facility served: 1) A #12 scoop (1/3 cup) of cauliflower instead of #8 (1/2 cup) of peas for five residents (Residents 4, 26, 35, 37 and 20);2) One resident on a soft and bite sized diet (Resident 25) received 1/3 cup instead of 1/2 cup of cauliflower; and3) Four residents on a renal diet (Resident 35, 37, 20 and 28) 1/2 cup instead of 1/3 cup of oven browned potatoes. This failure has the potential to result in residents not meeting the micronutrients (referred to as vitamins and minerals, are vital to healthy development, growth, disease prevention, and well-being) in the physician prescribed therapeutic diets which could compromise nutritional and medical status.During an observation of the lunch meal service, in the dining room, on 5/19/26 at 11:43 a.m., there were pans of the following in the steam table ( a commercial food service kitchen appliance to keep food warm, it is equipped with wells that hold heated water or steam) pork chops with sauteed onions, oven browned potatoes with a #8 scoop, green peas with a #8 scoop and steamed cauliflower with a #12 scoop. 1. During a review of the lunch menu for 5/19/26, it indicated for the regular and puree diet the following: smothered pork chop, three ounces and #8 scoop, respectively; #8 scoop for oven browned potatoes and # 8 scoop for seasoned green peas. For the liberalized renal diet it indicated a smothered pork chop, three ounces, #12 scoop oven browned potatoes, and #8 scoop seasoned green peas. During an observation of the lunch meal service, in the dining room, on 5/19/26 starting at 11:43 a.m., [NAME] 1 gave Food Service Worker 1 (FSW 1) six bowls of puree food items to put on Resident 26 and 4's meal trays. Surveyor asked FSW 2 to open the covered bowls. Puree cauliflower, potatoes and pork were in the bowls. (Cross Reference F804 and F805). During a review of Resident 26's meal ticket showed a consistent carbohydrate (CCHO- a diet designed to stabilize blood sugar levels by eating the exact same amount of carbohydrates at every meal) puree diet. The bowls of puree cauliflower, potatoes, and pork were placed on the lunch meal tray. During a review of Resident 4's meal ticket showed a puree diet with mildly thick liquids (flow like a thick cream soup or runny honey, recommended for people with swallowing difficulties). The bowls of puree cauliflower, potatoes, and pork were placed on the lunch meal tray. During the lunch meal observation in the dining room on 5/19/26, starting at 11:43 a.m., [NAME] 1 was scooping and serving cauliflower, pork and potatoes for Residents 35, 27, and 20. During a concurrent observation and review of Resident 35, 37 and 20's meal tickets indicated a liberalized renal diet. 2. During the lunch meal observation in the dining room on 5/19/26, starting at 11:43 a.m., [NAME] 1 was scooping and served #12 scoop of cauliflower to Resident 25's plate on the lunch tray. A concurrent review of Resident 25's meal ticket indicated a , no added salt, soft and bite sized diet. During a review of the lunch menu for 5/19/26 indicated for a soft and bite sized diet there were to get #8 scoop of bite sized smothered pork chop with puree gravy, #8 scoop oven browned potatoes, #8 bite sized soft chef's vegetable of choice. 3. During a review of the lunch menu for 5/19/26, it indicated for the liberalized renal diet a smothered pork chop, three ounces, #12 scoop oven browned potatoes, and #8 scoop seasoned green peas. During the lunch meal observation in the dining room on 5/19/26, starting at 11:43 a.m., [NAME] 1 was scooping and served #8 scoop of oven browned potatoes for Residents 35, 37, 20 and 28 and placed them on the plates and trays in the meal cart. During a concurrent observation and review of Resident 35, 37 and 20's meal tickets indicated a liberalized renal diet. Resident 35, 37 and 20 received #8 scoop of oven browned potatoes, #12 scoop of cauliflower, and a pork chop. During a review of Resident 28's meal ticket showed a liberalized renal, large portion diet and disliked vegetables. Resident 28's received a hamburger and #8 scoop of potatoes. During an interview once lunch meal service was completed with [NAME] 1 on 5/19/26 at 12:05 p.m., [NAME] 1 confirmed she used #12 scoop for cauliflower and #8 scoop for oven brown potatoes. During a concurrent review of the lunch menu with [NAME] 1, [NAME] 1 confirmed that the renal diet should have gotten #12 scoop of potatoes and that she put in the incorrect scoop in the cauliflower and potatoes. During an interview with the Registered Dietitian (RD) on 5/20/26 at 2:04 p.m., RD stated her expectation is for staff to follow menus and portion sizes. RD acknowledged that the menus need to be near the lunch meal service for them to reference during meal service. During a review of the facility policy and procedure titled Food Preparation Guidelines dated 2026, indicated the cook shall prepare menu items following the facility's written menus.

Based on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 15) was informed in advance, by the physician of the risks and benefits of proposed treatment when Resident 15 did not have a signed physician informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) prior to the administration of venlafaxine HCL (an antidepressant prescription medication used to relieve symptoms of depression such as feelings of sadness or loss of interest in activities). This failure resulted in Resident 15 receiving medication without being informed of the risks, benefits, or alternatives, limiting the resident's ability to make informed decisions about their care.During a concurrent interview and record review on 5/21/26 at 4:11 p.m. with the Director of Nursing (DON), Resident 15's Psychotherapeutic Drug Informed Consent Form (PDIC) for venlafaxine HCL dated 5/5/26, was reviewed. The PDIC was missing the physician's signature in the prescriber signature section and was instead electronically signed by Licensed Vocational Nurse (LVN) 3. The DON stated PDIC's are signed by the resident or responsible party and the prescribing physician after the resident is informed of the risks, benefits and alternatives. The DON stated the PDIC for venlafaxine HCL was signed by LVN 3 and Resident 15. The DON stated there was not a physician's signature on the PDIC. The DON stated the expectation was the PDIC should be signed by the physician. The DON stated it was important to have a completed PDIC because it showed that the resident was properly informed of the risks, benefits and alternatives. The DON stated it was the doctor's responsibility to inform residents of medication risks, benefits and alternatives. The DON stated without a signature on the Resident 15's PDIC there was no documentation the resident was informed of the side effects.During a review of Resident 15's admission Record (AR), dated 5/21/26, the AR indicated, Resident 15 was admitted to the facility on [DATE] with the diagnosis of .major depressive disorder, recurrent.During a review of Resident 15's Order Summary Report (OSR), dated 5/21/26, the OSR indicated, Resident 15 had a physician's order for . Venlafaxine HCL oral tablet 50 [milligram -unit of measurement] . Give 1 tablet by mouth one time a day related to Major Depressive Disorder .During a review of the facility's policy and procedure (P&P) titled Use of Psychotropic Medications, dated 2026, the P&P indicated, . Prior to initiating . a psychotropic medication, the resident . must be informed of the benefits, risks, alternatives . in advance of such initiation . The facility will document that the resident . was informed in advance of the risks and benefits . in a format the facility deems to use (e.g. written consent form.) .

Based on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for three of five sampled residents (Residents' 20, 21, and 35) when: 1. Resident 20 and 35 did not have a care plan for Enhanced Barrier Precaution (EBP-refer to an infection control intervention designed to reduce transmission of multi-resistant drug organisms that employ targeted gown and gloves use during high contact resident care activities) secondary to having dialysis access port. This failure placed Resident 20 and Resident 35 at risk of cross-contamination (unintentional transfer of harmful bacteria, virus, or allergens from one surface, object, or food to another) and not meeting their needs and care. 2. Resident 21's duloxetine (medication used to treat depression) medication was ordered on 3/10/26, care plan was not initiated until 4/29/26. This failure placed Residents 20, 21 and 35 at risk for harm by not identifying and monitoring side effects of duloxetine. 1. During a concurrent observation and interview on 5/20/26 at 11:10 a.m. in Resident 20's room, Resident 20 was observed sitting at the edge of his bed, appropriately dressed and well groomed. Resident 20 stated he goes to dialysis three days a week every Tuesday, Thursday and Saturday. Resident 20's dialysis port on his right chest with gauze (thin, translucent fabric with loose, open weave, most commonly made of cotton) and medipore tape (hypoallergenic, soft cloth surgical tape). During a review of Resident 20's admission Record [AR-a document containing resident profile information], dated 5/22/26, the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), shortness of breath and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent observation and interview on 5/19/26 at 9: 36 a.m. in Resident 35's room, Resident 35 stated he goes to dialysis every Tuesday, Thursday and Saturday. Resident 35's fistula (an abnormal tunnel or connection between two organs, vessels, or tubes) was on his left upper arm. Resident 35 stated only dialysis staff checked the site. During a review of Resident 35's AR dated 5/22/26, the AR indicated Resident 35 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD- irreversible kidney failure), chronic obstructive pulmonary disease (COPD-chronic lung disease causing difficulty in breathing) and hyperkalemia (too much potassium in the blood). During a concurrent interview and record review on 5/21/26 at 9:16 a.m. with Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 20's clinical record and stated Resident 20 was admitted to the facility on [DATE]. The MDSC stated Resident 20 was a dialysis resident and was an EBP. The MDSC stated she did not find a care plan for EBP and there should have been. The MDSC reviewed Resident 35's clinical record and stated Resident 35 was admitted to the facility on [DATE] and the EBP care plan was initiated 5/20/26. The MDSC stated it was the responsibility of the Director of Staff Development/Infection Preventionist (DSD/IP) to ensure there was a care plan in place. The MDSC stated a care plan was important in order for nursing staff to care for residents and monitor their conditions. 2. During concurrent observation and interview on 5/19/26 at 9:07 a.m. during the initial tour in Resident 21's room, Resident 21 was lying in bed watching TV. Resident 21 stated he had been in the facility for two months and was working with therapy for a broken left hand/arm sustained from a fall at home. Resident 21 stated he gets out of bed everyday to work with therapy and sometimes eats in the dining room but preferred eating in his room. During a review of Resident 21's AR dated 5/21/26, the AR indicated Resident 21 was admitted to the facility on [DATE] with diagnoses which included depression (persistent sadness, loss of interest in activities, and an inability to experience joy), fracture of shaft of left ulna (broken forearm) and muscle weakness. During a review of Resident 21's clinical record titled, Order Details, dated 5/22/26, the Order Details indicated, Duloxetine HCl [hydrochloride] Oral capsule Delayed Release Particles 60 MG [milligram-unit of measurement] Give 60mg by mouth at bedtime for m/b [manifested by] Self Isolation related to Depression, Unspecified . During a review of Resident 21's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 21's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognitive status) 0-15 scale (0-6- severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 14 out of 15 which indicated Resident 21 had no cognitive deficit. During a concurrent interview and record review on 5/21/26 at 2:09 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 21's clinical record. LVN 1 stated Resident 21 was admitted to the facility on [DATE] with the duloxetine medication. LVN 1 stated Resident 21's duloxetine care plan was initiated on 4/29/26, LVN 1 stated care plan should have been initiated within 24 hours of admission. LVN 1 stated care plan was every licensed nurses responsibility and it provide nursing staff guidance on how to care for residents. During an interview on 5/22/26 at 9:03 a.m. with LVN 2, LVN 2 stated care plans are the responsibilities of all licensed nurses. LVN 2 stated care plans directs nursing staff on how to take care of residents and to monitor for any side effects of medications and complications. LVN 2 stated care plans should be initiated as soon as a medication order was received. During an interview on 5/21/26 at 3:45 p.m. with Director of Staff Development/Infection Preventionist (DSD/IP), the DSD/IP stated all residents with medical device such as catheter, dialysis port, tube feeding and residents with wounds are automatically placed on EBP. The DSD/IP stated residents on EBP should be care planned right away on admission and followed up by IP. During an interview on 5/22/26 at 10:52 a.m. with the Director of Nursing (DON), the DON stated her expectation was to ensure a care plan was initiated as soon as an issue occurred or identified. The DON stated care plans should be initiated immediately for any new medications received. The DON stated for new admissions in the facility and infection control issues are identified, the admitting nurse should initiate a care plan immediately within 24 hours then the Infection Preventionist will follow-up. During a review of facility policy and procedure (P&P) titled, Comprehensive Care Plans, dated 2025, the P&P indicated, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes . The comprehensive care plan will describe . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. Any services that would otherwise be furnished . The resident's goals for admission, desired outcomes, and preferences . Resident specific interventions that reflect the resident's needs and preferences . During a review of facility policy and procedure (P&P) titled, Hemodialysis, dated 2025, the P&P indicated, . The staff will ensure that appropriate Personal Protective Equipment [PPE] id worn and follow current infection control practices when assessing dialysis access sites .

Based on observation, interview and record review, the facility failed to meet professional standards of practice for two of five sampled residents (Resident 20 and Resident 35) when Resident 20 and Resident 35 did not have an order for Enhance Barrier Precautions (EBP-refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities) upon admission to the facility due to presence of hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) catheters. This deficient practice placed Resident 20 and resident 35 at risk of cross contamination which could lead to more serious health conditions. During a concurrent observation and interview on 5/20/26 at 11:10 a.m. in Resident 20's room, Resident 20 was observed sitting at the edge of his bed, appropriately dressed and well groomed. Resident 20 stated he goes to dialysis three days a week every Tuesday, Thursday and Saturday. Resident 20's dialysis port on his right chest with gauze (thin, translucent fabric with loose, open weave, most commonly made of cotton) and medipore tape (hypoallergenic, soft cloth surgical tape). During a review of Resident 20's admission Record [AR-a document containing resident profile information], dated 5/22/26, the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), shortness of breath and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing. During a concurrent observation and interview on 5/19/26 at 9: 36 a.m. in Resident 35's room, Resident 35 stated he goes to dialysis every Tuesday, Thursday and Saturday. Resident 35's fistula (an abnormal tunnel or connection between two organs, vessels, or tubes) on his left upper arm. Resident 35 stated only dialysis staff checked the site. No EBP precautions observed on the door. During a review of Resident 35's AR dated 5/22/26, the AR indicated Resident 35 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD- irreversible kidney failure), chronic obstructive pulmonary disease (COPD-chronic lung disease causing difficulty in breathing) and hyperkalemia (too much potassium in the blood). During a concurrent interview and record review on 5/21/26 at 9:20 a.m. with Minimum Data Set Coordinator (MDSC), the MDSC reviewed Resident 20 and Resident 35's clinical records. The MDSC stated Resident 20 was admitted to the facility on [DATE] and goes to dialysis. The MDSC stated she did not find Resident 20's order for EBP and there should be. The MDSC stated Resident 35 was admitted to the facility on [DATE] and goes to dialysis. The MDSC stated Resident 35's EBP order was dated 5/20/26, the MDSC stated, the order should have been placed on admission. The MDSC stated the DSD/IP was in charge of making sure there was an order for EBP in place. During a concurrent interview and record review on 5/21/26 at 3:45 p.m. with the Director of Staff Development/Infection Preventionist (DSD/IP), Resident 20 and Resident 35's clinical records were reviewed. The DSD/IP stated Resident 20 and Resident 35 goes to dialysis three days a week. The DSD/IP stated Resident 20 and Resident 35 should have been an order for EBP on admission and placed on EBP immediately to ensure safety and prevent cross contamination (unintentional transfer of harmful bacteria, virus, or allergens from one surface, object, or food to another). The DSD/IP stated the admission nurse should have made sure to include an order for EBP when Resident 20 and Resident 35 were admitted to the facility then the IP will review and follow-up. The DSD/IP stated any residents with medical devices like dialysis port, catheter and wounds are automatically placed on EBP. During an interview on 5/22/26 at 9:10 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated any residents with wounds, dialysis port and catheters should be placed on EBP. LVN 2 stated admission nurse are responsible in ensuring order for EBP was in placed on admission. LVN 2 stated the DSD/IP was responsible in reviewing new admissions and EBP orders was in-placed for residents meeting criteria. During an interview on 5/22/26 at 11:05 a.m. with the Director of Nursing (DON), the DON stated her expectation was for the admission nurse to ensure EBP order was in placed for any residents with medical devices or lines like dialysis ports and wounds and not wait for the IP. The DON stated the night nurse then followed up with the admission. The DON stated the IP follow-up and ensured there was an order in placed. The DON stated new admissions are reviewed in the morning meetings to ensure resident records are accurate and complete. The DON stated it was important to ensure an order was in placed to prevent cross contamination which could lead to more serious health conditions. During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, dated 2025, the P&P indicated, .An order for enhanced barrier precautions will be obtained for residents with any of the following .indwelling medical devices [ .hemodialysis catheters] even if the resident is not known to be infected . The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education . Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk .

Based on interview and record review, the facility failed to act upon a Medication Regimen Review (MMR) irregularity for one of seven sampled residents (Resident 24) when the facility's Consultant Pharmacist recommended Resident 24's calcium (a mineral needed for bones, teeth, muscles, and nerves) administration time be changed to 10:00 a.m. or later due to medication interaction with levothyroxine (medication that replaces the natural thyroid hormone the body is missing and must be taken on an empty stomach), scheduled for 6:00 a.m. Resident 24's calcium administration time was instead changed to 8:00 a.m. without obtaining the required physician documentation.These failures resulted in the Consultant Pharmacists recommendations not being reviewed by the doctor and the potential to reduce the effectiveness of levothyroxine, placing Resident 24 at risk for the return of hypothyroid (a condition where the thyroid gland does not produce enough thyroid hormones) symptoms including weight gain, fatigue or cold intolerance.During a concurrent interview and record review on 5/21/26 at 4:23 p.m. with the Director of Nursing (DON), Resident 24's Consultant Pharmacist Medication Regimen Review (CPMRR), dated 12/23/25, was reviewed. The CPMRR indicated, the Consultant Pharmacist recommended changing the administration time of Resident 24's calcium to 10:00 a.m. or later due to interactions with her levothyroxine medication. The DON stated when a recommendation is received from the Consultant Pharmacist during a medication regimen review, she reviews the nursing aspect of the recommendation and then faxes the CPMRR to the physician. The DON stated the physician will write on the CPMRR if he agrees with the recommendation (a new order is written for the resident) or disagrees with the recommendation then send it back to the facility. The DON stated when she received a new order she adds the new order into the resident's electronic health record (EHR). The DON stated she was responsible for following up on all recommendations.During a concurrent interview and record review on 5/22/26 at 8:45 a.m. with the DON, Resident 24's Medication Administration Record (MAR), dated 01/2026 was reviewed. The MAR indicated, Resident 24's calcium administration time was changed on 1/4/26 from 10:00 a.m. to 8:00 a.m. The DON stated she was unable to locate documentation that the Physician was aware of the Consultant Pharmacist recommended Resident 24's calcium administration time change to 10:00 a.m. or later. The DON stated the MAR reflected a change in administration time from 10:00 a.m. to 8:00 a.m. which was two hours earlier than recommended. The DON stated that taking levothyroxine and calcium to close together may decrease Resident 24's absorption of the thyroid medication and it could be ineffective. During a review of Resident 24's admission Record (AR), dated 5/27/26 the AR indicated, Resident 24 was admitted to the facility on [DATE] with diagnosis including .Hypothyroidism, unspecified. during her stay.During a review of Resident 24's Order Summary Report (OSR), dated 5/21/26, the OSR indicated, Resident 24 had an active order for .Calcium/D3 [vitamin D3] oral tablet 500-5 mg [milligram - unit of measurement -mcg [microgram - unit of measurement] .Give 1 tablet by mouth one time a day for supplement. and .[levothyroxine] oral tablet.Give 100mcg by mouth in the morning for Hypothyroid.During a review of the facility's policy and procedure (P&P) titled Medication Regimen Review (MRR), dated 2026, the P&P indicated, .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.During a review of the facility's P&P titled Addressing Medication Regimen Review Irregularities (AMRRI), dated 2026, the P&P indicated, .It is the policy of this facility to provide Medication Regimen Review (MRR) for each resident in order to identify irregularities and respond to those irregularities in a timely manner.the reports must be acted upon.The attending physician must document in the resident's medical record that the identified irregularity has been reviewed.During a professional reference review retrieved from National Library of Medicine/National Center for Biotechnology Information found at https://pmc.ncbi.nlm.nih.gov/articles/PMC3092723/, titled Absorption of Levothyroxine When Coadministered with Various Calcium Formulation, dated 05/11, the professional reference review indicated .Coadministration of each of the three calcium preparations significantly reduced levothyroxine absorption by about 20%-25% compared with levothyroxine given alone.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 37) was free from unnecessary drugs when Resident 37's use of anticoagulant medication (refers to class of medication that are used to prevent clot extension and formation) had no monitoring for side effects. This failure resulted in Resident 37 receiving medication and had the potential to experienced side effects of medication without proper monitoring. During a concurrent observation and interview on 5/19/26 at 9:05 a.m. with Resident 37 in the hallway outside of room [ROOM NUMBER]. Resident 37 was observed sitting up in his wheelchair and was assisted by staff, left foot wrapped with gauze dressing (medical cloth patch or gauze made of loosely woven cotton), Resident 37 stated his left small toe was surgically amputated. During a review of Resident 37's admission Record, (AR-a document containing resident profile information), dated 5/21/26, the AR indicated Resident 37 was admitted to the facility on [DATE] with diagnoses which included absence of other left toe(s), chronic (long lasting) embolism (blockage of a blood vessel) and thrombosis (formation of a blood clot inside a blood vessel or the heart, which restricts or blocks the normal flow of blood) of other specified veins. During a review of Resident 37's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 37's Brief Interview for Mental Status (BIMS-screening tool sed to assess resident cognitive status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit)assessment score was 15 out of 15 which indicated Resident 37 had no cognitive deficit. During a review of Resident 37's clinical document titled, Order Summary Report, dated 5/22/26, the Order Summary Report indicated, . [brand name] Oral Tablet 20 MG (milligram- unit of measurement) . related to CHRONIC EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS . Order Date: 5/14/26, Start Date: 5/15/26 . During a concurrent interview and record review on 5/22/26 at 9:03 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 37's clinical record and stated she was familiar with Resident 37's care. LVN 2 stated Resident 37 was admitted to the facility on [DATE] and was admitted with the anticoagulant medication. LVN 2 stated she did not find an order for monitoring for the side effects of the anticoagulant medication. LVN 2 stated there should have been monitoring order in place but there was none. LVN 2 stated monitoring was important to monitor for presence of bleeding and any side effects like presence of blood in the stools and urine. During a concurrent interview and record review on 5/22/26 at 9:45 a.m. with Minimum Data Set Coordinator (MDSC), Resident 37's clinical record was reviewed. The MDSC stated she did not find monitoring order for Resident 37's anticoagulant order. The MDSC stated it was important to monitor use of anticoagulant to monitor any signs of bleeding which could lead to serious health problems. During an interview on 5/22/26 at 11:05 a.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses to ensure monitoring of anticoagulant use was in placed as soon as medication order was received. The DON stated, Resident 37 could have bleeding issues staff are not aware of which could lead to more serious health issues. The DON stated it was important to monitor anticoagulant use to monitor any signs and symptoms of bleeding to prevent complications. During a review of facility policy and procedure (P&P) titled High Risk Medications- Anticoagulant, dated 2026, the P&P indicated . Anticoagulants shall be prescribed by a physician or other authorized practitioner with clear indications for use . Routine labs, including baseline and subsequent labs shall be ordered for each resident requiring anticoagulant medication . The resident's plan of care shall alert staff to monitor adverse consequences .

Based on interview and review of facility documents, the facility failed to ensure there was a full time qualified Dietary Manager (DM) met state requirements, California Health and Safety Code (CA HSC) 1265.4(b) when the Registered Dietitian (RD) was not employed full-time. This failure resulted in puree food not in the proper form, puree foods not being prepared by methods that conserve nutritive value and flavor, menus not being followed and food stored not being monitored for cool down procedures for the 31 residents admitted to the facility. (Cross Reference F803, 804, 805, 812). During a review of the California Health and Safety Code (CA HSC) 1265.4 (a), If the facility employs a RD less than full-time, they shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. 1265.4 (b) stated, the dietetic services supervisor shall have completed one of seven recognized pathways, two of which include the completion of an education program approved by the Dietary Managers Association and successful completion of a certifying exam. In addition to the successful completion of a certifying exam the qualified manager must have received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. During an interview on 5/19/26 at 8:42 a.m with the DM and the Certified Dietary Manager (CDM), the CDM stated she is the CDM but only works at the facility part time or as needed but helps with the clinical only. The DM stated she is currently enrolled in a program, is about halfway complete and under supervision of the RD. DM stated the RD is usually at the facility once a week. During a review of DM personnel file on 5/20/26 at 10:11 a.m., the DM job description indicated the required qualifications was a certification as a dietary manager and must also meet State requirements for food service or dietary managers signed and dated on 7/30/25 by DM and administrator signature and dated 7/31/25. During an interview with the RD on 5/20/26 at 2:04 p.m., RD stated that about two weeks ago, this is her only building and the plan is for her to be at the facility at least eight hours a week but it may be more hours per week depending on the needs. During an interview with the Administrator (ADM) on 5/20/26 at 3:19 p.m., ADM stated the RD works in the building about eight hours a week and the CDM got another job so only works as needed. ADM stated the DM is in school and not qualified at this time.

Based on observation, interview and review of facility documents, the facility failed to ensure puree foods were prepared by methods that conserve nutritive value and flavor when [NAME] 1 made puree roasted potatoes and cauliflower were prepared with water for two residents (Residents 4 and 26) that were on a physician's prescribed puree diet. This can result in residents receiving improper nutrients from the food which can result in a decrease in meeting the nutrient needs which can further compromise their medical status. During an observation in the kitchen and concurrent interview with [NAME] 1 on 5/19/26 at 10:21 a.m, [NAME] 1 scooped two #8 (1/2 cup) scoop portions into blender then added, #24 scoop (1-1/3 ounces) butter, and five ounces of hot water from hot water dispenser spicket then blended. The measuring cup contained 8 ounces of hot water then after hot water was poured into blender there were three ounces of hot water left. [NAME] 1 used plastic spoon to stir then poured into two bowls. The puree potatoes had flecks of skin present, appeared very thin and watery. [NAME] 1 stated she is looking for creamy texture and only uses plastic spoon to stir food. [NAME] 1 stated after it sits she will determine if any thickener is needed. [NAME] 1 stated there was not a way to determine if food was the proper consistency and was just looking for creamy. During an observation in the kitchen and concurrent interview with [NAME] 1 on 5/19/26 at 10:41 a.m., while preparing the puree cauliflower. [NAME] 1 used two #8 scoops of cooked cauliflower, three ounces of hot water, two pumps of thickener and #24 scoop of butter. Cauliflower appeared to be thin. During a lunch meal observation, in the dining room, on 5/19/26 starting at 11:43 a.m., six bowls of puree food items were on the steam table. A concurrent observation and record review of the lunch meal ticket for Resident 26 and 4 at this time, indicated a consistent carbohydrate (CCHO - a diet designed to stabilize blood sugar levels by eating the exact same amount of carbohydrates at every meal) puree diet with thin liquids and a no added salt, puree diet with mildly thick liquids (flow like a thick cream soup or runny honey, recommended for people with swallowing difficulties) respectively. [NAME] 1 gave three bowls of puree foods to Food Service Worker (FSW 1) to place on the trays for the residents respectively. The puree strawberry crisp was on the trays in the cart. During a review of Resident 4's face sheet (FS), dated 5/20/26, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included dysphagia, unspecified (difficulty swallowing), mild protein-calorie malnutrition (early-stage nutritional deficiency where insufficient intake of calories and protein leads to subtle physical or metabolic changes). During a review of Resident 26's FS, dated 5/20/26, indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included dysphagia oropharyngeal phase (a medical condition characterized by difficulty initiating a swallow and transferring food or liquid from the mouth into the throat and esophagus), and moderate protein-calorie malnutrition (a nutritional deficit where a person takes in 50% to 75% of their energy needs leading to mild to moderate weight loss and some loss of muscle mass). During a review of the pureed oven browned potatoes recipe, dated 2026, indicated to place the number of servings needed from the regular prepared recipe, and blend in a food processor until smooth. If the consistency needs thinning: gradually add an appropriate hot liquid (i.e. broth, gravy, hot milk, sauce or reserved cooking liquid). During a review of the pureed cauliflower recipe dated 2026, it indicated to place the prepared vegetables and margarine in food processor and blend until smooth. It indicated under note: any liquid specified in the recipe is a suggested amount if needed and some recipe items will require no liquid added to achieve the desired consistency. It indicated if product needs thinning to gradually add an appropriate amount of liquid (NOT WATER). During an interview with the Registered Dietitian (RD) on 5/20/26 at 2:04 p.m., RD stated that water should never be used when preparing puree foods and the staff can use either milk, margarine, broth, gravy or sauce. RD stated using five ounces of water seemed like a lot for just two portions of puree and that would affect the nutritive value of the food. During a review of the facility Diet Manual for Puree diet, dated 2022, indicated to never use water as the liquid added to a pureed item. During a review of the facility policy and procedure titled Food Preparation Guidelines dated 2026, indicated the policy of the facility to prepare foods in a manner to preserve or enhance a residents' nutrition and hydration status. It indicated the cook shall prepare menu items following the facility's standardized recipes and food shall be prepared by methods that conserve nutritive value, flavor and appearance.

Based on observation, staff interviews and review of facility documents, the facility failed to ensure puree food was in the proper form for two sampled residents (Residents 4 and 26) on their lunch meal tray on 5/19/26. This failure has the potential to result in choking (when the airway is obstructed by food, drink, or foreign objects) for Residents 4 and 26 who were on the physician prescribed therapeutic diet. During an observation in the kitchen and concurrent interview with [NAME] 1 on 5/19/26 at 10:21 a.m, [NAME] 1 scooped two #8 (1/2 cup) scoop portions into blender then added, #24 scoop (1-1/3 ounces) butter, and five ounces of hot water from hot water dispenser spicket then blended. The measuring cup contained 8 ounces of hot water then after hot water was poured into blender there were three ounces of hot water left. [NAME] 1 used plastic spoon to stir then poured into two bowls. The puree potatoes had flecks of skin present, appeared very thin and watery. [NAME] 1 stated she is looking for creamy texture and only uses plastic spoon to stir food. [NAME] 1 stated after it sits she will determine if any thickener is needed. [NAME] 1 stated there was not a way to determine if food was the proper consistency and was just looking for creamy. During an observation in the kitchen and concurrent interview with [NAME] 1 on 5/19/26 at 10:41 a.m., while preparing the puree cauliflower. [NAME] 1 used two #8 scoops of cooked cauliflower, three ounces of hot water, two pumps of thickener and #24 scoop of butter. Puree cauliflower appeared a thin consistency. No testing of the puree cauliflower was done by [NAME] 1. During an observation, in the kitchen, on 5/19/2026 at 10:50 a.m., with a concurrent interview with Food Service Worker 2 (FSW 2), FSW 2 stated she is making dessert for two residents on the puree diet. Observed FSW 2 used two little plastic cups previously portioned of strawberry crisp. The cups were not completely filled and crips were put in small food processor with 2% milk not measured and a 1/2 pump food thickener. Then processed. FSW 2 stated she was looking for pudding consistency. FSW 2 confirmed she just looked for the consistency of pudding and she did not test it any way. FSW 2 stated she would just eye the milk to determine how much was needed when preparing the puree strawberry crisp. FSW 2 stated she thought it needed some more thickener and stated she was using another 1/2 pump. Observed FSW 2 then blend more then pour half of the mixture in two swirl cups. The cups were halfway full on the counter. During an observation and concurrent interview on 5/19/26 at 11:01 a.m., the Certified Dietary Manager (CDM) asked FSW 2 if she had measured the puree strawberry crisp. FSW 2 stated she measured the amount that was put in the food processor. Surveyor asked CDM to measure the amount in the swirl cups of puree strawberry crisp. The CDM used a spatula and put into a #8 scoop and it was about one ounce short of filling the scoop. The CDM told FSW 2 to make more strawberry crisp puree. FSW 2 did the same method to prepare more. Once completed she used a #8 scoop to portion both cups with puree strawberry crisp. It was unclear if the puree strawberry crisp was the proper consistency. During a lunch meal observation, in the dining room, on 5/19/26 starting at 11:43 a.m., six bowls of puree food items were on the steam table. A concurrent observation and record review of the lunch meal ticket for Resident 26 and 4 at this time, indicated a consistent carbohydrate (CCHO - a diet designed to stabilize blood sugar levels by eating the exact same amount of carbohydrates at every meal) puree diet with thin liquids and a no added salt, puree diet with mildly thick liquids (flow like a thick cream soup or runny honey, recommended for people with swallowing difficulties) respectively. [NAME] 1 gave three bowls of puree foods to food service worker (FSW 1) to place on the trays for the residents respectively. The puree strawberry crisp was on the trays in the cart. During a review of Resident 4's face sheet (FS), dated 5/20/26, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included dysphagia, unspecified (difficulty swallowing). During a review of Resident 26's FS, dated 5/20/26, indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included dysphagia oropharyngeal phase (a medical condition characterized by difficulty initiating a swallow and transferring food or liquid from the mouth into the throat and esophagus). During a review of the pureed oven browned potatoes recipe, puree cauliflower recipe, and puree strawberry peach crisp recipe, dated 2026, all indicated to perform appropriate International Dysphagia Diet Standardization Initiative (IDDSI) testing to ensure texture standards are met. During an interview with the Registered Dietitian (RD) on 5/20/26 at 2:04 p.m., RD stated that she expects staff to test for consistency as according to IDDSI and to do the spoon test after making the puree foods. RD stated she trained staff twice on the IDDSI diets and testing even showing videos as well as completed one on one training with them. RD stated it is her expectation that staff follow recipes. During a review of the facility in-services dated 3/2/26, indicated the subjects covered were IDDSI framework, what is the fork test, drink and food levels that included puree. It indicated names and signatures of kitchen staff present. FSW 2 was present, however, [NAME] 1 was not. No evaluation of competency was provided by the facility from the in-service. During a review of the facility in-service dated 12/19/25, indicated subjects covered were new recipes and diets, IDDSI. It indicated the summary and conclusion was to learn and understand new diets, textures and recipes. [NAME] 1 and FSW 2 were present. No evaluation of competency of staff was provided by the facility for the in-service. During a review of the IDDSI framework and detailed definitions, dated April 2026, indicated under the Puree Extremely Thick level 4, indicated under description/characteristics that it shows some very slow movement under gravity but cannot be poured, falls off spoon in a single spoonful when tilted and continues to hold its shape on a plate. It indicated to use IDDSI testing methods to decide if the food meets IDDSI level 4. It indicated for a fork drip test that the sample sits in a mound/pile above the fork; a small amount may flow through and form a short tail below the fork tines/prongs but it does not flow or drip continuously through the prongs of a fork. It indicated under the spoon tilt test, that the food is cohesive enough to hold its shape on the spoon and a full spoonful must plop off the spoon if the spoon is titled or turned sideways; a very gentle flick (using only fingers and wrist maybe necessary to dislodge the sample from the spoon, but the same should slide off easily with very little food left on the spoon. It further indicated that a thin film remaining on the spoon is acceptable however you should still be able to see the spoon through the thin film and the sample should not be firm and sticky. During a review of the facility policy and procedure titled Food Preparation Guidelines, dated 2026, indicated food shall be provided in a form (i.e.pureed) that meets each resident's individual needs.

Based on interview and record review, the facility failed to maintain accurate and confidential medical records in accordance with accepted professional standards and practices for one of five sampled residents (Resident 15) when Resident 15's electronic health record (EHR) contained annual History and Physicals (H&P - A comprehensive assessment of a person's medical history), that belonged to five different residents (Residents 6, 17, 24, 40, and 41).These failures resulted in the compromised accuracy of Resident 15's medical records and violated the confidentiality of Protected Health Information (PHI - any health-related information that identifies a specific person) for Residents 6, 17, 24, 40, and 41.Findings: During a concurrent interview and record review on 5/21/26 at 3:44 p.m. with Medical Records/Activities Director (MR/AD), Resident 15's EHR document titled Annual H&P Examination, dated 12/28/2025, was reviewed. Resident 15's Annual H&P Examination included H&P's that belonged to Residents 6, 17, 24, 40 and 41. MR/AD stated the records for Residents 6,17, 24, 40 and 41 were uploaded into the wrong resident's chart. MR/AD stated the H&P records for Residents 6, 17, 24, 40 and 41 should not have been in Resident 15's EHR. MR/AD stated the expectation at the facility was that each resident documents uploaded into the EHR should be verified through the review of the resident's name and date of birth (DOB) prior to uploading into the EHR. MR/AD stated private information about Residents 6, 17, 24, 40 and 41 could have been given to the wrong providers or facilities. MR/AD stated when Residents 6, 17, 24, 40 and 41's health information was found in Resident 15's EHR it was a Health Insurance Portability and Accountability Act (HIPAA - A law that is meant to keep your personal medical information private and secure) violation.During a concurrent interview and record review on 5/21/26 at 4:03 p.m. with the Director of Nursing (DON), Resident 15's EHR document titled, Annual H&P Examination, dated 12/28/25, was reviewed. Resident 15's Annual H&P Examination included H&P's that belonged to Residents 6, 17, 24, 40 and 41. The DON stated prior to giving MR documents for a resident, she would ensure the documents were for the correct resident. The DON stated Residents 6, 17, 24, 40 and 41 H&Ps were uploaded into Resident 15's EHR and should not have been. The DON stated her expectation was that medical records should be placed into the correct resident's chart. The DON stated it was important to ensure that information in a resident's chart is correct because medications, orders or treatments could be missed or performed on the wrong resident. The DON stated when Residents 6,17, 24, 40 and 41's health records were in Resident 15's EHR that was a HIPAA violation.During a review of the facility's job description (JD) titled Medical Records Clerk, dated 2023, the JD indicated, .Major Duties and Responsibilities.Ensures resident health information is protected.Additional Tasks.Maintains confidentiality and protected health information, including verbal, written, and electronic communications.During a review of the facility's policy and procedure (P&P) titled Documentation in Medical Record, dated 2026, the P&P indicated, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, interview and record review the facility failed to ensure sterile water bottles used for oxygen humidification were labeled with the open date for one of 32 residents (Resident 35) observed receiving oxygen therapy. This failure had the potential to result in the use of contaminated respiratory equipment and increased the risk of infection. Findings:During an interview on 5/19/26 at 9:36 a.m. in Resident 35's room, Resident 35 stated he had been admitted to the facility approximately six days prior. Resident 35 was observed wearing a nasal cannula connected to an oxygen concentrator and stated he had not used oxygen prior to admission, but used it at the facility as needed. The sterile water bottle attached to the oxygen concentrator for humidification was not labeled with the date opened. During a review of Resident 35's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 35 was admitted to the facility on [DATE] with a diagnosis which included chronic obstructive pulmonary disease (COPD-a chronic lung disease that made it difficult to breath due to damaged airways and reduced airflow in the lungs), atelectasis (a condition in which part of the lung did not fully expand with air, making it harder to breath normally), congestive heart failure ( a condition in which the heart did not pump blood effectively, which could cause fluid buildup in the lungs and body) and dependence on renal dialysis (a machine treatment that cleaned waste and extra fluid from the blood when the kidneys were no longer working properly. Dependence on renal dialysis meant the resident relied on this treatment to survive). During a review of Resident 35's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 35's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 indicated Resident 35 had no cognitive deficits. During a record review of Resident 35's Order Summary Report (OSR), dated 5/15/26, the OSR indicated Resident 35 had an order for oxygen therapy to change concentrator bottles on oxygen bottles as needed. During an interview on 5/20/26 at 3:10 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated nasal cannulas were changed during night shift and sterile water bottles used for oxygen humidification were replaced weekly or as needed. LVN 1 stated cannulas and sterile water bottles were dated and timed when changed, this was a standard Medication Administration Record (MAR) order, and replacement was part of Sunday night shift nursing duties. LVN 1 stated an unlabeled sterile water bottle should be replaced and labeled, and failure to do so increased the risk of infection. During an interview on 5/21/26 at 12:04 p.m. with the Infection Preventionist (IP), the IP stated oxygen humidification equipment was changed weekly, typically by respiratory therapy, and Resident 35 used oxygen daily. The IP stated the nasal cannula and sterile water bottle should be replaced and dated when changed. The IP stated dating was important to prevent contamination and that an undated sterile water bottle should be discarded and replaced due to infection control concerns. During an interview on 5/22/26 at 12:03 p.m. with the Director of Nursing (DON), the DON stated her expectation was for sterile water bottles used for oxygen humidification to be dated when opened and changed when due. The DON stated dating the bottle was important so staff would know how long it had been in use and whether it remained appropriate for continued resident use. The DON stated an opened bottle without a date created an infection control concern, as staff could not determine whether the sterile water was still safe for use. During a review of the facility's policy and procedure (P&P) titled, Respiratory Therapy Equipment Cleaning and Replacement Policy, dated 1/1/2026 the P&P indicated, 2. Equipment replacement schedule: daily (every 24 hours) bubble humidifiers (for all patients receiving oxygen therapy).4 labeling requirements all equipment that is issued, cleaned or replaced must be labeled clearly with: patient full name, room number, issue date, change date (issue date + 7 days, labels must be legible and updated immediately after each change.staff must verify labeling accuracy at the time of change.During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration , dated 2026 the P&P indicated, change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer.

Based on observation, interviews and record review, the facility failed to ensure Dietary [NAME] (DC) 1 was competent to carry out the functions of the food and nutrition services safely and effectively when DC 1 thawed frozen meat without running cold water. This failure had the potential to result in unsafe food being served, consumed, and could have cause food borne illness (contamination of food and occur at any stage of the food production, delivery and consumption chain) to 29 residents who were served food from the kitchen. Findings: During a concurrent observation and interview on 11/20/24 at 11:17 a.m. in the kitchen, with Dietary [NAME] (DC) 1, frozen meat was submerged in a bucket of water. DC 1 stated she pulled out the frozen meat to make dinner for 11/20/24. DC 1 stated she worked as a cook for nine months. DC 1 stated, I had a rapid training from my previous supervisor that was three days of training. DC 1 stated she was trained to defrost meat submerged in water. DC 1 stated she was not aware of having cold water running when frozen meat was submerged in water. DC 1 stated she normally pulled meat one to two days in advance and would thaw it out in the refrigerator before cooking it. DC 1 stated the kitchen staff did not thaw the frozen meat and today she had to thaw the frozen meat in a bucket of water. DC 1 stated she would wait to about 1 or two hours or when the meat felt soft before cooking it. DC 1 stated she was not sure if the cold running water needed to thaw out frozen products. During an interview on 11/21/24 at 4:38 p.m. with the Certified Dietary Manager (CDM), the CDM stated the DC should have the meat submerged in running cold water. The CDM stated it was important to have the running cold water to prevent food borne illness. The CDM stated resident could have gotten foodborne illness if the frozen meat was not thawed out correctly. The CDM stated the frozen meat should have been thawed within a certain time frame and temperature to ensure bacteria did not grow and prevent food borne illness. The CDM stated there were plenty of days for DC 1 to take out the frozen meat from the freezer and thawed it in the refrigerator. The CDM stated the potentially hazardous zone for meat product were at 40-degree Fahrenheit to 135-degree Fahrenheit. During an interview on 11/25/24 at 10:24 a.m. with the Registered Dietitian (RD) the RD stated DC 1 should have thawed the frozen meat in the refrigerator, in the microwave or by cooking. The RD stated it was the practice to put frozen meat in a container in running cold water. The RD stated it was important kitchen staff knew the policy and procedure for safety food practice. The RD stated DC 1 did not follow the policy and procedure for the facility food safety. The RD state all the kitchen staff should have known the food safety practice. During a review of the facility's dietary cook job description titled, Dietary [NAME] dated 2023, the job description indicated, .Major Duties and Responsibilities .Ensures that food procedures are followed in accordance with established policies .must be knowledgeable of food services practices and procedures . During a review of the facility's policy and procedure (P&P) titled, Food Safety Requirements dated 10/2022, the P&P indicated, .It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will be stored, prepared, distributed and served in accordance with professional standards for food services safety .Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness .4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards. a. Thawing -approved methods for thawing frozen food including thawing in the refrigerator, submerging under cold running water, thawing in the microwave oven, or as part of a continuous cooking process .

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice for food service safety when: 1 One opened box of pancake batter mix was not labeled with an open on date. 2. Residents snacks were not labeled with prepared on date an in refrigerator for residents to eat. 3. A hornet and wasp pesticide (bug spray) bottle was found below kitchen sink cabinet. 4. Six bags of muffins in the freezer were not labeled with the received-on date. 5. Resident refrigerator contained unlabeled foods with no received on date, resident name and content. 6. Uncooked frozen meat were found inside the resident refrigerator. These failures had the potential to transmit food-borne illnesses (caused by eating or drinking something that is contaminated with germs such as bacteria, viruses, or parasites or chemicals such as toxins or metals that can make people sick) and cross-contamination( transfer of harmful bacteria, parasites, or viruses from one food to another, or from surfaces to food ) to 29 of 29 sampled residents. Findings: 1. During an observation and interview on [DATE] at 8:05 a.m. in the kitchen with the Certified Dietary Manager (CDM) an open pancake mixed carton had no open on date. The CDM stated pancake box mix should have an open on date when kitchen staff opened it. During an interview on [DATE] at 4: 38 p.m. with the CDM, the CDM stated the pancake box mixed should be labeled when it was opened. The CDM stated it was important to date the pancake box, so kitchen staff knew how old the pancake mix was. The CDM stated residents could get sick if they consumed food beyond the expiration date. The CDM stated the kitchen staff did not follow the policy for labeling food. During an interview on [DATE] at 10:24 a.m. with the Registered Dietitian (RD), the RD stated, Every time they [kitchen staff] open something there should be an open date. The RD stated, it was important to date open items, so kitchen staff knew when to use the items. The RD stated the kitchen staff should have checked the items daily. The RD stated the CDM was responsible to make sure kitchen staff knew about food label requirements. The RD stated residents could get food borne illnesses if they consumed food that was beyond the used by date. The RD stated the facility failed to follow the policy when staff did not label the pancake mix with an open date. During a review of the facility's policy and procedure (P&P) titled, Date Marking for Food Safety dated ,d+[DATE], the P&P indicated, .The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared . 2. During a concurrent observation and interview on [DATE] at 8:10 a.m. in the kitchen with the Certified Dietary Manager (CDM), the residents' snacks located in a bin in the refrigerator was not labeled with prepared on date. The CDM stated resident snacks were made last night ([DATE]) and the snacks should have a prepared on date. The CDM stated the night cook should prepare the snacks and label with a date before placing in refrigerator for the residents to eat. The CDM stated it was important to date the snacks in the bin so residents would not consume snacks beyond the expiration date. The CMD stated, consuming snacks beyond the used by date could get residents sick and cause food borne illness. During an interview on [DATE] at 10:24 p.m. with the Registered Dietitian (RD), the RD stated the kitchen staff should be making resident snacks daily. The RD stated there should be a made by date on the bin when resident snacks are stored in the refrigerator. The RD stated residents could get sick if they consumed snacks past the expiration date. The RD stated, the kitchen staff did not follow facility policy when there was no date on the residents' snacks. During a review of the facility's policy and procedure (P&P) titled, Date Marking for Food Safety dated ,d+[DATE], the P&P indicated, .The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared . 3. During a concurrent observation and interview on [DATE] at 8:15 a.m. in the kitchen a bottle of hornet and wasp pesticide (bug spray) was found under the sink. The Certified Dietary Manager (CDM) stated it should not be in the kitchen and was not sure who brought the bug spray bottle in the kitchen. During an interview on [DATE] at 4:38 p.m. with CDM stated the hornet and wasp bug spray bottle should not have been stored in the kitchen. The CDM stated using the bug spray in the kitchen could have cross-contaminated resident food and residents could get sick. During an interview on [DATE]at 10:24 a.m. with the Registered Dietitian (RD), the RD stated, storing chemicals in the kitchen was not acceptable and it might cross-contaminate resident food. The RD stated cross-contamination could cause food borne illness. The RD stated, the kitchen staff did not follow their policy and procedure. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage dated revised ,d+[DATE], the P&P indicated, .8. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in storerooms for food or food preparation equipment and utensils . 4. During a concurrent observation and interview on [DATE] at 8:20 a.m. in the kitchen with the Certified Dietary Manager (CDM), six bags of muffins were not labeled with a received on date. The CDM stated the muffins were ordered sometime this month. The CDM stated the muffins should be labeled with the received on date before putting them in the freezer. During an interview on [DATE] at 4:38 p.m. with the CDM, the CDM stated the bags of muffins should have a label with received on date and an expiration date. The CDM read the facility policy and procedure and stated the kitchen staff did not follow the policy and procedure. The CDM stated it was important to label the muffins with a received on date to prevent serving it to residents past the expiration date. The CDM stated residents could have gotten food borne illness if served muffins past the expiration date. The CDM stated the muffins could have tasted bad and residents would not eat it. The CDM stated labeling the muffins with received on date would have ensured kitchen staff to use the old ones first. During an interview on [DATE] at 10: 24 a.m. with the Registered Dietitian (RD) the RD stated, It should have been labeled when they received it. The RD stated it was important to date the muffins with a received on date. The RD stated, We want to make sure we don't want to be serve expired items. The RD stated, consuming expired items could cause residents to become ill. The RD stated the best practice is to label every item with a received on date. The RD stated, kitchen staff did not follow their policy and procedure. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezer dated revised ,d+[DATE], the P&P indicated, .7. All food is appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (date of delivery) are marked on cases and on individual items removed from cases for storage. 5. During a concurrent observation and interview on [DATE] at 9:20 a.m. with the Certified Dietary Manager (CDM) one raisin carrot salad container, one beef and potatoes container, three cups of yogurt, a single frozen hot pocket, one opened bag of mozzarella were found in inside of the residents' freezer and refrigerator. The CDM stated all resident food items should have been labeled with the resident name and received date. During an interview on [DATE] at 4:38 p.m. with the CDM, the CDM stated it was important to label resident food item to ensure resident were getting their food. The CDM stated it was important to labeled resident food to prevent serving food to wrong resident and to prevent cross contamination. The CDM stated the Certified Nursing Assistance (CNA) were responsible for labeling resident food items. The CDM stated resident food items should have been thrown away past the expiration date. During a review of the facility's policy and procedure (P&P) titled, dated no date the P&P indicated, .2. All food items that are already prepared by family or visitors bought in must be labeled with content and dated . 6. During a concurrent observation and interview on [DATE] at 9:20 a.m. with the Certified Dietary Manager (CDM) 16 ounces of mild Italian ground sausage, 16 ounces of frozen ground beef and one roll of frozen chorizo were in the resident freezer/refrigerator. The CDM stated the resident freezer/refrigerator should not contain uncooked frozen meat. The CDM stated kitchen staff were not able to cook meat brought into the facility. During an interview on [DATE] at 4:38 p.m. with the CDM the CDM stated uncooked frozen meats should not have been in the resident refrigerator. The CDM stated the dietary staff were responsible for maintaining the temperature and housekeeping were responsible for cleaning the resident refrigerator. The CDM read the resident policy and stated the facility did not follow their policy and procedure. During a review of the facility's policy and procedure (P&P) titled, Resident Refrigerators dated ,d+[DATE], the P&P indicated, .Dietary and housekeeping staff shall clean the refrigerator weekly and discard any food that are out of compliance .Raw meat or eggs are not allowed in a resident's refrigerator .

Based on observation and interview during the survey period of 11/19/24 to 11/25/24, the facility failed to provide the minimum of at least 80 square feet (sq. ft- unit of measurement) per resident in multiple resident bedrooms, and at least 100 sq. ft in single residents rooms for 11 of 20 rooms (Rooms 1, 5, 6, 8, 9, 10, 11, 12, 18, 19, and 20), when the amount of usable living space was not adequate for residents. This failure had the potential for residents in Rooms 1, 5, 6, 8, 9, 10, 11, 12, 18, 19, and 20 to not have reasonable privacy or adequate space. Findings: During an environment tour with the Maintenance Director on 11/25/24 03:05 PM, the inspection indicated the following rooms did not meet the minimum square footage as required by regulation. These rooms were as follows: Room Number Square Feet # of Residents 1 120 2 2 120 1 3 118 1 4 118 1 5 92 1 6 174 3 7 102 1 8 118 2 9 117 2 10 117 2 11 117 2 12 111 2 13 114 1 14 110 1 15 113 1 16 118 1 17 111 1 18 117 2 19 92 1 20 95 1 However, variations were in accordance with the needs of the residents except for Residents in room [ROOM NUMBER]. The residents had a reasonable amount of privacy except for room [ROOM NUMBER]. Closets and storage space were adequate except for room [ROOM NUMBER]. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate except for room [ROOM NUMBER]. Wheelchairs and toilet facilities were accessible except for in room [ROOM NUMBER]. The waiver will not adversely affect the health and safety of residents except for Residents in room [ROOM NUMBER]. Recommend waiver to be continue in effect except for room [ROOM NUMBER]. _________________________________ _____ Health Facilities Evaluator Sup Signature Date

Based on observation, interview and record review, the facility failed to keep the environment free from insects in accordance with the facility's policy and procedure (P&P) Pest Control Program when ants were observed in the kitchen floor and cabinet. This failure led to insects being observed in the kitchen facility and had the potential to cross contaminate food being prepared in the kitchen for 29 residents. Findings: During a concurrent observation and interview on 11/19/24 at 8:15 a.m. in the kitchen with the Certified Dietary Manager (CDM), multiple live and dead ants were on the ground and under the sink of a cabinet. The CDM stated ants should not be in the kitchen. The CDM confirmed multiple ants were in the kitchen floor and under the sink cabinet. During an interview on 11/21/24 on 4:38 p.m. with the CDM, the CDM stated, ants should not be in the kitchen. The CDM stated, ants could have cross contamination (the transfer of harmful bacteria, parasites, or viruses from one food to another, or from surfaces to food) food and items in the kitchen. The CDM stated residents could have gotten sick from cross contamination. The CDM stated the kitchen staff should have cleaned up the dead ants. The CDM stated kitchen staff were responsible for keeping the kitchen cleaned. The CDM stated kitchen staff notified Maintenance Supervisor (MS) and the MS should have called pest control. The CDM stated she was not sure when the pest control came. During a concurrent interview and record review on 11/25/24 at 12:38 p.m. with the Administrator (ADM), the ADM stated the facility does not have pest control contract with a pest control company. The ADM stated, the MS was notified on 11/19/24 of ants in the kitchen and should have called pest control the same day. The ADM stated, ants can cause cross contamination in the kitchen. The ADM stated, If ants continue to be an issue in the kitchen, then the pest control should come out more than monthly. The ADM stated current pest control is not effective. During a concurrent interview and record review on 11/25/24 at 3:14 p.m. with the spell out MS, the MS stated, the kitchen staff notified him about ants on 11/17/24. The MS stated the pest control should have been contact on 11/17/24. The MS stated he contact the pest control company on 11/19/24. The MS stated the pest control company came out on 11/19/24. The MS stated current pest control program was not effective. The MS stated the kitchen could have used more pest control services due to pest. During a review of the facility's invoice titled, [Company Name] Pest Control dated 11/19/24, the invoice indicated, .[box checked] Ants .Notes: Kitchen baited for ants . During a review of the facility's policy and procedure (P&P) titled, Pest Control Program dated 10/2022, the P&P indicated, .It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodent .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for three of 16 residents (Residents 3, 9 and 23) when: 1. Resident 9's care plan was not developed to address the use and storage of Resident 9's Incentive Spirometer (IS - a hand-held device that helps people take slow deep breaths to improve lung functioning). This failure put Resident 9 at risk of infection and harm due to improper storage and use of the IS. 2. Resident 23's care plan was not developed to address the use and care of a nebulizer (a device that changes medication from a liquid to a mist so it can be inhaled into the lungs). This failure put Resident 23 at risk of infection and harm due to improper storage and use of Resident 23's nebulizer. 3. Resident 23's care plan was not developed and implemented to address Resident 23's non-compliance with the proper use and storage of Resident 23's oxygen tubing and nasal cannula (a tube that delivers oxygen through the nose to people who have low oxygen levels). This failure put Resident 23 at risk of infection and harm due to improper use and storage of Resident 23's oxygen tubing and nasal cannula. 4. Resident 9 and Resident 23's care plans were not developed and implemented to reflect assessments and interventions to address outside food stored on the bed and on the bedside tables longer than 3 days. This failure put Resident 9 and Resident 23 at risk of infection from food-born illness (illness caused by ingestion of contaminated food or beverages) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food) and may also provide an environment for attraction of pests. 5. Resident 3's care plan was not developed timely to address indwelling catheter (a thin, flexible tube that drains urine from the bladder into a collection bag outside the body). This failure did not allow the team to collaborate and communicate for Resident 3's needs, and had the potential for needs to go unmet. Findings: 1. During an observation on 11/22/24 at 8:49 a.m. in Resident 9's room, the Infection Prevention Nurse (IP) was observed waking Resident 9 up from sleeping to perform his Incentive Spirometer (IS) treatment. During a review of Resident 9's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 11/25/24, the AR indicated Resident 9 was admitted to the facility from the acute care hospital on 10/16/24 with diagnoses of osteomyelitis (inflammation of bone or bone marrow, usually due to infection), acquired absence (surgical removal of finger, toe, hand, foot, arm or leg) of right leg above the knee, acquired absence of left leg below the knee, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and repeated falls. During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 10/23/24, the MDS section C indicated Resident 9 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 9 was cognitively intact. During a concurrent interview and record review on 11/22/24 at 4:41 p.m. with the Minimum Data Set Nurse (MDSN), Resident 9's Care Plan (CP), undated was reviewed. The CP indicated there was no care plan in place for the use and storage of Resident 9's IS. The MDSN stated there was no care plan in place for changing the breathing apparatus (mouthpiece) or the breathing tube on the IS. The MDSN stated the mouthpiece and breathing tube on the IS should have been changed periodically. The MDSN stated if the IS mouthpiece and tubing were not changed, they could be a risk for infection for Resident 9. During a review of the facility's policy and procedure (P&P) titled, Care Plans, dated 10/2022, indicated, . it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices . all Care Assessment Areas [CAAs] triggered by the MDS will be considered in developing the plan of care . other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care . the comprehensive care plan will describe, at a minimum . the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record . 2. During a concurrent observation and interview on 11/19/24 at 12:30 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 23's room, Resident 23's nebulizer was observed on the floor. CNA 1 stated Resident 23's nebulizer should not have been on the floor. CNA 1 stated Resident 23's nebulizer on the floor was an infection control problem. CNA 1 stated Resident 23 could have gotten sick. During a review of Resident 23's AR dated 11/25/24, the AR indicated Resident 23 was admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), transient ischemic attack (TIA - a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), emphysema (a condition of the lungs where the air sacs are damaged and enlarged, causing breathlessness [difficulty breathing]), acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 23's MDS, dated [DATE], the MDS section C indicated Resident 23 had a BIMS score of 15, which indicated Resident 23 was cognitively intact. During a concurrent interview and record review on 11/22/24 at 4:20 p.m. with the MDSN, Resident 23's CP, undated was reviewed. The CP indicated no care plan for the use and storage of Resident 23's nebulizer. The MDSN stated there should have been a care plan in place for the use and storage of Resident 23's nebulizer. The MDSN stated it was not acceptable for Resident 23's nebulizer to be on the ground and not in a bag. The MDSN stated there was a risk of infection for Resident 23 if he used a dirty nebulizer. During a review of the facility's policy and procedure (P&P) titled, Care Plans, dated 10/2022, indicated, . it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices . all Care Assessment Areas [CAAs] triggered by the MDS will be considered in developing the plan of care . other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care . the comprehensive care plan will describe, at a minimum . the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record . 3. During a concurrent observation and interview on 11/19/24 at 10:34 a.m. with Resident 23 in Resident 23's room, Resident 23's oxygen tubing was observed wrapped around Resident 23's bed rail, not placed in a bag. Resident 23 stated he wanted the oxygen tubing on the bed rail and would use it when he needed it. During a concurrent observation and interview on 11/22/24 at 8:34 a.m. with the Infection Prevention Nurse (IP) in Resident 23's room, Resident 23 was observed putting his oxygen tubing cannula in his mouth. The IP stated she had given Resident 23 a bag to store his oxygen tubing and incentive spirometer, but Resident 23 had thrown them away. During an interview on 11/22/24 at 4:20 p.m. with the MDSN, the MDSN stated there should have been care plans for refusals of treatment and non-compliance. The MDSN stated the physician should have been notified of non-compliance. During an interview on 11/25/24 at 4:29 p.m. with the Director of Nursing (DON), the DON stated residents who were non-compliant should have had a care plan and interventions for non-compliance. The DON stated the resident's care plan would not be individualized if there was no care plan for non-compliance. During a review of the facility's policy and procedure (P&P) titled, Care Plans, dated 10/2022, indicated, . it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices . all Care Assessment Areas [CAAs] triggered by the MDS will be considered in developing the plan of care . other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care . the comprehensive care plan will describe, at a minimum . the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record . 4. During an observation on 11/19/24 at 10:35 a.m. in Resident 9's room, Resident 9 was observed dressed lying in bed. Resident 9 was observed to have no lower limbs. Resident 9 was observed with bags of store-bought food on his bed against the wall, loose food items (cookies and fried pork rinds). Resident 9's bedisde table was observed with bottles of condiments (hot sauce, pickled chilis, pickles, and onion dip), bottles of lotion, hair gel, and mouth swabs. During an observation on 11/19/24 at 12:27 p.m. in Resident 23's room, Resident 23 was observed dressed sitting up in his bed watching television (TV). Resident 23's bedisde table was obsreved with boxes of food, papers, a drinking tumbler, and towels. During a concurrent observation and interview on 11/22/24 at 8:55 a.m. with CNA 3, in Resident 9 and Resident 23's room, open food items were observed on Resident 9's bed and bedside table, and on a bedside table between Resident 23's bed and wall. CNA 3 stated when residents had open food items, staff would label the items with the resident's name and date. CNA 3 stated residents could keep their own food with them. CNA 3 stated she did not know the policy for how long residents could keep open food items in their room. During a concurrent record review and interview on 11/22/24 at 4:20 p.m. with the MDSN, Resident 9 and Resident 23's CPs, undated were reviewed. The care plans indicated there were no care plans for food brought into the facility for Resident 9 and Resident 23. The MDSN stated there should have been a care plan for food brought in and kept in Resident 9 and Resident 23's room. The MDSN stated residents could have food brought in, but the nurse should have been notified. The MDSN stated education should have been provided to Resident 9 to decrease certain foods due to Resident 9's diet. The MDSN stated Resident 9 was at risk for high blood sugar. The MDSN stated there was no CP for non-compliance in place for Resident 9. During an interview on 11/25/24 at 11:16 a.m. with the Director of Staff Development (DSD), the DSD stated the nurse was responsible for building the resident's care plan according to what the resident's needs were. The DSD stated resident care plans should have been completed when the nurse was talking to the resident, during the resident interview or assessment, or when the nurse was implementing the care plan. The DSD stated new residents should have had their care plans completed by the end of the nurse's shift. The DSD stated resident care plan revisions should have been completed right away to make the changes in resident care. The DSD stated care plans were revised by the MDSN, and nurses during their shift when they were able to see what was going on with the resident. The DSD stated the resident's care plan should have been ended, extended, or revised when a resident's goal was met. The DSD stated care plans were important because they gave guidelines and measurable goals for the resident. The DSD stated the care plan let staff know what was working and what was not working for the resident. The DSD stated the care plan was a map of resident care. The DSD stated Resident 9 and Resident 23's care plans were not individualized. During a review of the facility's policy and procedure (P&P) titled, Care Plans, dated 10/2022, indicated, . it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices . all Care Assessment Areas [CAAs] triggered by the MDS will be considered in developing the plan of care . other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care . the comprehensive care plan will describe, at a minimum . the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record . 5. During a review of Resident 3's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 11/25/24 the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of osteomyelitis (inflammation of bone or bone marrow, usually due to infection), paraplegia (loss of movement and/or sensation, to some degree, of the legs) arthritis (chronic condition that causes inflammation in the joints, tissues around the joints, or other connective tissues), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), acute kidney failure (sudden loss of kidney function that can occur within hours or days), chronic obstructive pulmonary disease (COPD-common lung disease that makes it difficult to breathe), unstageable pressure ulcer ( bed sores, pressure sore or pressure injury-a localized area of damaged skin or tissue caused by prolonged pressure) right heel, unstable pressure injury to the left heel, chronic pain, muscle weakness (occurs when your muscles are unable to contract properly, resulting in reduced strength), colostomy (a surgical procedure that creates an opening in the abdominal wall to divert the colon, or large intestine, and allow stool to drain into a bag), edema medical condition that occurs when fluid builds up in the body's tissues, causing swelling) and obstructive uropathy (a condition that occurs when urine can't drain properly through the urinary tract, causing urine to back up and damage the kidneys). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/7/24, the MDS section C indicated Resident 3 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 3 was cognitively intact. During an observation on 11/19/24 at 1:15 p.m. in Resident 3 room, Resident 3 had an indwelling foley catheter handing on the side of his bed. Resident 3 stated he was taking antibiotic for a urinary tract infection (UTI- a bacterial infection that affects the urinary tract). During an interview on 11/22/24 at 2:20 p.m. with the Minimum Data Set Nurse (MDSN), the MDSN stated, Care plan should be started right and should be complete within 48 hours after admission. During an interview on 11/20/24 at 2:39 p.m. with LVN 1, LVN 1 stated, nurses were responsible for inputting medication into resident chart. LVN 1 stated the DON and MDS were responsible for updating the care plans. During a concurrent interview and record review on 11/25/24 at 5:49 p.m. with the DON, Resident 3's Care Plan dated undated was reviewed. The DON stated the indwelling catheter care plan should have been done on 10/31/24 when resident was admitted to the facility. The DON stated the indwelling care plan was done on 11/14/24. The DON stated care plans were individualized and resident center. The DON stated care plans were done to direct resident goals and interventions of care. The DON stated it was important to develop the care plan within 24 hours after admission into the facility. The DON stated nurses should have done the care planning for Resident 3's indwelling catheter. The DON stated Resident's 3 care plan was not done on time. The DON stated Resident's 3 goals and interventions for his foley catheter could have been missed. The DON stated, We did not follow the policy and procedure. During a review of the facility's policy and procedure (P&P) titled, Care Plans, dated 10/2022, indicated, . it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices . all Care Assessment Areas [CAAs] triggered by the MDS will be considered in developing the plan of care . other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care . the comprehensive care plan will describe, at a minimum . the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . the facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record . During a review of the facility's P&P titled, Refusal of Treatment, dated 2/2015, indicated, . it is the policy of this facility to honor a resident's request not to receive medical treatment as prescribed by his/her physician . treatment is defined as care provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms . if a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing . the Care Plan Team will assess the resident's needs and offer the resident alternative treatments, if available . if the resident's refusal brings about a significant change, a reassessment will be made and such information will be incorporated into the resident's care plan . Documentation . shall include . the date and time the physician was notified as well as the physician's response . 49949

Based on observation, interview and record review, the facility failed to ensure the environment remained free from accident hazards for one of three residents (Resident 1) when Certified Nurse Assistant 2 placed a hot cup of soup at Resident 1 bedside table without first ensuring the temperature of the soup would not burn. CNA 1 was aware of Resident 1's physical limit to reach safely and left the hot cup of soup on the bedside table. These failures resulted in Resident 1 reaching for the hot cup of soup in an unsafe manner, spilling the hot soup on his chest and stomach and suffering burns to the skin that required wound care. Findings: During a review of Resident 1's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis which included but was not limited to hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), muscle weakness, pain in left shoulder and unspecified symptoms and signs involving the nervous system (referring to the brain and spinal cord). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive knowledge and understanding through thought, experience, senses and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During a review of Resident 1's Progress Notes, dated 4/14/24, Resident 1's Progress Note indicated .During rounds CNA brought to nurses' attention . [complaints of] pain and burning on [Resident 1's] chest and abdomen Resident is red across chest and abdomen. Blisters are present in the size of a quarter on the chest and the size of a dime on the abdomen . During a review of Resident 1's Initial Wound Evaluation & Management Summary, dated 4/19/24, the Initial Wound Evaluation & Management Summary, indicated, .Burn wound of the mid chest . mix between 1st and 2nd Degree (first degree burns affect outer layer of skin and second degree burns affect both the outer and underlying layer of skin) .per [physician] . During a review of Resident 1's Skin/Wound note, dated 4/19/24, the Skin/Wound note indicated . skin redness, burn wounds, (an injury to living tissue), blisters (bubbles on the skin filled with liquid) to the chest size: 15.0 x9.0 x 0.1 centimeter [cm: unit of measurement] . surface with open ulceration (break on the skin), light serous exudate (a clear or pale yellow, thin, and watery liquid), thick adherent necrotic tissue (dead skin) . left lower abdomen redness skin blister size 16.5 x 17.0 x 0 cm .with open ulceration light serous exudate . Surgical excisional debridement (surgical removal or cutting away of dead tissue) was performed . and abdomen . During a concurrent observation and interview on 5/6/24 at 4:16 p.m. with Resident 1 in his room, Resident 1 was observed with discolored spots on his chest and left side of stomach. Resident 1 stated he requested a hot cup of soup the early morning of 4/14/24. Resident 1 stated he has physical limits to his left hand. Resident 1 stated his hot cup of soup was left on his bedside table the early morning of 4/14/24, and when he reached for it he dropped the cup of soup on himself. Resident 1 stated he called for help so he could be cleaned up and have his linens changed. Resident 1 stated he needs assistance opening items during mealtimes but can feed himself. During an interview on 5/6/24 at 5 p.m., with the Certified Nursing Assistant (CNA) 1, CNA 1 stated when kitchen staff have left for the day during evening and night shift CNAs heat up food for the residents. CNA 1 stated they will heat up residents' personal food items in the microwave. CNA 1 stated she had not been trained to check the temperatures for food prior to serving the residents. During an interview on 6/3/24 at 12:38 p.m., with the Administrator (ADM), the ADM stated on 4/14/24 Resident 1 was provided with a cup of soup by staff. ADM stated Resident 1 spilled the cup of soup on himself causing Resident 1's burns to his chest and stomach. The ADM stated the facility did not have a procedure for staff to follow for reheating evening and nighttime snacks on 4/14/24. The ADM stated the night of 4/14/24 staff did not know to check temperatures of food items. During a phone interview on 6/3/24 at 3:45 p.m., with CNA 2, CNA 2 stated at approximately 3 a.m. on 4/14/24 Resident 1 requested a cup soup be prepared. CNA 2 stated she placed the water in the soup, microwaved the soup then placed it on his bedside table away from Resident 1. CNA 2 stated Resident 1 had fallen back asleep. CNA 2 stated she expected Resident 1 to call for assistance with the cup of soup when he woke up. CNA 2 stated CNA 3 let her know Resident 1 had dropped his soup on himself. CNA 2 stated there was no temperature guidelines for her to follow for heating up residents' food items. During a review of Investigation [for Resident 1] dated 4/14/24 completed by the Director of Staff Development (DSD) the Investigation [for Resident 1] indicated .both [CNA 2 and CNA 3] were counseled individually and educated on safety measures when providing hot liquid and food items. Temperatures regulations, thermometer use and appropriate temp no higher than 104 [Fahrenheit] . During an interview on 6/4/24 at 2:36 p.m., with DSD, the DSD stated the expectation was for staff to provide cold snacks outside of mealtimes, such as sandwiches, gelatin or cookies. DSD stated on 4/14/24 CNA 2 had not been trained on after hour food temperature guidelines. DSD stated his expectation is for staff to notify the nurse, check temperature of the food and reference the temperature log to provide food or liquid at the correct temperature. DSD stated on 4/14/24 CNA 2 did not check the temperature. During an interview on 6/10/24 at 8:50 a.m., with LVN 3, LVN 3 stated Resident 1 complained of pain from his burns during her morning rounds. LVN 3 stated she medicated Resident 1 and assessed his burns that were located on his upper chest and left side of his stomach. LVN 3 stated Resident 1 had blisters on his skin from where he was burned. During a review of the facility's job description titled, Certified Nursing Assistant, not dated, the job description indicated, . Participate in meal service including serving, clearing, and cleaning the dining room; Assures that the residents are positioned appropriately for meals; Assures the appropriate utensils are within reach of residents; Serves food trays and assists with feedings as indicated; Delivers and documents all a.m., p.m., and bedtime snacks and supplements; Provides hydration to all residents according to center policy .Identifies and reports changes in condition to charge nurse, supervisor, ADON and/or DON .Assists with meal service, Identifies residents at risk for nutritional problems and implements preventative measures; Checks items and food that is brought in by family members to assure it complies with the resident's orders, dietary needs, and safety . During a review of the facility's policy and procedure (P&P) titled, Incidents and Accidents, dated 11/15/2023, the P&P indicated, .Accidents refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident . An Incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member .The following incidents/accidents require an incident/accident report but are not limited to .Observed accidents/incidents .Pressure injuries/ulcers .Self-inflicted injuries .Unobserved injuries .

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable and homelike environment for 29 of 29 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 77, Resident 78, Resident 79, Resident 80) when the Air Conditioning system failed to work and residents were evacuated to the church across the street by the local Fire Department after prolonged exposure to ambient temperatures above 81 degrees Fahrenheit (Cross reference F684 and F908). The failure to maintain a safe and comfortable ambient temperature in the facility led to symptoms of heat exposure in 29 residents and heat related illnesses in seven of the 29 residents (Resident 4, Resident 6, Resident 12, Resident 15, Resident 24, Resident 27, and Resident 78) and required transfer to an acute care hospital. The local fire department and emergency services were called to assess the environment and determined the health and safety of the residents were at risk due to climbing facility temperatures and directed the facility staff to evacuate the residents to a nearby church; the residents were displaced for several hours. The Centers for Medicare & Medicaid Services Regional Office (CMS RO) reviewed the facility deficient practices and determined the identified potential serious harm to all residents and the serious actual harm to Resident 4, Resident 6, Resident 12, Resident 15, Resident 24, Resident 27, and Resident 78 warranted an Immediate Jeopardy (IJ) situation. An IJ was called by the District Office (DO) on 9/11/18 at 11:10 a.m., via telephone conference with the facility administrator. The DO explained to the facility administrator an amended 2567/Statement of Deficiencies would be submitted to the facility to reflect the IJ with scope and severity of L called at F 584 and F 908; and an additional deficient practice at F 684 with scope and severity of L would be added. A written Action Plan to address the IJ situation was requested to be submitted. An acceptable Action Plan was received on 9/14/18 and communicated to the facility Administrator. An onsite visit was conducted on 9/18/18 and validated implementation of interventions meant to address the IJ. The IJ was removed on 9/18/18 at 3:35 p.m. and communcated to the facility Administrator. Findings: On 7/26/18 at 9:54 a.m., during an interview, the Executive Director (ED - the facility Administrator) stated he received a text from the Director of Nurses (DON) on 7/21/18 at 7:40 a.m., which indicated the cooling unit for the facility had stopped working. The ED stated the water pump for the chiller (cooling unit) broke which caused the cooling unit to fail. The ED stated, We knew it was hot, taking temps (temperatures) were not that important . we were focused on repairs . we knew it (pump) was going to take a couple of hours to fix. The ED stated portable floor fans and two large coolers purchased by the facility had not kept the facility cool and the (name of city) Fire Department (FD) Chief ordered the evacuation of the residents on 7/21/18. The ED stated maintenance staff had requested the FD come and evaluate the facility's water supply when it was determined water was not being pumped through the cooling unit, which caused it to fail. The ED stated, I was not there . the FD took over and coordinated the transfer of residents to the hospital . 20 (residents) went to the (name) church across the street, seven went to the hospital, one to [MEDICAL TREATMENT], and one went with family. The ED stated all residents were evacuated by 5:45 p.m. from the facility. The ED stated he did not know why the FD came back to the facility the afternoon of 7/21/18. On 7/26/18 at 11:25 a.m., during an interview, the Director of Staff Development (DSD) stated she was notified by the DON of the broken air conditioner and was called in to work on 7/21/18. The DSD stated, We (meaning the DON and ED and herself) all arrived around the same time . 4:30 p.m. The DSD also stated EMS (Emergency Medical Service) was at the facility evaluating residents for heat exhaustion (a heat related illness) when she arrived. On 7/26/18 at 3:55 p.m., during an interview, the Maintenance Supervisor (MS) stated he was called into the facility the morning of 7/21/18. The MS stated he arrived at 10:00 a.m. The MS stated the Director of Plant Operations (DPO) had contacted a heating, ventilation, and air conditioning (HVAC) company and had the air conditioning unit evaluated. The MS stated it was determined water was not being supplied to the unit which caused it to fail. The MS stated, We thought it was a problem with the water supply so we called the fire department to see . later we found out it was the pump . around 12:00 (p.m.) The MS stated they were unsure of how long it would take to fix. The MS stated, It was a Saturday . we're lucky we could get it fixed. The MS stated maintenance communicated with the ED (Administrator) throughout the day to keep him informed of what was happening. On 7/26/18 at 6:55 p.m., during an interview, the DSD stated the ED or the DON should have determined earlier that day (7/21/18) if the evacuation of residents from the facility was necessary. The DSD stated the facility temperature felt warm when she arrived at the facility on 7/21/18 at around 4:30 p.m. The DSD stated, From what I saw, the residents were hot. The DSD also stated she had not taken a temperature of the facility environment nor had she asked residents if they were hot. The DSD stated her role on 7/21/18 was to assist with the evacuation only. On 7/27/18 at 1:50 p.m., during an interview, Certified Nursing Assistant (CNA) 12 stated she arrived to work at 6:10 a.m. on 7/21/18. CNA 12 stated the facility environment felt hot and muggy and mentioned it to the charge nurse. CNA 12 stated the charge nurse had spoken to the maintenance staff. CNA 12 stated, I was sweating just walking . the residents started feeling uncomfortable after lunch time. CNA 12 stated the Fire Department (FD) was at the facility at 11:30 a.m. and gave direction to the nurse to call the FD back at 2:00 p.m. if the temperatures did not get better. On 7/27/18 at 2:20 p.m., during an interview, CNA 6 stated, It started to get hot at 9:00 a.m. and after lunch at 12:00 p.m. it was really hot . I am not sure how hot it got . we started passing ice water after breakfast and wet cold towels were passed at 10:00 a.m .the residents verbalized feeling uncomfortable and hot. CNA 6 also stated she witnessed the FD at the facility twice. CNA 6 stated the maintenance manager brought fans and residents sat in the hallways. On 7/27/18 at 2:50 p.m., during an interview, CNA 5 stated she arrived to work at 2:15 p.m. on 7/21/18. CNA 5 stated, It (the facility) felt hotter inside than outside . they told me the AC (Air Conditioner) was broke. CNA 5 stated she had not checked the thermostats. CNA 5 stated, (Resident 3) looked dehydrated . he looked drowsy with eyes half opened and shut and he complained that it was really hot . the nurse told me to give him ice and sit him in front of a fan. CNA 5 also stated, the FD showed up . they said the facility was too hot . the fireman approached me and two other CNAs and asked us if we thought residents were safe here. We all responded no .as soon as we told them we started evacuation procedures. CNA 5 stated the ED, the DON, and the DSD arrived during the evacuation. On 7/27/18 at 3:20 p.m., during an interview, LN 3 stated on 7/21/18 she was the PM shift charge nurse for the facility. LN 3 stated the AM shift charge nurse (LN 5) reported (to the nursing staff) the facility's air conditioner was broken and cooling measures for the residents had been provided during the day. LN 3 also stated LN 5 reported the FD had been called to the facility twice and had given instructions to evacuate the residents if ambient (surrounding environment) temperatures in the facility rose throughout the day. LN 3 stated the FD Chief returned to the facility at 4:00 p.m. and ordered the evacuation of the residents when the maintenance staff had not purchased and delivered portable air conditioning units to the facility. LN 3 stated she was unable to reach church staff to open the church and initiate evacuation of the residents. LN 3 stated someone from the FD walked across the street to the church and had the church opened. LN 3 stated Resident 80 and Resident 2 were not included in the evacuation. LN 3 stated Resident 80 left for the scheduled 5:00 p.m. [MEDICAL TREATMENT] (mechanical procedure in which waste, salts, and fluid are filtered from blood) appointment. LN 3 stated Resident 2 was with family until 9:30 p.m. Review of receipt from the local hardware store provided by the facility staff dated and time stamped 7/21/18 at 1635 (military time for 4:35 p.m.), indicated two portable evaporator coolers were purchased after the facility evacuation was initiated by the FD. On 7/26/18 at 3:45 p.m., during an interview, the ED stated, I didn't think it was necessary to evacuate residents because repairs were close to being completed . I base my decision on not wanting to transfer residents . (name of DON), (name of DSD), (name of MS), and (name of Director Plant Operations-Maintenance) said no one was in any distress. The ED also stated the facility did not have an agreement with the church and the Pastor of the church. The ED stated, We don't have any transfer agreements with any facility for evacuation. On 7/30/18 at 10:20 a.m., during a telephone interview, the DON stated the AM shift charge nurse notified her of the broken air conditioning unit on 7/21/18 at approximately 8:00 a.m. The DON stated she instructed the charge nurse to contact maintenance staff and distribute ice water, cool wash rags, and fans to the residents. The DON also stated she instructed the charge nurse to monitor the residents for signs and symptoms of heat exhaustion. The DON stated, I told her to monitor for nausea and vomiting, excessive sweating, increased fatigue, (and) decreased level of consciousness. The DON stated the charge nurse told her maintenance staff had contacted a service technician and repairs to the air conditioner were being done. The DON stated the maintenance staff recorded facility temperatures and reported the temperature readings directly to the ED. The DON stated she did not know what the facility's ambient temperature was on 7/21/18. The DON stated she did not know what the facility temperature should have been in order to minimize the risk to resident's but considered 89 degrees Fahrenheit (F) a safe temperature. The DON stated she was notified by the PM nurse the FD mandated the evacuation. The DON stated nurses should have evacuated when residents were in distress or unsafe. Review of facility document titled, Daily Inspection Records dated 7/21/18, indicated an hourly log of temperature readings for 20 facility resident rooms including the dining room, the east hall, the west hall, and the north/south hall. The log indicated temperature readings were to be recorded hourly from 8:00 a.m. through 7:00 p.m. The log indicated omissions of recorded temperatures from 8:00 a.m. to 11:00 a.m. The first recorded temperature readings were at 12:00 p.m. for room one through room [ROOM NUMBER], including the dining room, the east hall, the west hall, and the north/south hall with temperatures ranging from 77 degrees F. up to 79 degrees F. Temperature readings at 1:00 p.m. in the areas listed ranged from 83 degrees F. to 84 degrees F. Temperature readings at 2:00 p.m. in the areas listed ranged from 85 degrees F. to 88 degrees F. Temperature readings at 3:00 p.m. in the areas listed ranged from 87 degrees F. to 88 degrees F. Temperature readings at 4:00 p.m. in the areas listed ranged from 86 degrees F. to 89 degrees F. Temperature readings at 5:00 p.m. in the areas listed ranged from 84 degrees F to 89 degrees F. Resident 1's progress noted dated 7/21/16 at 6:05 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to church across the street from facility . Resident 3's progress notes dated 7/21/18 at 6:27 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 5's progress notes dated 7/21/18 at 6:17 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 9's progress notes dated 7/21/18 at 7:21 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 10's progress notes dated 7/21/18 at 6:15 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 11's progress notes dated 7/21/18 at 6:27 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 13's progress notes dated 7/21/18 at 5:55 p.m., indicated, Resident evacuated from facility due to heat. Resident 14's progress notes dated 7/21/18 at 6:28 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 16's progress notes dated 7/21/18 at 5:48 p.m., indicated, Resident evacuated from facility due to heat. Resident 17's progress notes dated 7/21/18 at 6:13 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 18's progress notes dated 7/21/18 at 6:11 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 19's progress notes dated 7/21/18 at 6:08 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 20's progress notes dated 7/21/18 at 7:15 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 21 and Resident's 1's progress notes dated 7/21/18 at 6:05 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 22's progress notes dated 7/21/18 at 5:45 p.m., indicated, Resident evacuated from facility due to heat. Resident 23's progress notes dated 7/21/18 at 6:29 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 25's progress notes dated 7/21/18 at 5:58 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 26's progress notes dated 7/21/18 at 5:48 p.m., indicated, Resident evacuated from facility due to heat. Resident 77's progress notes dated 7/21/18 at 5:46 p.m., indicated, Resident evacuated from facility due to heat. Resident 79's progress notes dated 7/21/18 at 6:14 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 80's progress notes dated 7/21/18 at 6:24 p.m., indicated, Resident went to [MEDICAL TREATMENT] (a process used to remove toxins from the body) as scheduled. Resident will be at [MEDICAL TREATMENT] center during facility evacuation due to heat exposure for safety . On 7/30/18 at 3:05 p.m., during an interview, CNA 8 stated she worked on 7/21/18 during the morning shift. CNA 8 stated, It seemed like the ac (air conditioner) was not working when I came in at 6:15 a.m . the nurse told me it doesn't work . it felt stuffy, no ventilation. CNA 8 also stated alert residents had complained it was hot. CNA 8 stated, (Resident 19) looked dehydrated . seemed weaker than usual. CNA 8 stated Resident 19's room and room [ROOM NUMBER] were very hot. CNA 8 stated, We offered water and tried to open windows, but it was too hot . we brought up old fans from downstairs. On 7/30/18 at 3:10 p.m., during an interview, LN 5 stated she was the AM charge nurse on 7/21/18 who reported the broken air conditioning unit at 7:40 a.m. to the DON. LN 5 stated the night nurse from the previous shift told her in shift report she (night nurse) thought the air conditioner was not working properly. LN 5 stated the facility's temperature felt warmer than usual so she contacted the DON. LN stated, She (DON) told me to pass ice water to drink and cold towels. LN 5 stated they pulled fans from different areas for the residents as the day progressed. LN 5 stated the maintenance staff arrived later with additional fans. LN 5 stated Resident 78 complained of the heat and felt hot. LN 5 stated the FD came to the facility twice. LN 5 stated she was instructed to contact them (FD) if temperatures rose greater than 80 degrees F. LN 5 stated maintenance staff had contacted the FD the first time and was not sure who contacted the FD the second time. LN 5 stated, I didn't consider the situation an emergency because they were working on the AC (air conditioning). On 7/31/18 at 6:40 a.m., during concurrent interviews, CNA 9 stated they (CNA 9, CNA 10, and LN 4) worked on 7/21/18 during the night shift. CNA 9 stated the night shift started at 10:00 p.m. and the temperature in the facility still felt hot. CNA 9 stated fans were kept on through the night to cool down the facility. LN 4 stated she was told during shift report to monitor residents for heat exhaustion. LN 4 also stated residents that had transferred to the hospital during the evacuation returned to the facility that night (7/21/18) except for Resident 78, Resident 27, and Resident 80. On 7/31/18 at 4:00 p.m., during an interview, the local city FD Fire Chief stated, I was the contact on the scene because the nurse was having trouble reaching any of her supervisors . I told her I would assist in giving her direction as to evacuation. The FD Chief stated the evacuation of residents was initiated based on the facility's environmental temperature and potential risk to the residents. The FD Chief stated temperatures in the facility were well above 81 degrees F. and cooling measures initiated by the facility were ineffective. The FD Chief stated, One resident was bobbing his head like he was going to pass out . bedridden residents with multiple issues were transferred out. The FD Chief stated he had not spoken to the ED (Administrator) prior to 4:00 p.m. Review of the Fire Department Incident Report dated 7/21/18, indicated the FD was dispatched at 4:09 p.m. to the facility to assist in the removal of 29 convalescent residents after the mechanical breakdown of an HVAC unit. The report also indicated, Temperature inside the facility exceeded 80 plus degrees with multiple patients (residents) suffering from heat related illnesses . seven patients required transport to hospital via (by way of) ambulance. Resident 4's progress notes dated 7/21/18 at 6:18 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 4's local fire department patient care record dated 7/21/8 at 4:47 p.m., indicated, EMS (emergency medical services) arrived to find patient sitting upright on the bed at SNF (skilled nursing facility). Pt (patient) is (complaining of) nausea secondary to heat exhaustion. Pt has been at SNF with no air conditioning since this afternoon .Pt reassessed in route and Pt is no longer nauseated . Resident 4's acute care hospital record titled, After Visit Summary Report dated 7/22/18 at 1:41 a.m., indicated, Diagnosis: [REDACTED]. Resident 4's progress notes dated 7/22/18 at 2:54 a.m., indicated, Resident arrived back to the facility from ER (emergency room ). Resident 6's progress notes dated 7/21/18 at 6:07 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 6's acute care hospital records titled, Emergency Department Reports dated 7/21/18 at 5:59 p.m., indicated, Discharge Diagnosis: [REDACTED]. Resident 6's progress notes dated 7/21/18 at 11:10 p.m., indicated, Resident returned to facility at approximately 10:15 PM from (name of hospital). Resident 12's progress notes dated 7/21/18 at 6:29 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Review of Resident 12's record titled, Emergency Services Discharge Instructions dated 7/21/18 at 5:57 p.m., indicated, Discharge Diagnosis: [REDACTED]. Review of Resident 12's progress notes dated 7/21/18 at 11:14 p.m., indicated, Resident returned to facility at approximately 10:55 PM from (name of hospital) in stable condition. Resident 15's progress notes dated 7/21/18 at 4:32 p.m., indicated, Resident transferred to the ER (emergency room ) due to facility evacuation. MD ordered. Resident 15's (name of hospital) Visit Summary Report dated 7/21/18 at 9:38 p.m., indicated, Diagnosis: [REDACTED]. Resident 15's progress notes dated 7/22/18 at 1:03 a.m., indicated, Resident returned from hospital. Review of Resident 24's progress notes dated 7/21/18 at 6:12 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Review of Resident 24's record, titled, (name of hospital) Visit Summary Report dated 7/21/18 at 10:47 p.m., indicated, Diagnosis: [REDACTED]. Review of Resident 24's progress notes dated 7/22/18 at 1:08 a.m., indicated, Resident returned from hospital. Resident 27's progress notes dated 7/21/18 at 7:25 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 27's progress notes dated 7/22/18 at 1:24 a.m., indicated, Resident admitted to (name of hospital).(name of hospital) nurse stated that this resident would be transferred to ICU (Intensive care unit). Admitting Dix (diagnosis)[MEDICAL CONDITION] (infection), PENA (Pneumonia), and HERD (End stage [MEDICAL CONDITION]; kidney disease). Resident 27's (name of hospital) Order requisition dated 7/25/18 at 10:24 a.m., indicated, Discharge [DIAGNOSES REDACTED]. Resident 78's progress notes dated 7/21/18 at 5:56 p.m., indicated, Residents transferred to (name of hospital) d/T heat exposure . transferred via ambulance. Resident 78's progress notes dated 7/21/18 at 9:53 p.m., indicated, Nurse from (name of hospital) called and stated that resident was being admitted to acute care for COPED ([MEDICAL CONDITION]; lung disease) and PENA (Pneumonia; lung infection caused by germs). Resident 78 had not returned to the facility after repopulation on 7/21/18. On 7/30/18 at 3:10 p.m., during an interview, LN 5 stated Resident 78 was admitted to another Skilled Nursing facility from the hospital. On 7/30/18 at 2:23 p.m., during an interview, Resident 3 stated, It was very hot on Saturday (7/21/18) . I felt fatigued. It got very hot by mid-morning and I was given oxygen because I could not breathe. Resident 3 also stated the Director of Social Services (DSS) sat him in front of a floor fan to cool off. Resident 3 stated, A nurse checked my blood pressure and it was too high . I felt sick until Monday . I had difficulty breathing . I was using oxygen off and on until today . they offered ice water, towels wet with ice, but they didn't really work, I just felt bad. Resident 3's Minimum Data Set (MDS) Assessment, dated 7/23/18, indicated Resident 3's Brief Interview for Mental Status (BIMS) score was 13 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. Resident 3's Admission Record, dated 12/19/17, indicated Resident 3 had a history of [REDACTED]. On 7/30/18 at 2:31 p.m., during an interview in regards to 7/21/18, Resident 14 stated, It was very hot by 11 o'clock in the morning . the Fire Department came and moved us. Resident 14's MDS Assessment, dated 5/21/18, indicated Resident 14's BIMS score was 15 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. On 7/30/18 at 2:35 p.m., during an interview in regards to 7/21/18, Resident 11 stated, It started getting really hot mid-afternoon . really hot, sticky, muggy, and uncomfortable. Resident 11's MDS Assessment, dated 7/23/18, BIMS score was 12 of 15 which indicated the resident was moderately cognitively intact with regard to memory and ability to make reasonable judgements. On 7/30/18 at 3:52 p.m., during an interview and concurrent review of the resident's journal, Resident 1 stated, It was hot, it gave me a headache . I drank ice water. I was sweating, my shirt was all wet. Resident 1 pointed to his journal which he stated he kept for personal use. Resident 1 stated he made an entry in his journal on Saturday, dated 7/21/18, which read, Hot . I told them (staff), wet clothes and pillow. Resident 1's MDS Assessment, with ARD (Assessment reference date) of 6/25/18, indicated Resident 1's BIMS score was 13 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. On 7/31/18 at 5:11 p.m., during an interview, Resident 20 stated, My room was very hot . the air conditioner was running but it was very hot . I didn't see anyone taking temperatures .it started getting hot about 10:30 a.m. I had a fan, but I didn't think about using it. Resident 20's MDS Assessment, dated 6/18/18, indicated Resident 20's BIMS score was 15 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. On 7/31/ at 5:00 p.m., during an interview regarding 7/21/18, Resident 25 stated, We went to the church. The air conditioner wasn't working here. I have a fan, they turned it on for me when I came back . I was sweating to death, I never sweat. I was a little light headed, I didn't complain. It started getting hot about 12 noon. It was (name of staff) checking the temperatures . he didn't tell me how hot it was. Resident 25's MDS Assessment, dated 6/29/18, indicated Resident 25's BIMS score was 14 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. Review of All Facilities Letter (AFL 18-28) sent to healthcare facilities from the California Department of Public Health Licensing and Certification dated 7/5/18, indicated, Facilities must implement recommended precautionary measures to keep individuals safe and comfortable during extreme hot temperatures and must have a contingency plans in place to deal with the loss of air conditioning, or in the case when no air conditioning is available, take measures to ensure patients and residents are free from adverse conditions that may cause heat-related health complications . It is important that facility administrators monitor weather conditions for fluctuations in extreme temperatures and take extra precautions to ensure appropriate air conditioning equipment is well maintained and operating effectively. Review of the facility policy and procedure titled, Quality of Life- Homelike Environment dated 5/17, indicated, Residents are provided with a safe, clean, comfortable, and homelike environment .2. (h) Comfortable and safe temperatures (71 degrees F through 81 degrees F). Review of (name of weather service) forecast for 7/20/18 and 7/21/18 indicated outside temperatures in (area of the facility) reached a high of 105 degrees F. on 7/20/18 and a high of 100 degrees F. on 7/21/18.

Based on interview and record review, the facility failed to ensure that each resident received care and treatment (a fundamental principle) to enable residents to maintain their highest practicable level of physical, mental, and psychosocial wellbeing for 29 of 29 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 77, Resident 78, Resident 79, Resident 80) when the facility delayed in effectively addressing the needs of residents once the facility was aware of the non-functioning chiller unit for the heating ventilation air conditioning (HVAC) system which caused environmental temperatures to climb above 81 degrees Fahrenheit (F). (Cross reference F684 and F908) The failure to effectively address residents' needs when the environmental temperatures climbed above 81 degrees F led to symptoms of heat exposure in 29 residents and heat related illnesses in seven of the 29 residents (Resident 4, Resident 6, Resident 12, Resident 15, Resident 24, Resident 27, and Resident 78) and required transfer to an acute care hospital. The local fire department and emergency services were called to assess the environment and determined the health and safety of the residents were at risk due to climbing facility temperatures and directed the facility staff to evacuate the residents to a nearby church; the residents were displaced for several hours. The Centers for Medicare & Medicaid Services Regional Office (CMS RO) reviewed the facility deficient practices and determined the identified potential serious harm to all residents and the serious actual harm to Resident 4, Resident 6, Resident 12, Resident 15, Resident 24, Resident 27, and Resident 78 warranted an Immediate Jeopardy (IJ) situation. An IJ was called by the District Office (DO) on 9/11/18 at 11:10 a.m., via telephone conference with the facility administrator. The DO explained to the facility administrator an amended 2567/Statement of Deficiencies would be submitted to the facility to reflect the IJ with scope and severity of L called at F 584 and F 908; and an additional deficient practice at F 684 with scope and severity of L would be added. A written Action Plan to address the IJ situation was requested to be submitted. An acceptable Action Plan was received on 9/14/18 and communicated to the facility Administrator. An onsite visit was conducted on 9/18/18 and validated implementation of interventions meant to address the IJ. The IJ was removed on 9/18/18 at 3:35 p.m. and communcated to the facility Administrator. Findings: On 7/26/18 at 9:54 a.m., during an interview, the Executive Director (ED - the facility Administrator) stated he received a text from the Director of Nurses (DON) on 7/21/18 at 7:40 a.m., which indicated the cooling unit for the facility had stopped working. The ED stated the water pump for the chiller (cooling unit) broke which caused the cooling unit to fail. The ED stated, We knew it was hot, taking temps (temperatures) were not that important . we were focused on repairs . we knew it (pump) was going to take a couple of hours to fix. The ED stated portable floor fans and two large coolers purchased by the facility had not kept the facility cool and the (name of city) Fire Department (FD) Chief ordered the evacuation of the residents on 7/21/18. The ED stated maintenance staff had requested the FD come and evaluate the facility's water supply when it was determined water was not being pumped through the cooling unit, which caused it to fail. The ED stated, I was not there . the FD took over and coordinated the transfer of residents to the hospital . 20 (residents) went to the (name) church across the street, seven went to the hospital, one to [MEDICAL TREATMENT], and one went with family. The ED stated all residents were evacuated by 5:45 p.m. from the facility. The ED stated he did not know why the FD came back to the facility the afternoon of 7/21/18. On 7/26/18 at 11:25 a.m., during an interview, the Director of Staff Development (DSD) stated she was notified by the DON of the broken air conditioner and was called in to work on 7/21/18. The DSD stated, We (meaning the DON and ED and herself) all arrived around the same time . 4:30 p.m. The DSD also stated EMS (Emergency Medical Service) was at the facility evaluating residents for heat exhaustion (a heat related illness) when she arrived. On 7/26/18 at 3:55 p.m., during an interview, the Maintenance Supervisor (MS) stated he was called into the facility the morning of 7/21/18. The MS stated he arrived at 10:00 a.m. The MS stated the Director of Plant Operations (DPO) had contacted a heating, ventilation, and air conditioning (HVAC) company and had the air conditioning unit evaluated. The MS stated it was determined water was not being supplied to the unit which caused it to fail. The MS stated, We thought it was a problem with the water supply so we called the fire department to see . later we found out it was the pump . around 12:00 (p.m.) The MS stated they were unsure of how long it would take to fix. The MS stated, It was a Saturday . we're lucky we could get it fixed. The MS stated maintenance communicated with the ED (Administrator) throughout the day to keep him informed of what was happening. On 7/26/18 at 6:55 p.m., during an interview, the DSD stated the ED or the DON should have determined earlier that day (7/21/18) if the evacuation of residents from the facility was necessary. The DSD stated the facility temperature felt warm when she arrived at the facility on 7/21/18 at around 4:30 p.m. The DSD stated, From what I saw, the residents were hot. The DSD also stated she had not taken a temperature of the facility environment nor had she asked residents if they were hot. The DSD stated her role on 7/21/18 was to assist with the evacuation only. On 7/27/18 at 1:50 p.m., during an interview, Certified Nursing Assistant (CNA) 12 stated she arrived to work at 6:10 a.m. on 7/21/18. CNA 12 stated the facility environment felt hot and muggy and mentioned it to the charge nurse. CNA 12 stated the charge nurse had spoken to the maintenance staff. CNA 12 stated, I was sweating just walking . the residents started feeling uncomfortable after lunch time. CNA 12 stated the Fire Department (FD) was at the facility at 11:30 a.m. and gave direction to the nurse to call the FD back at 2:00 p.m. if the temperatures did not get better. On 7/27/18 at 2:20 p.m., during an interview, CNA 6 stated, It started to get hot at 9:00 a.m. and after lunch at 12:00 p.m. it was really hot . I am not sure how hot it got . we started passing ice water after breakfast and wet cold towels were passed at 10:00 a.m .the residents verbalized feeling uncomfortable and hot. CNA 6 also stated she witnessed the FD at the facility twice. CNA 6 stated the maintenance manager brought fans and residents sat in the hallways. On 7/27/18 at 2:50 p.m., during an interview, CNA 5 stated she arrived to work at 2:15 p.m. on 7/21/18. CNA 5 stated, It (the facility) felt hotter inside than outside . they told me the AC (Air Conditioner) was broke. CNA 5 stated she had not checked the thermostats. CNA 5 stated, (Resident 3) looked dehydrated . he looked drowsy with eyes half opened and shut and he complained that it was really hot . the nurse told me to give him ice and sit him in front of a fan. CNA 5 also stated, the FD showed up . they said the facility was too hot . the fireman approached me and two other CNAs and asked us if we thought residents were safe here. We all responded no .as soon as we told them we started evacuation procedures. CNA 5 stated the ED, the DON, and the DSD arrived during the evacuation. On 7/27/18 at 3:20 p.m., during an interview, LN 3 stated on 7/21/18 she was the PM shift charge nurse for the facility. LN 3 stated the AM shift charge nurse (LN 5) reported (to the nursing staff) the facility's air conditioner was broken and cooling measures for the residents had been provided during the day. LN 3 also stated LN 5 reported the FD had been called to the facility twice and had given instructions to evacuate the residents if ambient (surrounding environment) temperatures in the facility rose throughout the day. LN 3 stated the FD Chief returned to the facility at 4:00 p.m. and ordered the evacuation of the residents when the maintenance staff had not purchased and delivered portable air conditioning units to the facility. LN 3 stated she was unable to reach church staff to open the church and initiate evacuation of the residents. LN 3 stated someone from the FD walked across the street to the church and had the church opened. LN 3 stated Resident 80 and Resident 2 were not included in the evacuation. LN 3 stated Resident 80 left for the scheduled 5:00 p.m. [MEDICAL TREATMENT] (mechanical procedure in which waste, salts, and fluid are filtered from blood) appointment. LN 3 stated Resident 2 was with family until 9:30 p.m. Review of receipt from the local hardware store provided by the facility staff dated and time stamped 7/21/18 at 1635 (military time for 4:35 p.m.), indicated two portable evaporator coolers were purchased after the facility evacuation was initiated by the FD. On 7/26/18 at 3:45 p.m., during an interview, the ED stated, I didn't think it was necessary to evacuate residents because repairs were close to being completed . I base my decision on not wanting to transfer residents . (name of DON), (name of DSD), (name of MS), and (name of Director Plant Operations-Maintenance) said no one was in any distress. The ED also stated the facility did not have an agreement with the church and the Pastor of the church. The ED stated, We don't have any transfer agreements with any facility for evacuation. On 7/30/18 at 10:20 a.m., during a telephone interview, the DON stated the AM shift charge nurse notified her of the broken air conditioning unit on 7/21/18 at approximately 8:00 a.m. The DON stated she instructed the charge nurse to contact maintenance staff and distribute ice water, cool wash rags, and fans to the residents. The DON also stated she instructed the charge nurse to monitor the residents for signs and symptoms of heat exhaustion. The DON stated, I told her to monitor for nausea and vomiting, excessive sweating, increased fatigue, (and) decreased level of consciousness. The DON stated the charge nurse told her maintenance staff had contacted a service technician and repairs to the air conditioner were being done. The DON stated the maintenance staff recorded facility temperatures and reported the temperature readings directly to the ED. The DON stated she did not know what the facility's ambient temperature was on 7/21/18. The DON stated she did not know what the facility temperature should have been in order to minimize the risk to resident's but considered 89 degrees Fahrenheit (F) a safe temperature. The DON stated she was notified by the PM nurse the FD mandated the evacuation. The DON stated nurses should have evacuated when residents were in distress or unsafe. Review of facility document titled, Daily Inspection Records dated 7/21/18, indicated an hourly log of temperature readings for 20 facility resident rooms including the dining room, the east hall, the west hall, and the north/south hall. The log indicated temperature readings were to be recorded hourly from 8:00 a.m. through 7:00 p.m. The log indicated omissions of recorded temperatures from 8:00 a.m. to 11:00 a.m. The first recorded temperature readings were at 12:00 p.m. for room one through room [ROOM NUMBER], including the dining room, the east hall, the west hall, and the north/south hall with temperatures ranging from 77 degrees F. up to 79 degrees F. Temperature readings at 1:00 p.m. in the areas listed ranged from 83 degrees F. to 84 degrees F. Temperature readings at 2:00 p.m. in the areas listed ranged from 85 degrees F. to 88 degrees F. Temperature readings at 3:00 p.m. in the areas listed ranged from 87 degrees F. to 88 degrees F. Temperature readings at 4:00 p.m. in the areas listed ranged from 86 degrees F. to 89 degrees F. Temperature readings at 5:00 p.m. in the areas listed ranged from 84 degrees F to 89 degrees F. Resident 1's progress noted dated 7/21/16 at 6:05 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to church across the street from facility . Resident 3's progress notes dated 7/21/18 at 6:27 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 5's progress notes dated 7/21/18 at 6:17 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 9's progress notes dated 7/21/18 at 7:21 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 10's progress notes dated 7/21/18 at 6:15 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 11's progress notes dated 7/21/18 at 6:27 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 13's progress notes dated 7/21/18 at 5:55 p.m., indicated, Resident evacuated from facility due to heat. Resident 14's progress notes dated 7/21/18 at 6:28 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 16's progress notes dated 7/21/18 at 5:48 p.m., indicated, Resident evacuated from facility due to heat. Resident 17's progress notes dated 7/21/18 at 6:13 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 18's progress notes dated 7/21/18 at 6:11 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 19's progress notes dated 7/21/18 at 6:08 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 20's progress notes dated 7/21/18 at 7:15 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 21 and Resident's 1's progress notes dated 7/21/18 at 6:05 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 22's progress notes dated 7/21/18 at 5:45 p.m., indicated, Resident evacuated from facility due to heat. Resident 23's progress notes dated 7/21/18 at 6:29 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 25's progress notes dated 7/21/18 at 5:58 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 26's progress notes dated 7/21/18 at 5:48 p.m., indicated, Resident evacuated from facility due to heat. Resident 77's progress notes dated 7/21/18 at 5:46 p.m., indicated, Resident evacuated from facility due to heat. Resident 79's progress notes dated 7/21/18 at 6:14 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 80's progress notes dated 7/21/18 at 6:24 p.m., indicated, Resident went to [MEDICAL TREATMENT] (a process used to remove toxins from the body) as scheduled. Resident will be at [MEDICAL TREATMENT] center during facility evacuation due to heat exposure for safety . On 7/30/18 at 3:05 p.m., during an interview, CNA 8 stated she worked on 7/21/18 during the morning shift. CNA 8 stated, It seemed like the ac (air conditioner) was not working when I came in at 6:15 a.m . the nurse told me it doesn't work . it felt stuffy, no ventilation. CNA 8 also stated alert residents had complained it was hot. CNA 8 stated, (Resident 19) looked dehydrated . seemed weaker than usual. CNA 8 stated Resident 19's room and room [ROOM NUMBER] were very hot. CNA 8 stated, We offered water and tried to open windows, but it was too hot . we brought up old fans from downstairs. On 7/30/18 at 3:10 p.m., during an interview, LN 5 stated she was the AM charge nurse on 7/21/18 who reported the broken air conditioning unit at 7:40 a.m. to the DON. LN 5 stated the night nurse from the previous shift told her in shift report she (night nurse) thought the air conditioner was not working properly. LN 5 stated the facility's temperature felt warmer than usual so she contacted the DON. LN stated, She (DON) told me to pass ice water to drink and cold towels. LN 5 stated they pulled fans from different areas for the residents as the day progressed. LN 5 stated the maintenance staff arrived later with additional fans. LN 5 stated Resident 78 complained of the heat and felt hot. LN 5 stated the FD came to the facility twice. LN 5 stated she was instructed to contact them (FD) if temperatures rose greater than 80 degrees F. LN 5 stated maintenance staff had contacted the FD the first time and was not sure who contacted the FD the second time. LN 5 stated, I didn't consider the situation an emergency because they were working on the AC (air conditioning). On 7/31/18 at 6:40 a.m., during concurrent interviews, CNA 9 stated they (CNA 9, CNA 10, and LN 4) worked on 7/21/18 during the night shift. CNA 9 stated the night shift started at 10:00 p.m. and the temperature in the facility still felt hot. CNA 9 stated fans were kept on through the night to cool down the facility. LN 4 stated she was told during shift report to monitor residents for heat exhaustion. LN 4 also stated residents that had transferred to the hospital during the evacuation returned to the facility that night (7/21/18) except for Resident 78, Resident 27, and Resident 80. On 7/31/18 at 4:00 p.m., during an interview, the local city FD Fire Chief stated, I was the contact on the scene because the nurse was having trouble reaching any of her supervisors . I told her I would assist in giving her direction as to evacuation. The FD Chief stated the evacuation of residents was initiated based on the facility's environmental temperature and potential risk to the residents. The FD Chief stated temperatures in the facility were well above 81 degrees F. and cooling measures initiated by the facility were ineffective. The FD Chief stated, One resident was bobbing his head like he was going to pass out . bedridden residents with multiple issues were transferred out. The FD Chief stated he had not spoken to the ED (Administrator) prior to 4:00 p.m. Review of the Fire Department Incident Report dated 7/21/18, indicated the FD was dispatched at 4:09 p.m. to the facility to assist in the removal of 29 convalescent residents after the mechanical breakdown of an HVAC unit. The report also indicated, Temperature inside the facility exceeded 80 plus degrees with multiple patients (residents) suffering from heat related illnesses . seven patients required transport to hospital via (by way of) ambulance. Resident 4's progress notes dated 7/21/18 at 6:18 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 4's local fire department patient care record dated 7/21/8 at 4:47 p.m., indicated, EMS (emergency medical services) arrived to find patient sitting upright on the bed at SNF (skilled nursing facility). Pt (patient) is (complaining of) nausea secondary to heat exhaustion. Pt has been at SNF with no air conditioning since this afternoon .Pt reassessed in route and Pt is no longer nauseated . Resident 4's acute care hospital record titled, After Visit Summary Report dated 7/22/18 at 1:41 a.m., indicated, Diagnosis: [REDACTED]. Resident 4's progress notes dated 7/22/18 at 2:54 a.m., indicated, Resident arrived back to the facility from ER (emergency room ). Resident 6's progress notes dated 7/21/18 at 6:07 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 6's acute care hospital records titled, Emergency Department Reports dated 7/21/18 at 5:59 p.m., indicated, Discharge Diagnosis: [REDACTED]. Resident 6's progress notes dated 7/21/18 at 11:10 p.m., indicated, Resident returned to facility at approximately 10:15 PM from (name of hospital). Resident 12's progress notes dated 7/21/18 at 6:29 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Review of Resident 12's record titled, Emergency Services Discharge Instructions dated 7/21/18 at 5:57 p.m., indicated, Discharge Diagnosis: [REDACTED]. Review of Resident 12's progress notes dated 7/21/18 at 11:14 p.m., indicated, Resident returned to facility at approximately 10:55 PM from (name of hospital) in stable condition. Resident 15's progress notes dated 7/21/18 at 4:32 p.m., indicated, Resident transferred to the ER (emergency room ) due to facility evacuation. MD ordered. Resident 15's (name of hospital) Visit Summary Report dated 7/21/18 at 9:38 p.m., indicated, Diagnosis: [REDACTED]. Resident 15's progress notes dated 7/22/18 at 1:03 a.m., indicated, Resident returned from hospital. Review of Resident 24's progress notes dated 7/21/18 at 6:12 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Review of Resident 24's record, titled, (name of hospital) Visit Summary Report dated 7/21/18 at 10:47 p.m., indicated, Diagnosis: [REDACTED]. Review of Resident 24's progress notes dated 7/22/18 at 1:08 a.m., indicated, Resident returned from hospital. Resident 27's progress notes dated 7/21/18 at 7:25 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 27's progress notes dated 7/22/18 at 1:24 a.m., indicated, Resident admitted to (name of hospital).(name of hospital) nurse stated that this resident would be transferred to ICU (Intensive care unit). Admitting Dix (diagnosis)[MEDICAL CONDITION] (infection), PENA (Pneumonia), and HERD (End stage [MEDICAL CONDITION]; kidney disease). Resident 27's (name of hospital) Order requisition dated 7/25/18 at 10:24 a.m., indicated, Discharge [DIAGNOSES REDACTED]. Resident 78's progress notes dated 7/21/18 at 5:56 p.m., indicated, Residents transferred to (name of hospital) d/T heat exposure . transferred via ambulance. Resident 78's progress notes dated 7/21/18 at 9:53 p.m., indicated, Nurse from (name of hospital) called and stated that resident was being admitted to acute care for COPED ([MEDICAL CONDITION]; lung disease) and PENA (Pneumonia; lung infection caused by germs). Resident 78 had not returned to the facility after repopulation on 7/21/18. On 7/30/18 at 3:10 p.m., during an interview, LN 5 stated Resident 78 was admitted to another Skilled Nursing facility from the hospital. On 7/30/18 at 2:23 p.m., during an interview, Resident 3 stated, It was very hot on Saturday (7/21/18) . I felt fatigued. It got very hot by mid-morning and I was given oxygen because I could not breathe. Resident 3 also stated the Director of Social Services (DSS) sat him in front of a floor fan to cool off. Resident 3 stated, A nurse checked my blood pressure and it was too high . I felt sick until Monday . I had difficulty breathing . I was using oxygen off and on until today . they offered ice water, towels wet with ice, but they didn't really work, I just felt bad. Resident 3's Minimum Data Set (MDS) Assessment, dated 7/23/18, indicated Resident 3's Brief Interview for Mental Status (BIMS) score was 13 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. Resident 3's Admission Record, dated 12/19/17, indicated Resident 3 had a history of [REDACTED]. On 7/30/18 at 2:31 p.m., during an interview in regards to 7/21/18, Resident 14 stated, It was very hot by 11 o'clock in the morning . the Fire Department came and moved us. Resident 14's MDS Assessment, dated 5/21/18, indicated Resident 14's BIMS score was 15 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. On 7/30/18 at 2:35 p.m., during an interview in regards to 7/21/18, Resident 11 stated, It started getting really hot mid-afternoon . really hot, sticky, muggy, and uncomfortable. Resident 11's MDS Assessment, dated 7/23/18, BIMS score was 12 of 15 which indicated the resident was moderately cognitively intact with regard to memory and ability to make reasonable judgements. On 7/30/18 at 3:52 p.m., during an interview and concurrent review of the resident's journal, Resident 1 stated, It was hot, it gave me a headache . I drank ice water. I was sweating, my shirt was all wet. Resident 1 pointed to his journal which he stated he kept for personal use. Resident 1 stated he made an entry in his journal on Saturday, dated 7/21/18, which read, Hot . I told them (staff), wet clothes and pillow. Resident 1's MDS Assessment, with ARD (Assessment reference date) of 6/25/18, indicated Resident 1's BIMS score was 13 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. On 7/31/18 at 5:11 p.m., during an interview, Resident 20 stated, My room was very hot . the air conditioner was running but it was very hot . I didn't see anyone taking temperatures .it started getting hot about 10:30 a.m. I had a fan, but I didn't think about using it. Resident 20's MDS Assessment, dated 6/18/18, indicated Resident 20's BIMS score was 15 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. On 7/31/ at 5:00 p.m., during an interview regarding 7/21/18, Resident 25 stated, We went to the church. The air conditioner wasn't working here. I have a fan, they turned it on for me when I came back . I was sweating to death, I never sweat. I was a little light headed, I didn't complain. It started getting hot about 12 noon. It was (name of staff) checking the temperatures . he didn't tell me how hot it was. Resident 25's MDS Assessment, dated 6/29/18, indicated Resident 25's BIMS score was 14 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. Review of All Facilities Letter (AFL 18-28) sent to healthcare facilities from the California Department of Public Health Licensing and Certification dated 7/5/18, indicated, Facilities must implement recommended precautionary measures to keep individuals safe and comfortable during extreme hot temperatures and must have a contingency plans in place to deal with the loss of air conditioning, or in the case when no air conditioning is available, take measures to ensure patients and residents are free from adverse conditions that may cause heat-related health complications . It is important that facility administrators monitor weather conditions for fluctuations in extreme temperatures and take extra precautions to ensure appropriate air conditioning equipment is well maintained and operating effectively. Review of the facility policy and procedure titled, Quality of Life- Homelike Environment dated 5/17, indicated, Residents are provided with a safe, clean, comfortable, and homelike environment .2. (h) Comfortable and safe temperatures (71 degrees F through 81 degrees F). Review of (name of weather service) forecast for 7/20/18 and 7/21/18 indicated outside temperatures in (area of the facility) reached a high of 105 degrees F. on 7/20/18 and a high of 100 degrees F. on 7/21/18.

Based on observation, interview, and record review, the facility failed to maintain mechanical and electrical facility equipment in a safe operating condition for 29 of 29 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 77, Resident 78, Resident 79, Resident 80) when: 1. A pump which fed water into the facility's heating, ventilation, and air conditioning chiller unit (HVAC system) was not monitored, not maintained and failed to work on 7/21/18. 2. A fan in disrepair was provided for use to Resident 19. The failure to monitor and maintain facility mechanical and electrical equipment resulted in the breakdown of the facility HVAC system and the need to evacuate 29 residents from the facility (cross reference F584 and F 684); and directly led to seven residents (Resident 15, Resident 78, Resident 24, Resident 27, Resident 4, Resident 6, Resident 12) being transferred to an acute care hospital. The local fire department and emergency services assessed the safety of the residents and determined an unsafe temperature environment for the residents and ordered the evacuation to a nearby church; the residents were displaced for several hours. For Resident 19 the failure resulted in the use of a fan in disrepair and placed Resident 19 at potential harm for injury. The Centers for Medicare & Medicaid Services Regional Office (CMS RO) reviewed the facility deficient practices and determined the identified potential serious harm to all residents and the serious actual harm to Resident 4, Resident 6, Resident 12, Resident 15, Resident 24, Resident 27, and Resident 78 warranted an Immediate Jeopardy (IJ) situation. An IJ was called by the District Office (DO) on 9/11/18 at 11:10 a.m., via telephone conference with the facility administrator. The DO explained to the facility administrator an amended 2567/Statement of Deficiencies would be submitted to the facility to reflect the IJ with scope and severity of L called at F 584 and F 908; and an additional deficient practice at F 684 with scope and severity of L would be added. A written Action Plan to address the IJ situation was requested to be submitted. An acceptable Action Plan was received on 9/14/18 and communicated to the facility Administrator. An onsite visit was conducted on 9/18/18 and validated implementation of interventions meant to address the IJ. The IJ was removed on 9/18/18 at 3:35 p.m. and communcated to the facility Administrator. Findings: 1. On 7/26/18 at 9:54 a.m., during an interview, the Executive Director (ED - facility Administrator) stated the water pump for the chiller (HVAC unit) broke on 7/21/18 at 7:40 a.m. which caused the air conditioning cooling unit to fail. The ED stated, It just went out, there was no way of checking it. The ED stated the water pump had not been maintained and was not part of maintenance's monthly routine inspection. The ED stated, My plan now is researching how to maintain the pump. The ED stated he had not considered the water pump a major repair. On 7/26/18 at 3:55 p.m., during a group interview with the Maintenance Supervisor (MS) and the Director of Plant Operations (DPO), the MS stated he was called to the facility the morning of 7/21/18 and arrived at 10:00 a.m. The MS stated at 12:00 p.m. it was determined that the water pump which fed water into the chiller was broken. The MS stated, We thought it was a problem with the water supply so we called the Fire Department (FD) to see. The MS stated he had contacted a company to evaluate the pump. The MS also stated, They (company) felt the pump was an emergency and it (water pump) had to get fixed right away. The MS stated the company located a pump and had it replaced by 5:00 p.m. on 7/21/18. The MS stated they were unsure of how long it would take to fix. The MS stated, It was a Saturday . we're lucky we could get it fixed. The MS stated the maintenance staff communicated with the ED throughout the day to keep the ED informed of what was happening. The DPO stated, On Saturday (7/21/18) the service technician diagnosed water was not flowing through the chiller . the pump was bad . water was present but the pump did not pump water. The DPO also stated no type of maintenance to the water pump was performed prior to 7/21/18. The DPO stated, There is only one pump which is submerged in water . was unable to assess. On 7/26/18, at 3:55 p.m., during observation and concurrent interview outside the facility, a metal box stood next to the water pump unit. The DPO stated the metal box was the control box for the water pump. The DPO stated, The control box can tell if the pump is disconnected . The DPO stated no type of maintenance had been done to the control box. On 7/26/18 at 6:55 p.m., during an interview, the Director of Staff Development (DSD) stated the ED or the Director of Nurses (DON) should have determined earlier that day if the evacuation of residents from the facility was necessary. The DSD stated the facility temperature felt warm when she had arrived at the facility on 7/21/18 at 4:30 p.m. The DSD stated, From what I saw, the residents were hot. On 7/27/18 at 1:50 p.m., during an interview, Certified Nursing Assistant 12 (CNA 12) stated she arrived to work at 6:10 a.m. on 7/21/18. CNA 12 stated the facility environment felt hot and muggy and mentioned it to the charge nurse. CNA 12 stated the charge nurse had spoken to maintenance. CNA 12 stated, I was sweating just walking . the residents started feeling uncomfortable after lunch time. On 7/27/18 at 2:50 p.m., during an interview, CNA 5 stated she arrived to work at 2:15 p.m. on 7/21/18. CNA 5 stated, It (the facility) felt hotter inside than outside . they told me the AC (air conditioner) was broke. CNA 5 stated she had not checked the thermostats. CNA 5 stated, (Resident 3) looked dehydrated . he looked drowsy with eyes half opened and shut and he complained that it was really hot . the nurse (LN 5) told me to give him ice and sit him in front of a fan. CNA 5 stated, the FD (fire department) showed up . they said the facility was too hot . the fireman approached me and two other CNAs (CNA 13 and CNA 14) and asked us if we thought residents were safe here. We all responded no . as soon as we told them we started evacuation procedures. CNA 5 stated the ED, the DON, and the DSD arrived during the evacuation. On 7/27/18 at 3:20 PM, during an interview, Licensed Nurse 3 (LN 3) stated on 7/21/18 she was the PM shift charge nurse for the facility. LN 3 stated the AM shift charge nurse (LN 5) reported the facility's air conditioner was broken and cooling measures for the residents had been provided during the day. LN 3 also stated LN 5 reported the FD had been called to the facility twice and had given instructions to evacuate the residents if ambient (surrounding environment) temperatures in the facility rose throughout the day. LN 3 stated the FD Chief returned to the facility at 4:00 p.m. and ordered the evacuation of the residents when Maintenance (staff) had not purchased and delivered portable air conditioning units to the facility. On 7/31/18 at 4:00 p.m., during an interview, the (local) FD Fire Chief stated, I was the contact on the scene because the nurse (LN 5) was having trouble reaching any of her supervisors . I told her I would assist in giving her direction as to evacuation. The FD Chief stated the evacuation of residents was initiated based on the facility's environment and a potential for harm to the residents. The FD Chief stated temperatures in the facility were well above 81 degrees Fahrenheit (F) and cooling measures initiated by the facility were ineffective. The FD Chief stated, One resident was bobbing his head like he was going to pass out .bedridden residents with multiple issues were transferred out. The (local fire department) FD Chief stated he had not spoken to the ED prior to 4:00 p.m. when the ED arrived during the facility's evacuation. On 7/30/18 at 10:20 a.m., during a telephone interview, the DON stated the AM shift charge nurse (LN 5) notified her of the broken air conditioning unit on 7/21/18 at 8:00 a.m. The DON stated she instructed the charge nurse to contact the Maintenance Department staff and distribute ice water, cool wash rags, and fans to the residents. The DON also stated she instructed the charge nurse to monitor the residents for signs and symptoms of heat exhaustion. The DON stated, I told her to monitor for nausea and vomiting, excessive sweating, increased fatigue, (and) decreased level of consciousness. The DON stated the charge nurse told her maintenance had contacted a service technician and repairs to the air conditioner were being done. The DON stated maintenance recorded facility temperatures and reported the temperature readings directly to the ED. The DON stated she did not know what the facility's ambient temperature was on 7/21/18. The DON also stated she did not know what facility temperature should have been to minimize risks to residents but considered 89 degrees F. a safe temperature. The DON stated she was notified by the PM Nurse (LN 3) the FD mandated the evacuation. The DON stated nurses should have evacuated when residents were in distress or unsafe. Review of facility document titled, Daily Inspection Records dated 7/21/18, indicated an hourly log of temperature readings for 20 facility resident rooms including the dining room, the east hall, the west hall, and the north/south hall. The log indicated temperature readings were to be recorded hourly from 8:00 a.m. through 7:00 p.m. Recorded temperatures from 8:00 a.m. to 11:00 a.m. were omitted from the log. The first recorded temperature readings were at 12:00 p.m. for room one through room [ROOM NUMBER], including the dining room, the east hall, the west hall, and the north/south hall with temperatures ranging from 77 degrees F. up to 79 degrees F. Temperature readings at 1:00 p.m. in the areas listed ranged from 83 degrees F. to 84 degrees F. Temperature readings at 2:00 p.m. in the areas listed ranged from 85 degrees F. to 88 degrees F. Temperature readings at 3:00 p.m. in the areas listed ranged from 87 degrees F. to 88 degrees F. Temperature readings at 4:00 p.m. in the areas listed ranged from 86 degrees F. to 89 degrees F. Temperature readings at 5:00 p.m. in the areas listed ranged from 84 degrees F to 89 degrees F. The temperature range should have been maintained between 71 degrees F. and 81 degrees F. On 7/30/18 at 2:23 p.m., during an interview, Resident 3 stated, It was very hot on Saturday . I felt fatigued. It got very hot by mid-morning and I was given oxygen because I could not breathe. Resident 3 also stated, the Director of Social Services (DSS) sat him in front of a floor fan to cool off. Resident 3 stated, A nurse checked my blood pressure and it was too high . I felt sick until Monday . I had difficulty breathing . I was using oxygen off and on until today . they offered ice water, towels wet with ice, but they didn't really work, I just felt bad. Resident 3's Minimum Data Set (MDS) Assessment, dated 7/23/18, indicated Resident 3's Brief Interview for Mental Status (BIMS) score was 13 of 15 which indicated the resident was cognitively intact with regard to memory and ability to make reasonable judgements. On 7/30/18 at 2:35 p.m., during an interview in regards to 7/21/18, Resident 11 stated, It started getting really hot mid-afternoon . really hot, sticky, muggy, and uncomfortable. Resident 11's MDS Assessment, dated 7/23/18, BIMS score was 12 of 15 which indicated the resident was moderately cognitively intact with regard to memory and ability to make reasonable judgements. Resident 14's progress notes dated 7/21/18 at 6:28 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 16's progress notes dated 7/21/18 at 5:48 p.m., indicated, Resident evacuated from facility due to heat. Resident 79's progress notes dated 7/21/18 at 6:14 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 21's progress notes dated 7/21/18 at 6:05 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 1's progress notes dated 7/21/18 at 6:05 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 9's progress notes dated 7/21/18 at 7:21 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 77's progress notes dated 7/21/18 at 5:46 p.m., indicated, Resident evacuated from facility due to heat. Resident 18's progress notes dated 7/21/18 at 6:11 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 5's progress notes dated 7/21/18 at 6:17 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 11's progress notes dated 7/21/18 at 6:27 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 19's progress notes dated 7/21/18 at 6:08 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 23's progress notes dated 7/21/18 at 6:29 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 13's progress notes dated 7/21/18 at 5:55 p.m., indicated, Resident evacuated from facility due to heat. Resident 3's progress notes dated 7/21/18 at 6:27 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 26's progress notes dated 7/21/18 at 5:48 p.m., indicated, Resident evacuated from facility due to heat. Resident 10's progress notes dated 7/21/18 at 6:15 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 20's progress notes dated 7/21/18 at 7:15 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 17's progress notes dated 7/21/18 at 6:13 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Resident 22's progress notes dated 7/21/18 at 5:45 p.m., indicated, Resident evacuated from facility due to heat. Resident 25's progress notes dated 7/21/18 at 5:58 p.m., indicated, Resident was evacuated due to heat exposure for safety. Resident evacuated to church across the street. Review of the Fire Department Incident Report dated 7/21/18, indicated the FD was dispatched at 4:09 p.m. to the facility to assist in the removal of 29 convalescent residents after the mechanical breakdown of an HVAC unit. The report also indicated, Temperature inside the facility exceeded 80 plus degrees with multiple patients (residents) suffering from heat related illnesses . seven patients required transport to hospital via (by way of) ambulance. Resident 15's progress notes dated 7/21/18 at 4:32 p.m., indicated, Resident transferred to the ER (emergency room ) due to facility evacuation. MD ordered. Resident 15's (name of hospital) Visit Summary Report dated 7/21/18 at 9:38 p.m., indicated, Diagnosis: [REDACTED]. Resident 15's progress notes dated 7/22/18 at 1:03 a.m., indicated, Resident returned from hospital. Resident 78's progress notes dated 7/21/18 at 5:56 p.m., indicated, Residents transferred to (name of hospital) d/t heat exposure . transferred via ambulance. Resident 78's progress notes dated 7/21/18 at 9:53 p.m., indicated, Nurse from (name of hospital) called and stated that resident was being admitted to acute care for [MEDICAL CONDITION] ([MEDICAL CONDITION]; lung disease) and PNA (Pneumonia; lung infection caused by germs). Resident 78 had not returned to the facility. On 7/30/18 at 3:10 p.m., during an interview, LN 5 stated Resident 78 was admitted to another facility from the hospital. Resident 27's progress notes dated 7/21/18 at 7:25 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 27's progress notes dated 7/22/18 at 1:24 a.m., indicated, Resident admitted to (name of hospital).(name of hospital) nurse stated that this resident would be transferred to ICU (Intensive care unit). Admitting dx (diagnosis)[MEDICAL CONDITION] (infection), PNA (Pneumonia), and [MEDICAL CONDITION] (End stage [MEDICAL CONDITION]; kidney disease). Resident 27's (name of hospital) Order requisition dated 7/25/18 at 10:24 a.m., indicated, Discharge [DIAGNOSES REDACTED]. Resident 4's progress notes dated 7/21/18 at 6:18 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 4's (name of hospital) Visit Summary Report dated 7/22/18 at 1:41 a.m., indicated Diagnosis: [REDACTED]. Resident 4's progress notes dated 7/22/18 at 2:54 a.m., indicated, Resident arrived back to the facility from ER (emergency room ). Resident 6's progress notes dated 7/21/18 at 6:07 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 6's Emergency Services Discharge Instructions dated 7/21/18 at 5:59 p.m., indicated, Discharge Diagnosis: [REDACTED]. Resident 6's progress notes dated 7/21/18 at 11:10 p.m., indicated, Resident returned to facility at approximately 10:15 PM from (name of hospital). Resident 12's progress notes dated 7/21/18 at 6:29 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 12's Emergency Services Discharge Instructions dated 7/21/18 at 5:57 p.m., indicated, Discharge Diagnosis: [REDACTED]. Resident 12's progress notes dated 7/21/18 at 11:14 p.m., indicated, Resident returned to facility at approximately 10:55 PM from (name of hospital) in stable condition. Resident 24's progress notes dated 7/21/18 at 6:12 p.m., indicated, Resident evacuated from facility due to heat exposure for safety. Resident evacuated to Hospital; (name of hospital). Resident 24's (name of hospital) Visit Summary Report dated 7/21/18 at 10:47 p.m., indicated Diagnosis: [REDACTED]. Resident 24's progress notes dated 7/22/18 at 1:08 a.m., indicated, Resident returned from hospital On 7/26/18 at 3:55 p.m., during an observation and concurrent interview, the air conditioning cooling unit which facility staff referred to as the chiller was located in the basement of the facility. Air filters were not dated. Water pipes located on the chiller were covered with a white crystal like substance and were leaking clear fluid to pans below. The pans were filled with a dirty dark liquid and a green-black foam like substance floated on top of the liquid. Multiple portions of the chiller's air duct were secured with plastic tape and a foam was used to seal gaps. Multiple cut wires hung from a wall of the chiller unit. Two motors located on the back of the chiller which the MS referred to as compressors were covered in black grease. The MS stated he had changed the filters on the chiller one week ago. The MS stated, I changed it (filters) . I didn't date it . the process is to date filters so you know when it was last done. The MS stated the crystal like substance on the chiller's water pipes was condensation and the liquid below was drippings from the condensation. The MS also stated, The wires on the chiller are dead but we need to fix that. The Director of Plant Operations (DPO) stated the chiller was the only cooling unit for the facility. The DPO stated the building was built in 1949 and thought the chiller was the original cooling unit. The DPO stated he had no blue prints for the chiller unit. Review of an estimate from (name of HVAC company) dated 7/23/18, indicated, Chiller repairs . Replace starter overload to the correct size and amps, replace all safety controllers (oil and pressure) service both compressors and replace oil . replace filter drier on circuit#2 that's leaking . replace thermostat control . Electrical wire and settings . refrigerant R-417C . Review of document provided by the MS titled, Monthly Inspection Records dated (YEAR), indicated inspections were to be done (MONTH) through (MONTH) (YEAR). The log contained omissions for (MONTH) through (MONTH) (YEAR). The log had an X entered in a box labeled July; item- chiller filters maintained. The document omitted who performed the maintenance on the unit and the date and time the maintenance was performed. Review of All Facilities Letter (AFL 18-28) sent to healthcare facilities from the California Department of Public Health Licensing and Certification dated 7/5/18, indicated, Facilities must implement recommended precautionary measures to keep individuals safe and comfortable during extreme hot temperatures and must have a contingency plans in place to deal with the loss of air conditioning, or in the case when no air conditioning is available, take measures to ensure patients and residents are free from adverse conditions that may cause heat-related health complications . It is important that facility administrators monitor weather conditions for fluctuations in extreme temperatures and take extra precautions to ensure appropriate air conditioning equipment is well maintained and operating effectively. 2. On 7/23/18 at 11:03 a.m., during an observation in room [ROOM NUMBER], a desk fan with two missing press-button control switches sat on Resident 19's dresser drawer. The missing control switches left two finger sized holes on the operation panel at the base of the fan. The fan was plugged into the wall and was on. Resident 19 was laying in bed facing the fan. On 7/24/18 at 4:00 p.m., during an interview, the Maintenance Supervisor (MS) stated the broken fan was pulled from his work room in the basement and given to Resident 19. The MS stated the fan was used to cool Resident 19's room when the chiller (air conditioning cooling unit) stopped working on 7/21/18 and Resident 19's room was too hot. The MS stated, It should not have been used due to risk for injury to the resident. Two of the buttons were missing and the resident is confused . I removed the fan yesterday when I saw it in his room. Resident 19's MDS Assessment, dated 6/15/18, indicated Resident 19's BIMS score was nine of 15 which indicated the resident was moderately cognitively intact with regard to memory and ability to make reasonable judgements. Review of policy and procedure titled, Equipment- General Use for All Residents dated 8/06, indicated, Wheelchairs, walkers, crutches, canes, etc. are maintained by our facility .