Every finding on record at Sage Post Acute

Based on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1, identified as a high risk for falls, was provided consistently close monitoring/supervision to minimize complications and prevent falls when Resident 1 slipped out of the sling (a mobility aid used to safely move, lift, or reposition an individual with limited physical strength or balance) and fell on the floor during a 2-person mechanical lift (Hoyer Lift, a specialized lifting device used to safely transfer patients between beds, wheelchairs, toilets and/or floor) transfer from bed to wheelchair (w/c). This failure resulted in Resident 1 sustaining a laceration to the left (L) forehead, transferred to the hospital for evaluation, and was found with serious head injuries. 1. A review of Resident 1's admission Record, printed on 7/8/26, indicated Resident 1 was originally admitted to the facility in 2018 with diagnoses that included traumatic brain injury (disruption of normal brain function caused by an external force), Down Syndrome (Trisomy 21, a genetic condition caused by an extra full or partial copy of chromosome 21 [smallest human autosome]), epilepsy (a chronic brain disorder characterized by recurrent, unprovoked seizures [a sudden, abnormal surge of electrical activity in the brain]) and impulse disorder (a mental health condition characterized by an inability to resist harmful urges). A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 4/10/26, indicated, Resident 1was sometimes understood and can sometimes understand, with severely impaired cognition. Resident 1 was totally dependent (helper does all the effort to complete the activity) on all activities of daily living (ADLs, the basic self-care tasks an individual does on a day-to-day basis). Resident 1 has impairment to both upper (shoulder, elbow, wrist hand) and lower (hip, knee, ankle and foot) extremities, required w/c use, and a two (2) person transfer with a mechanical lift. A review of Resident 1's Care Plan, initiated date of 8/8/18, indicated Resident 1 was at high risk for falls related to (r/t) Down Syndrome, seizure disorder, muscle weakness, and poor safety awareness. A review of Resident 1's Care Plan, initiated date 9/25/18, indicated Resident 1 has an ADL self-care performance deficit r/t his medical condition which required total dependence on transfer by two staff, to move between surfaces and as necessary. A review of Resident 1's Care Plan, initiated date 4/27/26, indicated Resident 1 had an actual fall on 4/23/26 with serious injuries. Interventions/Tasks included, do not attempt to move resident during seizure activity and if seizure occurs, staff to return resident to bed and assume recovery position. A review of Resident 1's Care Plan, initiated date 4/27/26, indicated Resident 1 had a cerebral vascular accident (CVA, a stroke), affecting L frontal lobe hemorrhage (bleeding inside the brain tissue) r/t fall from mechanical lift. A review of Resident 1's Fall Risk Assessment, dated 7/10/25, indicated a reason for assessment request was due to other reasons. Resident 1 had no history of falls within the last six months, was confined to a chair, and oriented. A review of Resident 1's Fall Risk Assessment, dated 4/23/26, indicated a reason for assessment request was due to recent fall. Resident 1 had no history of falls within the last six months, was confined to a chair, and oriented. A review of Resident 1's Skin Integrity Sheet, dated 4/23/26, indicated Resident 1 sustained a laceration (a jagged, deep tear) to the L eyebrow, with scant amount of bleeding, and was sent out to the hospital for evaluation. A review of Resident 1's Situation Background Appearance Review and Notify (SBAR, a communication tool used to transfer critical patient information between members of the team) Change of Condition Notes, dated 4/23/26, indicated Resident 1 had a fall from the mechanical lift and sustained a cut above the L eyebrow, with slight bleeding. Resident 1 was alert at this time with no change in level of consciousness. A review of Resident 1's Facility Reported Event, dated 4/24/26, indicated Resident 1 had taken a fall on 4/23/26, during the morning shift while Resident 1 was being transferred from bed to w/c, with two-person assistance using the mechanical lift. Resident 1 was noted to be cooperative but was wiggling a lot during the transfer and slid through the L side of the sling to the floor and was sent out to the hospital for further evaluation. A review of Resident 1's Hospitalist Discharge summary, dated [DATE], indicated Resident 1 was admitted to the hospital on [DATE], at 10:04 a.m., indicated reason for admission was due to laceration to L forehead. Work up showed unremarkable labs. Computed Tomography of the Head (CTH, rapid, non-invasive x-ray scan used by neurologists and emergency rooms to quickly identify bleeding, strokes, tumors, or severe trauma in the brain) with Impression, indicated, 1. Moderate hemorrhagic contusion (a brain bruise) involving the L frontal lobe. 2. L frontal scalp hematoma (a blood clot). 3. Diffuse atrophy (widespread shrinkage of brain tissue) with concomitant ventricular dilation (enlargement of both lower heart chambers [left and right ventricles]). Resident 1's Final Diagnosis indicated, focal hemorrhagic contusion of cerebrum (a bruise on the brain tissue accompanied by bleeding) due to the fall and intracranial hemorrhage (a life-threatening medical emergency involving bleeding inside the skull). Further review of Resident 1's Discharge Summary indicated Resident 1 developed dysphagia (difficulty swallowing) and was placed on dysphagia diet following Speech Therapy Swallowing Evaluation. A review of the facility's document titled, Sling Sizes List, updated 7/7/26, indicated, 1. Each patient will have personal shower and transfer sling.3. Shower slings not to be used for transfers. During an interview on 7/8/26, at 1:42 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 4/23/26, during the morning shift (7 a.m. to 3:30 p.m.), Resident 1 was ready to be transferred from bed to w/c. While Resident 1 was in bed, the sling was placed under Resident 1, sling bar was lowered to Resident 1, all four sling straps attached to the sling bar, and made sure straps were securely attached to the clips. CNA 1 stated with two-person assistance using the mechanical lift, Resident 1 was cooperative but was wiggling a lot during the transfer. CNA 1 was controlling the hand-held remote in her hand standing behind the mechanical lift, while CNA 2 was trying to position the w/c in front of CNA 2 when Resident 1 slipped out from the L side of the sling and fell to the floor. Resident 1 fell on his L side and sustained a small laceration to the L eyebrow, with small amount of bleeding. CNA 1 denied seeing Resident 1 hit his head on an object. During concurrent observation and interview on 7/9/26, at 10:30 a.m., with the Director of Staff Development (DSD), DSD showed the sling used for Resident 1 at the time of the fall incident. A large-sized, mesh type sling was labeled with Resident 1's name. DSD stated this type of sling was to be used for showers only. DSD further stated on the day Resident 1 fell out of the sling with the two-person transfer using a mechanical lift, and with Resident 1 wiggling more than usual, the two CNAs should have lowered Resident 1 back to the bed for safety. During a follow-up observation and interview on 7/9/26, at 12:25 p.m., with CNA 1, CNA 1 demonstrated the scenario regarding Resident 1's fall incident. CNA 1 stated she was five feet two inches tall, stood behind the lift controlling the lift and hand-held remote, and from the bed, slowly lifted the sling with Resident 1 at eye level when Resident 1 slipped out from the L side of the sling and fell to the floor between the mechanical lift and A bed. CNA 1 stated Resident 1 wiggled more than usual and was almost near the w/c from where CNA 2 stood behind waiting for Resident 1 to get lowered from the mechanical lift. None of the two CNAs guided or gently supported Resident 1 while being moved from bed to w/c. CNA 1 also stated she could not tell whether Resident 1 was having a seizure at the time of transfer on 4/23/26. CNA 1 stated she was aware what a seizure was but had no knowledge that Resident 1 had this medical condition. CNA 1 had no answer as to why on the day of the fall, a mesh-type shower sling, instead of the solid fabric transfer sling, was used on Resident 1's transfer from bed to w/c. During concurrent observation and interview on 7/9/26, at 1:02 p.m., with CNA 4, Resident 1 was situated in the hallway next to Nursing Station 1 and Resident 1's room. Resident 1 was reclined in a w/c, seated on a solid, blue-colored fabric with green piping sling underneath. CNA 4 stated since Resident 1's recent fall incident, Resident 1 has been placed on a three-person transfer using a mechanical lift, with one CNA controlling the hand-held remote, and two CNAs on each side gently guiding the resident during transfers.A review of the facility's In-service Training Records indicated, an in-service titled, All CNAs Must Use Gait Belt for Transfers, Use Sling for Hoyer Lift - 2 People All the Time, dated 1/15/26, was provided to all nursing staff. An in-service titled, Transfer Techniques & Hoyer Lift Sling Transfers, dated 3/6/26, was provided to the CNAs. Further review of the Training Records indicated another in-service titled, Safe Lifting Using a Mechanical Lift - Hoyer Lift 2 People at All Times, dated 4/23/26, was provided to all facility staff. A one-to -one in-service titled, Sling & Transfers, dated 4/23/26, was provided to CNA 1 and CNA 2. A review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised December 2007, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of the facility's P&P titled, Lifting Machine, Using a Mechanical, revised July 2017, indicated, The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device.Mechanical Lifts may be used for task that require.transferring a resident from bed to chair.Before using a lifting device, assess the resident's condition.Is the resident agitated, resistant or combative.Check the resident's comfort level.Gently support the resident as he or she is moved.Double check the sling. A review of the facility's P&P titled, Safe Lifting and Movement of Residents, revised July 2017, indicated, In order to protect the safety and well-being of staff and residents, and to provide quality care, this facility uses appropriate techniques and devices to lift and move residents.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding to safe lifting and moving of residents.Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis.Such assessments shall include.Cognitive status; Whether the resident is usually cooperative with staff.Enough slings, in the sizes required by the residents in need, will be available at all times. CNA 2 was unavailable for interview.

Based on interview and record review for two of five sampled residents (Resident 4 and Resident 5), the facility failed to follow their policies and procedures (P&P) for reporting to appropriate agencies a verbal altercation, on 6/9/26 between Resident 4 and Resident 5. This failure to report promptly resulted in:1. No documentation reporting a verbal altercation between Resident 4 and Resident 5 to Law Enforcement within the required regulatory timeframe.2. Potential to negatively impact the protection of all 85 facility residents from abuse. A review of Resident 4's admission Record indicated Resident 4 was readmitted to the facility in 2025 with diagnoses that included dementia (memory loss; a group of thinking and social symptoms that interferes with daily functioning) and hearing loss. A review of Resident 4's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 4/4/26, indicated Resident 4 was sometimes understood and was able to sometimes understand, with severely impaired cognition. Resident 4 was totally dependent (helper does all the effort to complete the activity) on all activities of daily living (ADLs, the basic self-care tasks an individual does on a day-to-day basis). A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility in 2026 with diagnoses that included dementia with other behavioral disturbance. A review of Resident 5's MDS, dated [DATE], indicated Resident 5 was sometimes understood and was able to sometimes understand, with severely impaired cognition. Resident 5 required substantial/maximal assistance (helper does more than half the effort to complete the activity) on all ADLs. A concurrent review of Resident 4 and Resident 5's Incident Reports, dated 6/9/26, indicated at 6:50 a.m., a Certified Nursing Assistant (CNA) reported to Licensed Vocational Nurse 2 (LVN 2) that Resident 4 was having a verbal argument with the roommate, Resident 5. Both LVN 2 and LVN 3 immediately went to the residents' room and found both residents already separated by a CNA. Resident 4 was lying in her bed while Resident 5 was seated in her own bed. When LVN 2 asked Resident 4 what the verbal argument was all about, Resident 4 stated, I am just waiting for a diaper change. When LVN 3 asked Resident 5 what happened, Resident 5 stated Resident 4 was lazy and needed to get up and work. A review of Resident 4's Situation Background Appearance Review and Notify (SBAR, a communication tool used to transfer critical patient information between members of the team) Change of Condition Notes, dated 6/9/26, indicated Medical Doctor (MD) was notified of the verbal altercation between Resident 4 and Resident 5, on 6/9/26, at 7 a.m. Resident 4's Responsible Party (RP) was notified on 6/9/26, at 12 p.m. A review of Resident 5's SBAR, dated 6/9/26, indicated MD was notified of the verbal altercation between Resident 4 and Resident 5, on 6/9/26, at 9 a.m. while Resident 5's RP was notified on 6/9/26, at 11 a.m. A concurrent review of Resident 4 and Resident 5's 5-Day Summaries, dated 6/11/26, indicated MD, both residents' respective RPs, and two state agencies were notified. Both state agencies were faxed supporting documents. However, the facility was unable to provide any written documentation that Law Enforcement was notified of the alleged incident. During concurrent interview and record review on 7/9/26, at 1:15 p.m., with LVN 2, LVN 2 stated Director of Nursing (DON) contacted the Law Enforcement Agency to report the alleged incident but was told to just follow facility protocol. LVN 2 was unable to provide documentation or record of telephone conversation placed by the DON to the Law Enforcement Agency. A review of the email conversation between this writer and the Administrator (ADM), on 7/13/26, indicated ADM was unable to provide a written documentation to support that DON contacted the Law Enforcement Agency to report the alleged incident between Resident 4 and Resident 5, A review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated July 2017, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting 1. All alleged violations involving abuse.will be reported by the facility Administrator, or his/her designee, to the following persons or agencies .e) Law enforcement officials.An alleged violation of abuse.will be reported immediately but not later than: a) Two (2) hours if the alleged violation involves abuse.3. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone.Notices will include as appropriate.What immediate action was taken by the facility.

Based on observation, interview, and record review, for one of three sampled residents (Resident 2), the facility failed to ensure Resident 2, identified as a high risk for falls, was provided consistently with close monitoring/supervision and comprehensive care plan interventions to address Resident 2's nursing and safety needs were implemented, to minimize complications and prevent falls when Resident 2 had an unwitnessed fall inside Resident 2's room. This failure negatively impacted Resident 2's quality of care and services received resulting in Resident 2 being transferred to the emergency department (ED) for evaluation and found with fracture of surgical neck with greater tuberosity extension (a bony facture that travels into the large bump at the top of the upper arm bone).A review of Resident 2's admission Record, printed on 5/1/26, indicated Resident 2 was admitted to the facility in 2024 with diagnoses that included Alzheimer's Disease (a brain condition that causes a progressive decline in memory, thinking, learning, and organizing skills) and osteoporosis (thinning of the bones). A review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 2/2/26, indicated, Resident 2's primary language was Vietnamese and had severely impaired cognition. Resident 2 required substantial/maximal assistance (helper does more than half the effort) to complete the activities of daily living (ADLs, the basic self-care tasks an individual does on a day-to-day basis). A review of Resident 2's Care Plan, initiated date 2/1/24, indicated the resident was at risk for falls/injuries related to (r/t) confusion, unaware of safety needs, and osteoporosis. Interventions included bed at lowest position, initiated 2/12/25, chair alarm when in chair to monitor rising and alert staff of unsafe transfers. Monitor for functioning and placement every shift, initiated 2/18/25, and bed in lowest position at night, initiated 2/1/24. A review of Resident 2's Care Plan, post fall, initiated date 4/25/26, indicated Resident 2 had an actual fall with unknown injury. Resident 2 with discoloration and swelling to right upper arm, and an 8/10 pain score. Interventions included, .Continue interventions on the at-risk plan. A review of Resident 2's Physician Order, dated 2/19/25, indicated Bed alarm, check placement and functioning every shift. A review of Resident 2's Physician Order, dated 4/27/26, indicated Provide floor mat on the floor every shift. A review of Resident 2's Fall Risk Assessment, dated 4/26/26, indicated Resident 2 had history of falls within the six months. A review of Resident 2's Situation Background Appearance Review and Notify (SBAR, a communication tool used to transfer critical patient information between members of the team) Change of Condition Notes, dated 4/26/26, indicated Resident 2 was found on the floor on resident's right side near the bed. There was no documentation of whether the bed was at the lowest position, nor a floor mat placed next to the bed. A review of Resident 2's Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Notes, dated 4/27/26, indicated an IDT recommendation of floor mat placed at bedside for fall prevention. A review of Resident 2's IDT Notes Addendum (an update added to the existing notes), dated 4/29/26, indicated an added recommendation of bed and pressure alarms applied. During a concurrent observation and interviews on 7/9/26, at 1:20 p.m., with Activity Assistant 2 (AA 2), and Certified Nursing Assistant 6 (CNA 6), Resident 2 was observed seated in a wheelchair (w/c) positioned in front of the Nurses Station 1. AA 2 confirmed Resident 2's chair alarm was not put in place. AA 2 further stated the chair alarm was used to alert the staff in case Resident 2 attempted to get up from the w/c. CNA 6 stated CNA 6 forgot to attach the chair alarm when Resident 2 was set up in the w/c in the morning. CNA 6 stated Resident 2 had a high risk for fall. During a follow-up concurrent observation, interviews, and record reviews, on 7/9/26, at 1:30 p.m., with Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 4 (LVN 4), inside Resident 2's room, the bed was observed without a floor mat in place. Both RN 1 and LVN 4 had no idea where the floor mat was stored when not in use. RN 1 confirmed Resident 2 had Physician Orders for bed alarm and/or chair alarm and floor mat next to the bed. RN 1 also stated there was no Informed Consent (IC) for ordered chair and bed alarm, only phone notification to Resident Representative (RR) was required since alarms were not considered as restraints according to the Administrator (ADM). During an interview on 7/9/26, at 1:40 p.m., with ADM, ADM stated Resident 2 was a high risk for falls, had poor safety awareness, and had no capacity to make medical decisions. According to the ADM, interventions to prevent further falls for Resident 2 included a bed and/or chair alarm, putting the bed in the lowest position, and a floor mat next to the bed. ADM further stated these interventions were indicated in Resident 2's Kardex (a snapshot of a patient's medical history, care plan, and daily needs) for staff's quick reference. During telephone interview on 7/9/26, at 3:45 p.m., with CNA 5, CNA 5 stated she was not made aware of Resident 2's Physician Order for a floor mat, bed or chair alarm. CNA 5 stated she only knew of the bed in low position. A review of the facility's policy and procedure (P&P) titled, Fall and Fall Risk, Managing, revised 2007, indicated, based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.In conjunction with the attending Physician, staff will identify and implement relevant interventions (e.g., hip padding [chair or bed alarm] or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling.

Based on observation, interview and records review the facility failed to supervise one of three sampled residents (Resident 1), when Resident 1 was left unsupervised and unattended in a shower chair in her room.This deficient practice resulted in Resident 1 falling out of shower chair, sustaining L5 (5th lumbar- lower back bone) compression fracture (broken bone due to a collapse).During a review of Resident 1' admission Record (record that contains biographical information) printed on 5/11/26, indicated Resident 1 was admitted to the facility in March 2016, with multiple diagnosis including muscle weakness, dementia (decline in cognitive function), osteoarthritis of knees (chronic degenerative joint disease). During a review of Resident 1's Minimum Data Set (MDS, an assessment to plan care) assessment dated [DATE] indicated, Resident 1's Brief Interview for Mental Status (BIMS, an evaluation for mental status) score was eight (8) out of 15, indicating Resident 1's mental status was moderately impaired. The assessment indicated Resident 1 required facility staff supervision or touching assistance, where staff provided verbal cues and/or touching/steadying as she completed upper body dressing, lower body dressing, showers and personal hygiene. During a review of Resident 1's fall risk assessment (an evaluation to determine likelihood of falling) dated 6/24/25, indicated Resident 1 was at moderate risk for falls related to use of medications to control blood pressure, impaired recall ability, impaired vision, incontinence of bladder (involuntary leakage of urine), and her being confined to bed. During a review of Resident 1's fall risk care plan dated 9/13/24 indicated Resident1 was at moderate risk for falls due to gait/balance problems, vision loss, her preference to perform self-care and mobilization with walker and wheelchair. The care indicated for all facility staff to anticipate and meet her needs. During an observation and interview with Resident 1 on 5/11/26 at 1:25 p.m., Resident 1 was standing in her room, trying to get her walker. Resident 1 stated she was almost blind and it was hard for her to see things. Resident 1 stated she could not remember how she fell. During an interview on 5/12/26 at 9:29 a.m., with Certified Nursing Assistant (CNA 1, who was the assigned staff when Resident 1 fell on 3/4/26), CNA 1 stated that she helped Resident 1 to take the shower, took Resident 1 back to her room in a shower chair. CNA 1 stated Resident 1 asked her to bring water for her, CNA 1 left room while Resident 1 was still in the shower chair (unsupervised and unattended) to bring water. CNA 1 stated when she went back to the room, she saw Resident 1 was on the floor next to the bed. CNA 1 stated she did not know Resident 1 was at risk for falls. During a review of Resident 1's nursing progress notes dated 3/4/26 indicated, [Resident 1] found on the floor in sitting position next to shower chair in her room after being left to dress independently following a shower. [Licensed nurse, LN 1] assessed the resident immediately after the fall. [Resident 1] was alert and oriented and complained of neck pain and back pain. Rectal bleeding (blood passing through anus) was noted during assessment. No other visible external bleeding noted [Resident 1] assisted back to bed with staff assistance .Due to complaints of pain and noted bleeding 911 activated and [Resident 1] transferred to [Acute Care Hospital Emergency Room] for further evaluation. During a review of Resident 1's Acute Care Hospital- History and Physical progress notes dated 3/4/26, indicated Resident 1 had L5 (the fifth lumbar vertebra [lower back]) compression fracture after the ground level fall at the facility. During an interview on 5/11/26 at 2:10 p.m., with the Director of Nursing (DON), the DON stated CNAs should make sure to transfer residents to their bed after shower to make sure they are safe and secure before leaving the resident's room. A review of facility's policy and procedure titled Bath, Shower/Tub revised [DATE], indicated .31. Assist with dressing and grooming as needed. 32. Assist the resident into bed or chair. 33. Place the call signal within easy reach of the resident. A review of the facility's policy and procedure Fall and Fall Risk Managing revised December 2007, indicated Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week. This failure presents a threat to residents reaching their highest practicable level of well-being and had the potential to endanger the health and safety of residents. Findings: During a concurrent interview and record review on 8/12/25 at 9:00 a.m., with the Accounts Payable/Payroll (APP),the facility's licensed staffing schedules for the month of January 2024 through March 2024 were reviewed, the staffing schedule indicated there were no RNs scheduled to work eight hours a day during the following dates: 1. For the month of January 2024: 1/1/24; 1/6/24; 1/7/24; 1/13/24; 1/14/24; 1/20/24; 1/21/24; 1/26/24; 1/27/24 and 1/28/24. 2. For the month of February 2024: 2/3/24; 2/4/24; 2/10/24; 2/11/24; 2/17/24; 2/18/24 and 2/24/24.3. For the month of March 2024: 3/2/24; 3/9/24; 3/10/24; 3/16/24; 3/17/24; 3/23/24; 3/24/24; 3/30/24 and 3/31/24. During a concurrent interview and record review on 8/12/25 at 9:00 a.m., with the PC,the facility's licensed staffing schedules for the month of April 2024 through June 2024 indicated there were no RNs scheduled to work eight hours a day during the following dates: 1. For the month of April 2024: 4/19/24. 2. For the month of May 2024: 5/16/24.3. For the month of June 2024: 6/07/24 and 6/13/24. During an interview on 8/14/25, at 12:20 p.m., with the Director of Nurses (DON), stated the risk of not having an RN in the facility for eight hours a day was the quality of care the residents received would be affected. DON further stated, the residents needed an RN to assess them if there was a change in the residents' condition. During a review of the facility's policy and procedure (P&P) titled Departmental Supervision, Nursing, revised August 2022, the P&P indicated; . 2. A registered nurse provides at least eight (8) consecutive hours every 24 hours, seven (7 days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident .

Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for six out of 24 final sampled residents (Residents 7,11,16,26,28 and 37).This had potential for the facility to provide treatment and services against the residents' wishes. Findings: 1. During a review of Resident 7's admission Record, dated 8/14/25, indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease (an interruption in the flow of blood to cells in the brain). During a review of Resident 7's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/25/25 under Section C, indicated a score of 3, meaning Resident 7 had severe cognitive impairment. During a review of Resident 7's Physician Orders for Life-Sustaining Treatment (or POLST) form, dated 9/13/24, under information and signatures, it showed no information on the presence of an advanced directive. 2. During a review of Resident 11's admission Record, dated 8/14/25, indicated, Resident 11 was admitted to the facility on [DATE] with diagnoses that included respiratory failure. Review of Resident 11's MDS dated [DATE] under Section C, indicated Resident 11's short and long-term memory was impaired, and had severely impaired decision-making capacity. During a review of Resident 11's POLST form, dated 8/4/24, under information and signatures, it showed no information on the presence of an advanced directive. 3. During a review of Resident 16's admission Record, dated 8/14/25, indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities). Review of Resident 16's MDS dated [DATE] under Section C, indicated a score of 5, meaning Resident 16 had severe cognitive impairment. Review of Resident 16's medical records showed a POLST dated 11/11/24, under information and signatures, under information and signatures, it showed no information on the presence of an advanced directive. 4. During a review of Resident 26's admission Record, dated 8/14/25, indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a sickness characterized by weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 26's MDS dated [DATE] under Section C, it indicated a score of 15, meaning Resident 21 was cognitively intact. During a review of Resident 26's POLST form, dated 10/27/23, under information and signatures, it showed no information on the presence of an advanced directive. 5. During a review of Resident 28's admission Record, dated 8/14/25, indicated Resident 28 was admitted to the facility on [DATE] with diagnoses that included heart disease. During a review of Resident 28's MDS dated [DATE] under Section C, it indicated a score of 15, meaning Resident 28 was cognitively intact. During a review of Resident 28's POLST form, dated 6/2/25, under information and signatures, it showed no information on the presence of an advanced directive. 6. During a review of Resident 37's admission Record, dated 8/14/25, indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included heart failure. During a review of Resident 37's MDS dated [DATE] under Section C, it indicated a score of 13, meaning Resident 37 was cognitively intact. During a review of Resident 37's POLST form, dated 7/29/25, under information and signatures, it showed no information on the presence of an advanced directive. During a concurrent interview and record review on 8/13/25, at 9:22 a.m., with the Social Service Director (SSD), SSD reviewed Residents 7,11,16,26,28 and 37's medical records and stated there were no documentation that advance directives were discussed and followed up with the residents and their responsible parties. During an interview on 8/14/25, at 12:14 p.m., with the Director of Nursing (DON), DON stated that the facility residents' advance directives were supposed to be followed up by the SSD. Further stated the importance of advanced directives was to help ensure that the resident's wishes for medical care were carried out in case the resident becomes incapacitated. During a review of the facility's policy and procedure (P&P) titled Advanced Directives, Revised September 2022, indicated, .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy .1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.a. The resident or representative is given the option to accept or decline assistance.b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance . The CMS Interpretive Guidance states that facilities are required to obtain a written record of resident advance directives upon admission and maintained in the medical record. Importantly, residents have a right to refuse to create an advance directive so the advance directive or the refusal to create an advance directive must be documented.

Based on observation, interviews, and record reviews the facility failed to ensure Medications are accurately and safely acquired, received, dispensed, stored, and administered for two of four Residents, Resident 16 and Resident 28 during medication administration, not following their facility's policy and procedure and standards of practice:1. When Licensed nurse left Resident 16s medications (1 tab of Ferrous sulfate [to prevent and treat low iron anemia] 325 milligrams (mg) and 1 tablet of multivitamin) unattended on top the medication cart when administering medication to Resident 16. 2. When Licensed Nurse left Resident 28's medications (1 tablet of Aspirin [used to treat mild pain, arthritis, it also lowers the risk of heart attack, stroke, or blood clot] 81 mg chewable) unattended on top of the medication cart. This failure has the potential for other Residents to have access and ingest medication that was not intended for them, Residents getting wrong medication, wrong dose, risk for allergic reaction, risk injury, and hospitalization. Findings: 1. During an observation and an interview on 8/12/2025 at 09:17 A.M., with Registered Nurse (RN) 1, RN 1 took out Resident's 28 chewable Aspirin 81 mg from the original brand medication cup, placed in a medication cup, RN1 then left the medication unattended on top of the medication cart and walked away, out through the double doors to the front lobby/facility entrance. When interview RN 1 stated the drug in the medication cup was Resident's 28's Aspirin 81 mg and she was supposed to put it back in the medication cart before she walked away. RN 1 further stated this is for safety, if anyone had picked up the medication, especially for those residents who are not alert, they will swallow it and that is not a good thing. During a review of Resident 28's Facesheet, the Facesheet indicated Resident 28 is [AGE] years old, was admitted to the facility in 2025 with diagnosis of Diastolic Congestive Heart Failure (a chronic in which the heart does not pump blood as well as it should), Primary Hypertension (high blood pressure) and Atherosclerotic Heart Disease (a disease of the arteries characterized by deposition of plaques of fatty material on their inner walls) of Coronary Artery. 2. During an observation and an interview on 8/13/2025 at 08:53 A.M. with Registered Nurse (RN) 2, RN 2 left Resident 16's Multivitamin and Ferrous Sulfate unattended on top of the medication cart and went into Resident 58's room to assist the Podiatrist. When interviewed, RN 2 stated the two pills are ferrous sulfate and multi-vitamin and that they were for Resident 16. RN 2 stated she was in Resident 58's room, assisting the Podiatrist, that the Podiatrist was explaining something about Resident 58's Podiatry care. RN 2 stated the medications should have been placed back in the medication cart and not left unattended on the medication cart to prevent other Residents from picking it up and swallowing it. RN 2 stated it's for Resident safety. During a record review of Resident 16's Face sheet, the Face sheet indicated Resident 16 is [AGE] years old, was admitted to the facility in 2024 with diagnosis of Fracture of Femur (a complete or partial break in a bone) following insertion of orthopedic implant (medical devices used to replace, support, and stabilize bones that have been damaged), joint prothesis left leg in 2024 and Osteoporosis. During an interview on 8/13/2025 at 09:36 A.M. with Director of Nursing (DON), ADON stated Licensed Nurses should never leave medications unattended and on top of the medication cart for Resident's safety or drug overdose, and to prevent allergic reaction. ADON stated any Resident, or anybody can pick up those medication and swallow them. During a review of Facility Policy and Procedure (P & P), titled Administering Medications, dated April 2019, the P & P indicated, Policy heading. Medication are administered in a safe and timely manner, and as prescribed. 5. Medication administration time are determined by resident need and benefits, not staff convenience. Factors that are considered include. a. enhancing optimal therapeutic effect of the medication. b. preventing potential medication or food interaction. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administering before giving the medication. 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the med cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on Observation, interviews, and Record Reviews the facility failed to ensure Medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with: the prescriber's order; manufacturer's specifications (not recommendations) or accepted professional standards and principles which apply to professionals providing services) rates are 5 percent or lesser for three out of five residents (Resident 1, 16, and 68) during medication administration:1. When Licensed Nurse administered Alendronate medication (a medication used to prevent and treat osteoporosis [a condition in which the bones become thin and weak and break easily] in men and women) for Resident 16, was Administered to resident 16, not following Physicians orders or medication bubble pack labeling instructions and professional standards of practice.2. When Licensed Nurse administered Amlodipine medication (medication used to treat high blood pressure and certain types of chest pain) to Resident 1and Resident 68 with incomplete medication labeling instruction, not following Physician's instructions and professional standards of practice.This failure had the potential for Resident 1, 16, and 68 not getting the desire outcome of their medication and effectiveness, significant med error, hospitalization, and even injury or death.Findings: 1. During an observation on 8/13/2025 at 08:53 AM with Registered Nurse (RN) 2, RN 2 administered Resident 16's Alendronate medication without following the medication packaging instructions, Physician's order and the MAR. RN 2 did not give a full glass of water after or prior to administering Resident 16's Alendronate medication. RN 2 gave 30 millimeters (ml) of orange juice instead. During an interview on 8/13/25 at 09:10 AM with 2, RN 2 stated that Resident had already had breakfast that morning prior to administering his Alendronate medication and breakfast was served around 0700 on 8/13/2025. During a record review of Resident 16's Face sheet, the Face sheet indicated Resident 16 is [AGE] years old, was admitted to the facility in 2024 with diagnosis of Fracture of Femur (a complete or partial break in a bone) following insertion of orthopedic implant (medical devices used to replace, support, and stabilize bones that have been damaged), joint prothesis left leg in 2024 and Osteoporosis. During a review of Resident 16's Physician Order Summary, the Physician Order Summary indicated, Fosamax oral tablet 70 mg (Alendronate Sodium) give 1 tablet by mouth one time a day every 7 day(s) for osteoporosis in the morning with full glass of water at least 30 minutes before first meal, ordered date 7/15/2025, with start date 7/16/2025 and no end date. During a review on 8/14/2025 at 0940 AM with ADON, of Resident 16's Medication Administration Record (MAR) dated August 2025, Resident 16's Alendronate medication 70 mg was scheduled on the MAR to be given at 0900 A.M. for the entire month. RN 2 documented Resident 16's Alendronate medication at 0900 A.M. There were documented initials at 09:00 A.M., on Residents 16's MAR for 8/6/2025 and 8/13/2025 Alendronate medication administration. Resident 16's MAR indicated, Fosamax oral tablet 70 mg, give one tab by mouth one time a day every 7 days for osteoporosis in the morning with full glass of water at least 30 minutes before first meal, ordered 7/15/2025 at 22:37 p.m. During an interview on 8/14/2025 at 09:36 AM with Assistant Director of Nursing (ADON), ADON stated nursing staff must follow whatever direction is on the medication label and instructions given by pharmacy on the Medication Administration Record (MAR). ADON further stated Fosamax is given by night shift nurses at 0600 A.M., 30 minutes prior to their first meal or any food or drink, and the residents should stay upright at least 30 minutes before the meal. ADON stated not following the specific Physicians orders and packaging labeling will have a negative outcome, will result in poor absorption of medication and it would give less concentration in the blood. ADON further stated Resident conditions will not get better and he has recently just had a bone fracture. 2. During an observation on 8/12/2025 at 08:39 AM with Registered Nurse (RN) 1. Resident 68's Amlodipine 2.5 milligrams (mg) medication pack instructions parameters for Heart Rate (HR) had omission (missing) the number 60. RN 1 administered Resident 68's Amlodipine 2.5 mg medication without clarifying or reconciling the medication packaging label instructions to the Physician's order. During an observation on 8/12/2025 at 09:05 AM with RN 1. Resident 1's Amlodipine 2.5 mg medication pack instructions parameters for HR were missing the number 60. RN 1 administered Resident 1's Amlodipine 2.5 mg medication without clarifying or reconciling the medication packaging label instructions to the Physician's order. During an interview on 8/13/2025 at 09:18 AM with RN 1, RN 1 stated the bubble pack was missing the 60 for HR parameters. RN used a black sharpie and added number 60 on both Resident 68's and Resident 1's Amlodipine 2.5 mg medication bubble packs without clarifying or reconciling the bubble pack to the physician's order. RN 1 stated the bubble packs should have been updated and crossed or double check with two License nurses prior to administering and updating the bubble pack. RN 1 stated not doing this will put the residents at risk for medication error and not following what the Physician had ordered. During an interview on 8/13/2025 at 09:26 AM with Registered Nurses (RN) 3, RN 3 stated if a medication is missing an instruction or the HR parameters is not visible, nurses should call the pharmacy or check MAR for medication instruction clarification. During a record review of Resident 1's Face sheet, the Face sheet indicated Resident 1 is [AGE] years old, was admitted to the facility in 2024 with Primary Hypertension (high blood pressure) and Chronic Embolism (sudden blocking of an artery) and Thrombosis (blood clot forming a vein or artery, which can be life threatening) of left femoral vein. During a record review of Resident 68's Face sheet, the Face sheet indicated Resident 68 is [AGE] years old, was admitted to the facility in 2025 with diagnosis Essential Primary Hypertension (high blood pressure), Presence of Cardiac Pacemaker (a small electronic implanted in the chest to regulate a slow or irregular heart rate), device, and Atrioventricular block complete (a heart rhythm disorder that causes the heart to beat more slowly than it should, caused by communication problem within the heart electrical conduction system). During a review of Resident 1's Physician's Order Summary, the Physician Order Summary indicated, Amlodipine Besylate oral tablet 2.5 mg (Amlodipine Besylate) give 3 tablets by mouth one time a day for HTN hold for SBP less than100 or HR less than 60, order 6/28/2025, start date 06/29/2025, no end date. During a review of Resident 1's MAR, the MAR indicated, schedule for August 2025, amlodipine oral tablet 2.5 mg give 3 tablets by mouth one time a day for HTN hold for SBP less than 110 or HR less than 60, order date 09/28/2025 12:02. During an interview on 8/12/2025 at 09:18 AM with Director of Nursing (DON), DON stated if medication packing need clarification or is missing instructions, nursing staff should return the medication pack to the pharmacy for safety of the residents as safety for the licensed nurses as well. DON also stated this is to prevent allergic reactions or any other medication error. During an interview on 8/14/2025 at 09:36 AM with Assistant Director of Nursing (ADON) stated nursing staff must follow whatever direction is on the medication label instructions given by pharmacy on the Medication Administration Record (MAR).ADON stated for the HR parameters, the nurses should follow the physician's order because it's a physician's order and blood pressure meds cause the resident's HR (pulse) to drop. If the labeling is wrong or incomplete on a medication package, nursingstaff must return the medication pack back to the Pharmacy because it's not correct labeling or medication instructions. During a review of Facility Policy and Procedure (P & P), titled Administering Medications, dated April 2019, the P & P indicated, Policy heading. Medication are administered in a safe and timely manner, and as prescribed. 4. Medication are administered in accordance with prescriber orders, including any required time frames.5. Medication administration time are determined by resident need and benefits, not staff convenience. Factors that are considered include. a. enhancing optimal therapeutic effect of the medication. b. preventing potential medication or food interaction. honoring resident choices and preferences, consistent with his or her care plan. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administering before giving the medication.

Based on observation, interview and record review, the facility failed to ensure residents were served palatable, flavorful food and properly cooked vegetables.This deficient practice placed the residents at risk of decreased nutrient intake possibly leading to weight loss and/or nutritional medical complications who received food from the kitchen.1. During observation on 8/13/25 at 12:47 p.m., in the facility conference room, two test trays containing one regular and another puree (blending or mashing regular food into a smooth, pudding-like consistency, eliminating lumps and making it easier to swallow) were presented. 2. During a concurrent observation and interview on 8/13/25 at 12:47 p.m with the Assistant Dietary Manager (ASDM) and Dietary Manager (DM) a regular and puree texture meal was sampled immediately following the delivery of the last resident tray. The regular tray contained citrus barbeque and mixed vegetables. The puree tray contained citrus barbeque and mixed vegetables. Temperatures of the food were measured with the surveyor's calibrated thermometer. The pureed citrus barbeque chicken was 147.6 Fahrenheit ( F), and the pureed mixed vegetables was 165.4 F. The regular citrus barbeque chicken was 151 F, and the regular mixed vegetables was 141.2 F. The regular mixed vegetables was overcooked, lacked color and was bland. The pureed citrus barbeque chicken lacked color, was not palatable and the mixed vegetables was bland. felt barely warm in the mouth and the pureed zucchini felt barely warm in the mouth and tasted bland. ASDM and DM stated pureed food was not palatable and the regular food mixed vegetables lacked color and looks overcooked. ASDM also stated that they steam the vegetables and doesn't normally look like that. 3. During review of the facility's policy and procedure (P&P) titled. Meal Service: Tray Assembly, dated 2023, indicated, Residents will receive their food at appropriate temperatures and appetizing appearance. 4. During a review of the article, Quality and Nutrient Loss in the Cooking Vegetable and Its Implications for Food and Nutrition Security in Ethiopia: A Review, dated 4/2023 on the website https://www.dovepress.com/quality-and-nutrient-loss-in-the-cooking-vegetable-and-its-implication-peer-reviewed-fulltext-article-NDS, the article indicated, Overcooked vegetables will not make you ooh and aah because they lose their visual appeal, become mushy, and lose much of their natural flavor.71 Cooking destroys some of the nutritional value of vegetables; for example, vitamin C is destroyed by heat, so the longer you cook, especially at high temperatures, the less vitamin C will remain.

Based on interview, record review and observation, the facility did not ensure that food was stored, prepared, and served in a safe and sanitary manner when the following was noted:1. Food preparation utensils and equipment were not cleaned and/or maintained in good condition.2. A 2 slice and conveyor toaster were not maintained in clean condition.3. One knife blade tip was bent.4. Microwave has brown stain and chipped turntable.5. Cup/Food container lids was in drawer without original packaging.6. An industrial can opener was not maintained in clean condition.7. Tray line pans and sheet pans were not air dried and were stacked wet.8. Pots and pans were not air dried and stacked wet.10. The oven was not maintained in clean condition.11. Nine expired food items.These failures placed 76 residents who received food from the kitchen at potential risk for food borne illnesses and/or illness related to use of contaminated utensils and expired food. 1. During a concurrent observation and interview on 8/11/25 at 9:47 a.m. with Assistant Dietary Manager (ASDM), in the kitchen, the following expired food items were observed: Freezer 3: Parmesan Cheese EXPIRATION: 5/2025 Over main stove: bottle of Teriyaki Sauce EXPIRATION: 7/30/2025 Fridge 4: 3 containers Plain Greek non-fat yogurt EXPIRATION: 5/14/2025 Fridge 4: 1 container Low-fat Cottage Cheese EXPIRATION: 7/2025 Fridge 4: 3 cans Whipped Cream EXPIRATION: 4/24/2025ASDM stated that usually do rotation of foods when delivery of foods come on Tuesday and Thursday and were not sure why these are still here but will take care of it.During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2023, the P&P indicated, .3.Older items should be rotated to use the FIFO (First in- First out). According to the 2022 Federal Food Code, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. 2. During a concurrent observation and interview on 8/13/25 at 3:31 p.m. with ASDM, in the kitchen, multiple cup/food container lids were not found in kitchen draw loose and not in original packaging or in closed containers. ASDM stated that the lids were used for the resident coffee, hot tea or meal item, but, will take care of it. During a review of the facility's P&P titled, Sanitation and Infection Control , dated 2001, the P&P indicated, .2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas. 3. During a concurrent observation in the kitchen and interview on 8/13/25 at 3:40 p.m. with ASDM, in the kitchen, the following were observed: Tray line: o 1 Tray line lid with bent edgeso 6 flat Tray line pans with rust and dentso 6 long Tray line pans with rust and dentso 5 square Tray line pans with rust and baked on food particleso 2 rectangular Tray line pans with multiple dentso 4 Tray line covers dented on all corners 2 whisks with wood handle that is faded with open areas 1 knife with bent tip 1 metal masher with wood handle that is faded with open areas 1 red stained plastic spoon 6 loaf pans with baked on food particles 3 cutting boards with multiple cuts and deep grooves 4 fry pans with multiple scratches to the non-stick coating 8 pots dented with baked on food particles and scratches 1 pot missing plastic handle cover 1 metal bowl dented 3 large muffin pans dented and with multiple rusted areas 2 medium muffin pans dented and with multiple rusted areas ASDM stated that most of these items get a lot use and when run stuff through the dishwasher, the wood gets affected. ASDM stated that will take them and have them replaced. During a review of the facility's P&P titled, Meal Service, dated 2023, the P&P indicated, .7. Plates and serving equipment; plates, cups, silverware, special feeding devices, that are chipped According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. 4. During a concurrent observation in the kitchen and interview on 8/13/25 at 3:57 p.m. with ASDM, in the kitchen, the following were observed: 6 loaf pans were stacked wet 4 metal mixing bowls were stacked wet 5 muffin pans were stacked wet 2 cutting boards were stacked wet 6 long pans were stacked wet ASDM stated that don't have much space to dry stuff but will do in-service to let staff know. According to the 2022 Federal Food Code, after cleaning and sanitizing, equipment and utensils are to be air-dried or used. According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. 5. During a concurrent observation and interview on 8/13/25 at 4:27 p.m. with ASDM, in the kitchen, the inside of the microwave had dark brown spots and stains to vents. Also, glass turn table had moderate chip to outer edge. ASDM stated that they clean it regularly and may have get a new one. During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2001, the P&P indicated, .2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas. According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. According to the 2022 Federal Foode Code, The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. 6. During a concurrent observation and interview on 8/13/25 at 4:36 p.m. with ASDM, in the kitchen, an industrial stove and oven showed moderate build-up of grease to the 4 burners and burner plates/foil. In addition, knobs had moderate build-up grease and dust behind it and both ovens had heavy buildup of grease and burnt on food. There was foil on one side of oven with moderate grease and burnt on food. Oven glass to both have moderate to heavy grease build up. Also, the secondary oven had rust to the hinges and inside. ASMD stated that expectation is that it is cleaned after they cook and it's cleaned once a week; the last time was cleaned was this past Sunday. ASDM also stated that the second oven is used sometimes but not all the time.According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation. 7. During a concurrent observation and interview on 8/13/25 at 4:50 p.m. with ASDM, in the kitchen, the following were observed: Conveyor toaster with moderate build up of crumbs and burnt food particles; top of toaster ha peeling black paint and knobs had moderate buildup of grease 2 slice toaster inside had moderate buildup of crumbs and burnt particles ASDM stated that may not be able to clean and might have to purchase new ones.According to the 2022 Federal Food Code, food-contact surfaces of equipment and utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulation.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program when the laundry department did not have a separate space for clean and unclean hampers. This failure placed the residents at increased rate of healthcare- associated infections. Findings: During a concurrent observation and interview on 8/14/25 at 10:00 a.m., with Laundry Worker (LW) 1, in the soiled linen room, LW 1 sanitized a dirty hamper and placed the then sanitized hamper together with the dirty hampers in the soiled linen room. LW1 acknowledged that after she emptied the used linens and clothes from the dirty hampers to the washing machine, she sanitized and returned the hampers to the soiled linen room, mixed with the dirty hampers because there was no space to store the clean and sanitized hampers. Stated the clean hampers were then brought to the facility hallways to collect residents' used linens and clothes. During an interview on 8/14/25 at 10:15 a.m., with the Laundry Supervisor (LS) 1, LS 1 confirmed that the clean hampers were stored together with the dirty hampers in the soiled linen room, stated the risk of mixing the clean and dirty hampers was spread of infection. During an interview on 8/14/25 at 12:14 p.m., with Director of Nursing (DON), stated the risk of storing the clean and dirty hampers together in the soiled utility room was the spread of infection amongst the staff and the residents. During a review of facility's policy and procedure(P&P) titled, Laundry and Bedding, Soiled, revised September 2022 P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection and prevention control .

Based on record review and interviews, the facility failed to ensure Resident 51's wallet was protected from loss.This deficient practice had the potential to result in Resident 51 not having access to their items in their wallet and/or feelings of living in a safe, homelike environment.During a review of Resident 51's admission Record, dated 8/14/25, indicated, Resident 51 was admitted to the facility on [DATE] with diagnoses that included cachexia (weakness of the body due to severe chronic illness), hypokalemia (low potassium), dysphagia (trouble swallowing) and acute kidney failure (kidney don't work) and that he was his own responsible party. During a review of Resident 51's Inventory List, dated 5/3/25, the Inventory List indicated, Resident 51 had 1 wallet listed among the items. During an interview on 8/12/25 at 10:55 a.m. with Resident 51, Resident 51 stated that my wallet has been missing for about 2 weeks and I told them about it but it goes in one ear out the other and nobody cares about it so now I no wallet which had my money and my ID (identification) so what am I supposed to do?. During a concurrent interview and record review on 8/12/25 at 1:09 p.m. with Registered Nurse (RN) 3, Resident 51's Inventory List, dated 5/3/25 was reviewed. the Inventory List indicated, Resident 51 had 1 wallet listed among the items. RN 3 stated she was not aware about the missing wallet but does see the resident did came in with one, also if it was missing they fill out a form and notify the Social Worker, but she will discuss with Resident 51. During a review of the facility's policy and procedure (P&P) titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, [undated], indicated, 3. Our facility will exercise reasonable care to protect the resident from loss or theft including b. Providing measures to safeguard resident valuables from easy public access.d. Promptly responding to and investigating complaints of theft or misappropriation of property.

Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of individuals representing different departments of the facility) initiated a care conference meeting for one of 24 sampled residents for seven months. As a result, Resident 69's responsible party was not able to participate in planning his care.Findings:During a review of Resident 69's admission Record, dated 8/14/25, indicated, Resident 69 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities).Review of Resident 69's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/23/25 under Section C, indicated Resident 69's short and long-term memory was impaired, and had severely impaired decision-making capacity. During a concurrent interview and record review on 8/13/25 at 3:41 p.m., with the Minimum Data Set Coordinator (MDSC), stated Resident 69's last care conference was held on December 2024. Also stated the care conference should be done quarterly (every four months). Further stated that the purpose of the care conference was to update the resident's responsible party of the resident's current plan of care, give update for any changes in care and for the responsible party to give an input in the resident's care plan. Stated if there was no care conference done for the resident, then the resident had no voice in his plan of care. During an interview on 8/14/25, at 3:58 p.m., with the Director of Nursing (DON), DON stated that Resident 69's care conference should have been done quarterly. Stated the importance of the care conference was to plan the care of the resident, discuss any change in medications, change in resident's condition and any changes in the plan of care. During a review of the facility's policy and procedure (P&P) titled Care Planning- Interdisciplinary Team, Revised March2022, indicated, The interdisciplinary team is responsible for the development of resident care plans.4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.

Based on observation and interview, the facility failed to provide residents with at least 80 square feet (sq. ft.) per resident for rooms occupied by multiple residents in 6 (Rooms 5, 23, 26, 28, 29, and 30) of 45 resident rooms in the facility. The failure had the potential for reduced space for staff to deliver care and lack of sufficient space for storage of residents' belongings. Findings: Based on an observation on 8/13/25, at 8:13 a.m., with the Facility's Maintenance Director (FMD), the following rooms and corresponding square footage (sq. ft.) were identified: Rooms 5, 23, 26, 28, 29, and 30 were observed as follows: room [ROOM NUMBER] had two beds and measured 145 sq ft, equaling 72.5 sq ft per resident. room [ROOM NUMBER] had three beds and measured 230 sq ft, equaling 76.7 sq ft per resident. room [ROOM NUMBER] had two beds and measured three beds and measured 220 sq ft, equaling 73.3 sq ft per resident. room [ROOM NUMBER] had three beds and measured 220 sq ft, equaling 73.3 sq ft per resident. room [ROOM NUMBER] had three beds and measured 225.5 sq ft, equaling 75.2 sq ft per resident; and room [ROOM NUMBER] had three beds and measured 220 sq ft, equaling 73.3 sq ft per resident. During random observations of care and services from 8/11/25 to 8/14/25, residents and staff never complained about the room size and staff have enough room to do their job. There was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings and no negative consequences attributed to the decreased space and/or safety concerns in the identified rooms. Granting of the room size waiver recommended.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) with impaired mental status received adequate supervision to prevent accident hazards when Resident 1 left the facility and was found and brought to the police station by a concerned citizen. This failure resulted in Resident 1's elopement (elopement is when a patient or resident who is incapable of adequately protecting themselves, departs the health care facility unsupervised and undetected) and had the potential for Resident 1 to be dehydrated, injured, or struck by a motor vehicle. Findings: During a review of Resident 1's Annual Minimum Data Set (MDS - Resident assessment and care guide tool), dated 4/20/24, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 04 and indicated poorly impaired mental status. The MDS indicated Resident 1 was unable to recall the correct year, month and day of the week. The MDS indicated Resident 1 used a manual wheelchair for mobility. The MDS indicated Resident 1 responded only to simple and direct communication. The MDS further indicated Resident 1 had diagnosis of Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 1's progress notes, dated 5/30/24, the progress notes indicated on 5/29/24 at 8:10 p.m., Resident 1 eloped from the facility and the police were notified. The progress notes indicated the police dispatcher mentioned Resident 1 was brought to the police station by a concerned citizen. The progress notes further indicated Resident 1's Family Member (FM1) brought Resident 1 back to the facility. During a concurrent observation and interview, on 6/13/24, at 11:20 a.m., with the Administrator (Admin), Resident 1's room observed with two sliding doors that exited directly into the car parking lot. An exit alarm was observed located on top of the exit sliding doors. The Admin stated the sliding door exit alarm next to Resident 1's bed was found to be loosely connected and not working when Resident 1 eloped from the facility. During a concurrent observation and interview, on 6/13/24, at 11:30 a.m., Resident 1 was observed sitting in a wheelchair in the activity room, verbally responsive with incomprehensible sounds. During a concurrent interview and record review, on 6/13/24 at 12:35 p.m., with Admin, Admin stated Resident 1 attempted to open her room's sliding door in the past. Admin could not provide documentation that addressed Resident 1's attempts to open sliding door that exited into the car parking area, offered room change, and revised care plan prior to the elopement. During an interview on 6/13/24 at 1:39 p.m., with Maintenance Staff (MS), MS stated usually he checked facility's exit door alarms monthly for proper functioning. MS said he did not keep records of scheduled checks or maintenance. MS stated the string to the exit door alarm next to Resident 1's bed was disconnected and loosely screwed. MS stated he reattached the alarm string with a washer to have it in place. MS stated removing the exit door alarm string deactivated the alarm. During an interview on 6/13/24 at 2:45 p.m., Licensed Vocational Nurse (LVN 1), LVN 1 stated she was on duty as charge nurse when Resident 1 eloped. LVN 1 stated she was aware Resident 1 was confused and wandered with risk for elopement. LVN 1 stated one staff member told her Resident 1 was missing. LVN 1 said she went to Resident 1's room, the sliding door was opened, and the alarm to the sliding door was not working. LVN 1 said the exit alarm did not make a sound, the alarm string cord was disconnected and pulled out. LVN 1 said Resident 1's wheelchair was next to her bed and Resident 1 was not in her room. LVN 1 said she called the police right away informed police Resident 1 was missing. Police informed LVN 1 that Resident 1 was found and brought to the police station by a good citizen. During an interview on 6/14/24 at 11:30 a.m., FM 1 stated she was at the facility to visit Resident 1 on 5/29/24 at about 8:00 p.m. when staff could not find Resident 1. FM 1 said staff told her Resident 1 was missing. FM 1 stated she called the Police and was informed that Resident 1 was found about nine blocks away from the facility and was brought to the police station by a good citizen. FM 1 stated she drove to the police station and brought Resident back to the facility. FM 1 stated staff told her Resident 1 was last seen after dinner around 5:30 p.m. FM 1 stated she told the charge nurse about her concern regarding the opened sliding doors in Resident 1''s room several days before Resident 1 left the facility. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised December 2007, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure narcotic medications were signed out according to professional standards for 1 (Resident #209) of 2 sampled residents reviewed for pain management and failed to ensure narcotic reconciliation counts were completed for 1 of 1 medication room and 1 of 2 medication carts. Findings included: A facility policy titled, Controlled Substances, revised in 04/2019, revealed, 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. The policy indicated, 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. The policy further indicated, Upon Administration: a. The nurse administering the medication is responsible for recording: (1) name of the resident receiving the medication; (2) name, strength and dose of the medication; (3) time of administration; (4) method of administration; (5) quantity of medication remaining; and (6) signature of nurse administering medication. 1. An Admission Record revealed the facility admitted Resident #209 on 05/11/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of pain to left hip. Resident #209's care plan included a Focus area, initiated on 05/12/2024, that indicated the resident was at risk for pain. An intervention dated 05/12/2024 directed staff to administer analgesics per physician's orders. Resident #209's Order Summary Report, listing active orders as of 05/14/2024, contained an order, dated 05/11/2024, for hydrocodone-acetaminophen (a pain medication) 10-325 milligrams (mg), give one tablet by mouth every four hours as needed (PRN) for pain. Resident #209's CONTROLLED DRUG RECORD Individual Patient's Narcotic Record, revealed the pharmacy filled nine tablets of the resident's hydrocodone-acetaminophen on 05/11/2024. Per the record, Licensed Vocational Nurse (LVN) #6 signed as having administered one tablet on 05/12/2024. However, the column to document the time was not completed. During an interview on 05/14/2024 at 4:11 PM, LVN #6 verified it was her initials on Resident #209's CONTROLLED DRUG RECORD Individual Patient's Narcotic Record and indicated she should have recorded the time she removed the medication and administered it to the resident. During a concurrent observation and interview on 05/13/2024 at 12:25 PM, LVN #4 stated Resident #209 had complained of pain and had received their hydrocodone 10-325 about an hour prior to the interview. During the interview, a prefilled medication card containing Resident #209's hydrocodone-acetaminophen was observed. There were seven pills in the card with two empty slots that had been punctured. At this time, LVN #4 reviewed Resident #209's CONTROLLED DRUG RECORD Individual Patient's Narcotic Record, and she confirmed there was no documentation on the record indicating she had removed and administered a dose of the hydrocodone-acetaminophen approximately one hour earlier. LVN #4 said she failed to sign the medication out as she should have. In the presence of the surveyor, LVN #4 then signed Resident #209's CONTROLLED DRUG RECORD Individual Patient's Narcotic Record to reflect a tablet was removed and administered on 05/13/2024 at 10:50 AM. LVN #4 said she forgot to sign the medication out on the narcotic record. During an interview on 05/16/2024 at 10:10 AM, the Director of Nursing (DON) stated staff were to sign narcotics out on the narcotic record. During an interview on 05/16/2024 at 10:31 AM, the Administrator stated the staff should follow the rules of medication administration. The Administrator stated staff should sign narcotics out on the narcotic log. 36105 2. A Controlled Dugs Count Record for a Unit 2 Narcotic Box, dated 04/2024, revealed the form was formatted for the off-going and oncoming nurses to conduct controlled drug counts three times per day at shift change. There were six shift changes in which no nurse documented the performance of a drug count and 24 shift changes in which only one of two nurses documented the performance of the drug counts. An 8-Hour Controlled Drugs-Count Record for Unit 2A, dated 04/2024, revealed three shift changes in which no nurse documented the performance of a drug count and 15 shift changes in which only one of two nurses documented the performance of the drug counts. A Controlled Drugs Count Record for Unit 2A, dated 05/2024, revealed one shift change in which no nurse documented the performance of a drug count and ten shift changes in which only one of two nurses documented the performance of the drug counts. During an interview on 05/14/2024 at 7:42 AM, Licensed Vocational Nurse (LVN) #4 stated that nurses were supposed to sign the narcotic count sheets immediately after they counted the narcotics with another nurse during a shift change. She stated that both the oncoming nurse and off-going nurse signed the count sheet at shift change as documentation they verified the narcotic counts. LVN #4 further stated when nurses signed the count forms, they were taking accountability for the narcotic count. She stated the blank spaces on the count sheets should have been signed and stated that she could not say if the counts were completed or not because of the blank spaces. During an interview on 05/15/2024 at 9:49 AM, LVN #3 stated when nurses signed the narcotic count sheet, they were taking accountability for the narcotics and verifying the narcotic count was correct. LVN #3 acknowledged that the narcotic count sheets were the facility's documentation to show the count was completed and verified. During an interview on 05/16/2024 at 9:14 AM, the Infection Control Specialist (ICS) stated the nurse coming onto their shift and the nurse leaving their shift should go into the medication room to verify the lock and seal on the narcotic box was intact and sign the count sheet. He stated the blank spaces on the Narcotic Box count sheet for the emergency kit, and the narcotic count sheets for the medication carts should have been signed, to show the narcotics were accounted for. The ICS stated the only proof they had that they completed a narcotics count was the signed sheets. During an interview on 05/15/2024 at 2:54 PM, the Pharmacist stated she checked the narcotic count documents when she came to the facility and checked the narcotics inventory. She stated when the off-going and the oncoming nurse signed the narcotic count sheets, they were verifying that the count was correct and indicating the oncoming nurse was assuming responsibility for those narcotics at that time. The pharmacist stated if there were missing signatures on the narcotic count sheets, it was significant because the oncoming nurse was responsible if a medication was missing. She stated the count sheets were a way to identify any discrepancies immediately. During an interview on 05/16/2024 at 9:34 AM, the Director of Nursing (DON) stated the narcotic count sheets were intended to track the narcotics to make sure they were not being used by other people. She stated the count sheets were documentation to prove the counts were completed, and with the blank spaces, the facility could not prove the counts were completed. During an interview on 05/16/2024 at 3:59 PM, the Administrator stated she expected the off-going nurse and the oncoming nurse to count the narcotics together between shifts, to ensure the medications were accounted for. During an interview on 05/17/2024 at 9:29 AM, the DON stated she was ultimately responsible for auditing the narcotic sheets to ensure they were completed shift-to-shift .

Based on observation, interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure enhanced barrier precautions (EBP) were implemented and catheter collection bags were kept off the floor for 3 (Residents #13, #5, and #50) of 3 sampled residents with indwelling urinary catheters. Findings included: CDC guidelines titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed Enhanced Barrier Precautions Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator - Wound care: any skin opening requiring a dressing In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a 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. An undated facility policy titled, Enhanced Barrier Precautions, revealed, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. The policy also indicated, 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy also indicated, 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. The policy further indicated, 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. A facility policy titled, Catheter Care, Urinary, revised in 08/2022, revealed, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Under the section titled, Infection Control, the policy specified, 2. Be sure the catheter tubing and drainage bag are kept off the floor. 1. An Admission Record revealed the facility originally admitted Resident #13 on 04/12/2024 and readmitted the resident on 04/23/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident did not have an indwelling urinary catheter at the time of the assessment. Resident #13's care plan revealed a Focus area, initiated on 04/13/2024, that indicated the resident had bowel and bladder incontinence. The care plan did not address the presence of an indwelling urinary catheter. A hospital Discharge Summary, dated 04/23/2024, revealed the resident had renal failure and was being discharged from the hospital to a skilled nursing facility with hospice services. The Discharge Summary did not indicate the resident had an indwelling urinary catheter. Resident #13's Order Summary Report, listing active orders as of 05/14/2024, revealed no orders related to an indwelling urinary catheter. The Order Summary Report also did not reveal any orders directing staff to implement EBP related to the presence of an indwelling urinary catheter. On 05/13/2024 at 10:14 AM, the resident was observed sitting on their bed with an indwelling urinary catheter in place. The resident's catheter bag was on the floor. There was no hanging device observed on the top of the catheter drainage bag to secure the bag to the bed. During the observation, Licensed Vocational Nurse (LVN) #4 came into the room and answered a question for the resident but did not address the catheter drainage bag being on the floor. At the time of the observation, there were no posted signs to indicate the resident was on EBP due to the resident having an indwelling urinary catheter. On 05/13/2024 at 11:44 AM, Resident #13's catheter drainage bag was observed on the floor in the resident's room. On 05/14/2024 at 4:04 PM, Resident #13 was observed in the dining area with the catheter drainage bag in a privacy bag, which was resting on the floor. On 05/15/2024 at 7:56 AM, Resident #13's catheter drainage bag was in a privacy bag, which was resting on the floor. On 05/15/2024 at 9:27 AM, Certified Nursing Assistant (CNA) #2 stated catheter drainage bags should be in a privacy bag, hung on the side of the bed and should not touch the ground. On 05/15/2024 at 10:10 AM, LVN #4 stated the catheter drainage bag should be in a privacy bag and it should not be on the floor because that was unsanitary. On 05/15/2024 at 4:06 PM, the Director of Nursing (DON) stated the catheter drainage bag should never be on the floor and indicated that it would be an infection control issue. On 05/16/2024 at 10:04 AM, the DON stated the facility required gloves for catheter care, and if there was a possibility for spillage, staff should wear a gown. The DON stated that she did not know about EBP. On 05/16/2024 at 2:49 PM, the DON stated they had educated themselves on EBP and would be implementing the needed PPE that day. On 05/16/2024 at 10:39 AM, the Administrator stated there should not be a catheter drainage bag on the floor and stated that that it was an infection control concern. On 05/16/2024 at 4:03 PM during a follow up interview, the Administrator stated they were not previously aware of EBP requirements. 2. An Admission Record revealed the facility originally admitted Resident #5 on 03/29/2018 and readmitted the resident on 12/19/2019. According to the Admission Record, the resident had a medical history that included a diagnosis of retention of urine. Resident #5's care plan revealed a Focus area, initiated on 09/25/2019, that indicated the resident had a suprapubic catheter related to a diagnosis of urinary retention. Resident #5's Order Summary Report, listing active orders as of 05/14/2024, revealed an order, dated 06/03/2021, for a suprapubic catheter. The Order Summary Report did not reveal any orders directing staff to implement EBP. On 05/14/2024 at 9:03 AM, Resident #5's room was observed with no signage to indicate staff were to use EBP. During an observation on 05/15/2024 at 8:12 AM, staff provided Resident #5 a bed bath and only wore gloves to provide close contact care inside the resident's room. There was no signage on the door directing staff to implement EBP. On 05/15/2024 at 7:52 AM, Resident #5's catheter drainage bag was inside a privacy bag, and the privacy bag was resting on the floor. On 05/15/2024 at 9:27 AM, Certified Nursing Assistant (CNA) #2 stated catheter drainage bags should be put in a privacy bag and hung on the side of the bed and should not touch the ground. CNA #2 said Resident #5 was not on any type of precautions, so he only wore gloves when providing care to the resident. On 05/15/2024 at 11:39 AM Licensed Vocational Nurse (LVN) #8, a treatment nurse, stated she was required to wear gloves and a mask for the resident's and her protection. LVN #8 stated the resident was not on any infection control precautions. On 05/15/2024 at 11:48 AM, the Infection Control Specialist (ICS) stated gloves were the only required PPE for catheter care. He further stated catheters should not be on the floor due to infection control concerns because the floor was contaminated. On 05/15/2024 at 4:06 PM, the Director of Nursing (DON) stated the catheter bag should never be on the floor and indicated that it would be an infection control issue. On 05/16/2024 at 10:04 AM, the DON stated the facility required gloves for catheter care, and if there was a possibility for spillage, staff should wear a gown. The DON stated that she did not know about EBP. On 05/16/2024 at 2:49 PM, the DON stated they had educated themselves on EBP and would be implementing the needed PPE that day. On 05/16/2024 at 10:39 AM, the Administrator stated there should not be a catheter bag on the floor and stated that that it was an infection control concern. On 05/16/2024 at 4:03 PM during a follow up interview, the Administrator stated they were not previously aware of EBP requirements. 36105 3. An Admission Record revealed the facility originally admitted Resident #50 on 04/19/2024 and readmitted the resident on 05/10/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2024, revealed Resident #50 had short-term and long-term memory problems and had severe cognitive impairment for daily decision making, per a staff assessment of mental status (SAMS). The MDS revealed Resident #50 was always incontinent of bowel and bladder and did not indicate that the resident had an indwelling urinary catheter at the time of the assessment. Resident #50's care plan, last updated on 05/10/2024, revealed no Focus area addressing the presence of an indwelling urinary catheter. An observation on 05/13/2024 at 2:07 PM revealed Resident #50 lying in their bed with a urinary catheter in place. The resident's catheter drainage bag was hanging on the right side of the bed. The catheter drainage bag was on the floor. An observation on 05/14/2024 at 6:53 AM revealed Resident #50 lying in their bed. The resident's catheter drainage bag was on the fall mat on the right side of the bed. An observation on 05/14/2024 at 7:10 AM revealed Resident #50 lying in their bed. The resident's catheter drainage bag was on the fall mat on the floor on the right side of the bed. An observation on 05/14/2024 at 10:58 AM revealed Resident #50 lying in their bed. The resident's catheter drainage bag was on the fall mat on the floor on the right side of the bed. An observation on 05/14/2024 at 12:07 PM revealed Resident #50's catheter drainage bag was on the fall mat on the floor on the right side of the resident's bed. During an observation on 05/15/2024 at 8:21 AM, Certified Nursing Assistant (CNA) #5 provided Resident #50 a bed bath and indwelling urinary catheter care. CNA #5 wore gloves but did not wear a gown while providing care. During an interview on 05/15/2024 at 11:19 AM, CNA #5 stated she knew how to care for each resident by checking the CNA care plan or a nurse would inform her. CNA #5 stated a nurse informed her Resident #50 had a urinary catheter when they readmitted to the facility. She stated when she provided care for Resident #50, she provided catheter care the way she learned in school. CNA #5 stated the appropriate personal protective equipment (PPE) for catheter care was gloves. She stated if the resident was on contact precautions, then appropriate PPE was a gown and gloves. CNA #5 stated the catheter drainage bag should not be on the floor because of a risk of infection. During an interview on 05/15/2024 at 11:23 AM, Licensed Vocation Nurse (LVN) #4 stated she did not know about EBP. During an interview on 05/15/2024 at 11:44 AM, LVN #3 stated she had not been educated about EBP. She stated catheter drainage bags should not be on the floor. LVN #3 stated there was a greater chance of infection from the drainage bag being on the floor or fall mat. During an interview on 05/15/2024 at 11:50 AM, the Infection Control Specialist (ICS) stated for catheter care and a bed bath, the appropriate PPE was gloves. He stated the catheter drainage bag should hang from the bed and not be on the floor. He stated the floor and the fall mat were contaminated and could cause an infection for the resident. During an interview on 05/15/2024 at 1:10 PM, LVN #8 stated she expected the catheter drainage bag to be off the floor or the fall mat because both were contaminated and posed a risk of infection. During an interview on 05/15/2024 at 4:06 PM, the Director of Nursing (DON) stated the catheter drainage bag should never be on the floor and indicated that it would be an infection control issue. During an interview on 05/16/2024 at 10:04 AM, the DON stated that she did not know about EBP. During an interview on 05/16/2024 at 2:49 PM, the DON stated they had educated themselves on EBP and would be implementing the needed PPE that day. During an interview on 05/16/2024 at 3:59 PM, the Administrator stated she expected the resident's catheter bag to not be touching the floor. She stated there was a potential risk of exposing bacteria into the drainage bag because anything touching the floor was exposed to germs and bacteria. The Administrator stated she had just become aware of EBP.

Based on interview, record review, and review of the Centers for Medicare & Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments. Specifically, the facility failed to accurately code the presence of an indwelling urinary catheter for 1 (Resident #5) of 3 sampled residents who had urinary catheters and failed to accurately code the use of an antiplatelet medication for 1 (Resident #19) of 1 resident reviewed for MDS discrepancies. Findings Included: 1. The CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, dated October 2023, SECTION H: BLADDER AND BOWEL, revealed, Coding Instructions Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances A-D were used in the past 7 days. H0100A, indwelling catheter (including suprapubic catheter and nephrostomy tube). The user's manual further indicated, for section H0300 Urinary Continence staff should, Code 9, not rated: if during the 7-day look-back period the resident had an indwelling bladder catheter, condom catheter, ostomy, or no urine output. An Admission Record revealed the facility originally admitted Resident #5 on 03/29/2018 and readmitted the resident on 12/19/2019. According to the Admission Record, the resident had a medical history that included a diagnosis of retention of urine. Resident #5's care plan revealed a Focus area, initiated on 09/25/2019, that indicated the resident had a suprapubic catheter related to a diagnosis of urinary retention. Resident #5's Order Summary Report, listing active orders as of 05/14/2024, revealed an order, dated 06/03/2021, for a suprapubic catheter. An annual MDS, with and Assessment Reference Date (ARD) of 04/08/2024, revealed Resident #5 had moderate impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems, per a staff assessment of mental status (SAMS). Section H0100 was coded as none of the above and did not reflect the presence of an indwelling urinary catheter. Section H0300 was coded to reflect the residents was always incontinent of urine, instead of a 9 to reflect not rated due to the presence of an indwelling catheter. During a telephone interview on 05/15/2024 at 12:39 PM, the MDS Coordinator stated the presence of suprapubic catheters should be coded in Section H of the MDS. The MDS Coordinator stated that Resident #5's MDS was not coded correctly, and it was inaccurate. During an interview on 05/16/2024 at 10:19 AM, the Director of Nursing (DON) stated that she believed there was a section of the MDS to code the presence of indwelling catheters. The DON stated Resident #5's MDS was not coded correctly. During an interview on 05/16/2024 at 10:29 AM, the Administrator stated there was a section of the MDS to code the presence of a suprapubic indwelling catheter. The Administrator stated if a resident had an indwelling catheter, this section of the MDS should be accurately coded to ensure the resident received proper treatment. 37935 2. The CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, dated October 2023, section N0415: High Risk Drug Classes: Use and Indication, indicated, Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. The user's manual indicated, N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g. [exempli gratia, for example], aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days. An Admission Record indicated the facility admitted Resident #19 on 04/21/2018. According to the Admission Record, the resident had a medical history that included a diagnosis of cerebral infarction due to cerebral venous thrombosis, nonpyogenic (a form of stroke). Resident #19's care plan revealed a Focus area, initiated on 06/12/2022, that indicated the resident received Plavix (clopidogrel, an antiplatelet medication) related to cerebral infarction. Resident #19's Order Summary Report, listing active orders as of 05/14/2024, contained an order, dated 06/01/2018, for Plavix Tablet (Clopidogrel Bisulfate) 75 mg [milligrams] give 1 [one] tablet by mouth in the morning. A quarterly MDS, with an Assessment Reference Date (ARD) of 03/16/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of a 4, which indicated the resident had severe cognitive impairment. Section N0415 was coded to reflect that the resident was taking an anticoagulant medication and did not indicate that the resident was taking an antiplatelet medication. During an interview on 05/15/2024 at 12:44 PM, the MDS Coordinator stated Resident #19 was receiving Plavix. The MDS Coordinator said the resident's MDS was coded to reflect the resident received an anticoagulant because she considered Plavix an anticoagulant, instead of an antiplatelet medication. During an interview on 05/15/2024 at 3:03 PM, the Administrator stated facility staff should follow the RAI manual instructions for MDS coding. During an interview on 05/16/2024 at 9:20 AM, the Director of Nursing (DON) stated the MDS Coordinator was responsible for completing MDS assessments and ensuring they were accurate. During an interview on 05/16/2024 at 9:27 AM, the Administrator stated that the MDS Coordinator was responsible for completing and coding MDS assessments accurately.

Based on interview, record review, and facility policy review, the facility failed to complete a baseline care plan within 48 hours of admission for 1 (Resident #207) of 3 residents reviewed for baseline care plans. Findings included: A facility policy titled, Care Plans - Baseline, revised in 12/2016, revealed, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. An Admission Record, indicated the facility admitted Resident #207 on 05/12/2024. According to the Admission Record, the resident had a medical history that included diagnoses of atherosclerotic heart disease, end stage renal disease, dependence on renal dialysis, chronic pain syndrome, and insomnia. Resident #207's Baseline Care Plan, dated 05/12/2024 at 6:36 PM, revealed a status of In Progress. The sections addressing Dietary/Nutritional Status, Therapy, Social Services, Comments [and preferences], Plan of Care, and signatures of staff completing the baseline care plan, the resident, and the resident's representative were not complete. During an interview on 05/16/2024 at 9:20 AM, the Director of Nursing (DON) stated Resident #207's baseline care plan was not complete. During an interview on 05/16/2024 at 4:20 PM, Licensed Vocational Nurse (LVN) #6 stated baseline care plans were to be completed within 48 hours of admission and said staff must have just missed following up on the completion of Resident #207's baseline care plan. During a follow-up interview on 05/16/2024 at 10:25 AM, the DON stated baseline care plans should be completed within 48 hours of a resident's admission. She stated the baseline care plan for Resident #207 was not completed timely. During an interview on 05/16/2024 at 10:35 AM, the Administrator stated baseline care plans should be initiated at the time of a resident's admission and should be completed within 48 hours of admission.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a care plan addressing the use of anticoagulant medications for 1 (Resident #47) of 5 sampled residents reviewed for unnecessary medications and failed to develop a care plan addressing urinary catheters for 2 (Resident #13 and Resident #50) of 3 sampled residents with indwelling urinary catheters. Findings included: A facility policy titled, Anticoagulation - Clinical Protocol, revised in 11/2018, revealed, 1. As a part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated. A facility policy titled, Catheter Care, Urinary, revised in 08/2022, revealed, Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 1. An Admission Record revealed the facility admitted Resident #47 on 02/13/2024. According to the Admission Record, the resident had a medical history that included diagnoses of personal history of pulmonary embolism and heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/2024, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was taking an anticoagulant medication. Resident #47's care plan, last updated on 05/08/2024, revealed no Focus area that addressed the use of anticoagulant medication. Resident #47's Order Summary Report, listing active orders as of 05/15/2024, contained an order, dated 02/14/2024, for Eliquis (an anticoagulant) 5 milligram (mg) by mouth twice daily for blood clots. During an interview on 05/15/2024 at 2:11 PM, Licensed Vocation Nurse (LVN) #4 stated the nurse admitting a resident updated the care plan but all nurses were responsible for ensuring care plans were updated. She stated the use of anticoagulant medication should be addressed on the care plan. LVN #4 reviewed Resident #47's care plan and stated the use of an anticoagulant was not addressed on the care plan. During an interview on 05/15/2024 at 3:00 PM, the Director of Nursing (DON) stated the use of anticoagulants should be addressed on the care plan and residents taking anticoagulant medications should be monitored for signs and symptoms of bruising and bleeding. The DON stated the use of an anticoagulant was not addressed on Resident #47's care plan. She stated that nurses, as well as the MDS Coordinator, were responsible for updating care plans. During an interview on 05/16/2024 at 10:43 AM, the Administrator stated the use of anticoagulants should be addressed on the care plan. 2. An Admission Record revealed the facility originally admitted Resident #13 on 04/12/2024 and readmitted the resident on 04/23/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident did not have an indwelling urinary catheter at the time of the assessment. Resident #13's care plan revealed a Focus area, initiated on 04/13/2024, that indicated the resident had bowel and bladder incontinence. The care plan did not address the presence of an indwelling urinary catheter. A hospital Discharge Summary, dated 04/23/2024, revealed the resident had renal failure and was being discharged from the hospital to a skilled nursing facility with hospice services. The Discharge Summary did not indicate the resident had an indwelling urinary catheter. On 05/13/2024 at 10:14 AM, the resident was observed sitting on their bed with an indwelling urinary catheter in place. During an interview on 05/15/2024 at 10:10 AM, Licensed Vocational Nurse (LVN) #4 reviewed Resident #47's care plan and stated that she did not see any information about the resident's indwelling urinary catheter. LVN #4 stated it was the admitting nurse's responsibility to ensure the information regarding an indwelling catheter was entered on the resident's care plan. During an interview on 05/15/2024 at 11:03 AM, the Director of Nursing (DON) stated an indwelling urinary catheter should be addressed on the care plan. After reviewing Resident #13's medical record, the DON stated Resident #13 was readmitted from the hospital with a catheter. The DON then reviewed the resident's care plan and confirmed the care plan did not address the resident's indwelling urinary catheter. The DON said the nurse that admitted the resident back from the hospital should have added the catheter to the resident's care plan. During an interview on 05/16/2024 at 10:39 AM, the Administrator stated there should be a care plan in place addressing the presence of an indwelling urinary catheter. 36105 3. An Admission Record revealed the facility originally admitted Resident #50 on 04/19/2024 and readmitted the resident on 05/10/2024. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2024, revealed Resident #50 had short-term and long-term memory problems and had severe cognitive impairment for daily decision making, per a staff assessment of mental status (SAMS). The MDS revealed Resident #50 was always incontinent of bowel and bladder and did not indicate that the resident had an indwelling urinary catheter. Resident #50's care plan, last updated on 05/10/2024, revealed no Focus area addressing the presence of an indwelling urinary catheter. Observations on the following dates and times revealed Resident #50 had an indwelling urinary catheter: - 05/13/2024 at 2:07 PM, - 05/14/2024 at 6:53 AM, - 05/14/2024 at 7:10 AM, - 05/14/2024 at 10:58 AM, - 05/14/2024 at 12:07 PM, - 05/14/2024 at 1:29 PM, and - 05/15/2024 at 11:07 AM. During an interview on 05/15/2024 at 11:23 AM, Licensed Vocation Nurse (LVN) #4 stated there should be a care plan for Resident #50's catheter, but she did not find one. During an interview on 05/15/2024 at 12:39 PM, the MDS Coordinator stated that when a resident readmitted to the facility with a catheter, the admitting nurse or the nurse the next day should update the resident's care plan to include the catheter. She stated she had not been to the facility since Resident #50 readmitted , but the nurse who identified the catheter should have added it to the care plan. During an interview on 05/16/2024 at 9:49 AM, the Director of Nursing (DON) stated catheter information should be added to the care plan by the admitting nurse. During an interview on 05/16/2024 at 3:59 PM, the Administrator stated she expected the admitting nurse to complete a readmission assessment to capture catheter information. The Administrator stated the nurse should have updated the care plan when she identified Resident #50 had a catheter.

Based on observation, interview, and record review, the facility failed to maintain and implement the infection prevention policy and procedure (P&P) for transmission based precautions (TBP-how germs spread, including what protective equipment to use) during a concurrent [DIAGNOSES REDACTED]-CoV-2 (commonly known as COVID-19- a new coronavirus causing a respiratory illness and outbreak that is easily spread) when: 1. Staff wore the same gown while providing direct care to all residents in Station 2 red zone (a designated area where all residents have tested positive for COVID-19). 2. Station 2 red zone- staff used the same gloves to provide direct care to multiple residents and used Alcohol Based Hand Rub (ABHR - A liquid, gel or foam containing alcohol used to sanitize hands) to sanitize gloved hands. 3. Personal Protective Equipment (PPE -gloves, gown, faceshield, mask) worn to minimize exposure to hazards that cause injuries and illnesses) were not readily available outside each resident room in Station 2 red zone. 4. Station 2 red zone had all resident room doors open. 5. Station 2 red zone had no TBP signage posted on or by the resident rooms. 6. Housekeeping staff used 10% bleach solution that was no longer recommended for use, and did not measure the correct amount of 10% bleach for proper dilution to disinfect all high touch surface areas. 7. Soiled linens were left in bags outside of the facility. These failures have the potential to result in the spread of COVID-19 through droplets. The complications of COVID-19 include, but are not limited to, pneumonia (lung infection), acute [MEDICAL CONDITION], life threatening organ injury or death . An immediate jeopardy ( IJ, a situation when the provider's noncompliance with one or more requirements has caused or has the potential to cause serious injury, harm, or death to a resident) was called on 12/9/20 at 3:18 p.m., in the presence of the Director of Nursing, Infection Preventionist, Regional Administrator and corporate assistant by surveyor. An acceptable plan of action was submitted from the Skilled Nursing Facility (SNF) at 4:12 p.m. The IJ was abated on 12/10/20 at 6:15 p.m., in the presence of the Director of Nursing and Regional Administrator. Findings: 1. During a concurrent observation and interview on 12/9/20 at 12:01 p.m., with the Director of Nursing (DON) near the entrance to Station 2 red zone, multiple staff were seen in the hallway wearing disposable isolation gowns. DON statconfirmed staff wear the same disposable isolation gown during their entire shift, unless it becomes soiled. During a review of the facility's P&P, Use of Masks, Gowns, and Eye Protection to Conserve Supplies, and revised on April 2020 indicated, The extended use of isolation gowns, disposable or cloth, is discouraged. This is the practice that involves an HCP (Health Care Personnel) using the same gown when interacting with multiple patients with the same infectious disease housed in the same area (COVID-19 patients residing in an isolation cohort). This practice can only be considered if there are no additional co-infectious [DIAGNOSES REDACTED]. 2. During an observation on 12/9/20 at 12:01 p.m., near the entrance to Station 2 red zone, multiple staff were seen in the hallway wearing exam gloves. During a concurrent observation and interview on 12/9/20 at 3:25 p.m., CalMAT (California Medical Assistance Team) emergency response team member (CalMAT 2) was seen leaving room [ROOM NUMBER] wearing two pairs of exam gloves. CalMAT 2 removed the top pair of exam gloves and applied ABHR to gloved hands. CalMAT 2 stated it was the policy to double glove and apply ABHR to gloved hands. During a review of the P&P, Gloves, reviewed June 2020 which indicated, When gloves are indicated they shall be used only once and discarded into the appropriate receptacle located in the treatment or exam room. Furthermore, Surgical or examination gloves shall not be washed or disinfected for reuse. During a review of the P&P, Infection Prevention and Control in LTC, reviewed March 2020 indicated, Double-gloving is not an acceptable practice to avoid a glove change or a hand hygiene opportunity. 3. During an observation on 12/9/20 at 12:01 p.m., in Station 2 red zone, 14 of 15 occupied resident rooms did not have PPE readily available at the entrance for staff. During an interview on 12/9/20 at 3:25 p.m., with CalMAT 2, CalMAT 2 stated they (CalMAT emergency response team) tried to place PPE on tables outside each resident's room for staff to use but, it didn't work. During a review of the P&P, Infection Prevention and Control in LTC, reviewed March 2020 which indicated, Personal Protective Equipment will be stocked on or in a covered cart (to avoid contamination before use) outside the isolated resident's room for easy access before caring for isolated resident. 4. During a concurrent observation and interview on 12/9/20 at 12:20 p.m., with DON near the entrance to Station 2 red zone, 17 of 17 resident room doors were left open. DON stated the doors should be closed, but CalMAT emergency response team keeps them open. During an interview on 12/10/20 at 12:31 p.m., with Regional Administrator (Admin), Admin stated he told the CalMAT emergency response team that resident doors needed to be kept closed in the red zone, but they continue to leave them open. During a review of the P&P, Infection Prevention and Control in LTC, reviewed March 2020 indicated, Airborne Precautions; Door to the resident's room to be closed and the resident must remain in the room. 5. During a concurrent observation and interview on 12/9/20 at 12:16 p.m., with DON in station two red zone, 14 of 17 resident rooms did not have TBP signage. Three of 17 resident rooms had insufficient TBP signage which included signs for contact precautions and not the PPE required before entering the room. DON stated TBP signage was posted at the entrance to the red zone. During a review of the P&P, Infection Prevention and Control in LTC, reviewed March 2020 which indicated, Provide appropriate signage and post outside the door frame where the sign may be easily seen. 6. During a concurrent observation and interview on 12/9/20 at 12:40 p.m., with the Housekeeper, Housekeeper showed a clear plastic spray bottle labeled Disinfectant, used to clean high touch surfaces. Housekeeper demonstrated the process for mixing the Disinfectant including filling the spray bottle with water and adding Clorox bleach. When asked how much bleach is added, Housekeeper stated just a little or its too strong. During an interview on 12/10/20 at 3:30 p.m., with Admin, Admin stated facilities were instructed not to use 10% bleach solution as a disinfectant. Admin was unsure why the facility is still using a bleach solution. During a review of the P&P, Disinfecting Solutions, dated May 2019 which indicated, It is the policy of this facility to phase out the usage of mixed bleach cleaners into pre-mixed solutions. Unless there are emergencies or shortages of cleaners only, will this practice be allowed. The P&P included a measurement guide for mixing 2.75%, 5.25-6.25%, and 8.25% bleach strength solutions that did not include 10% bleach. 7. During a concurrent observation and interview on 12/9/20 at 11:51 p.m., with CalMAT 1, outside of Station 1 red zone, five wheeled soiled linen bins were filled above the brim, lids open, with clear bags of soiled linens. CalMAT 1 stated soiled linens weare typically collected at 7:30 a.m. every morning and was not sure why the soiled linens had not been collected. During a review of the P&P, Linen Handling, dated January 2020 which indicated, Soiled linen hampers should be kept covered with all linen tucked inside to control infection and odors .Linen hampers should be emptied routinely when they are ¾ full.

Based on observation, interview, and record review, the facility failed to ensure to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and implemented their policy and procedure for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff when Employee 1 started to work at the facility without screening at the entrance (Employee 1 was symptomatic for COVID-19). This deficient practice posed a risk for infection disease (COVID-19 disease) for 63 of 63 residents at the facility and 40 of 40 employees who were working at the facility. Immediate Jeopardy (IJ) was called on 12/4/20 at 2:20 p.m.; Regional Director (RD), Acting Director of Nursing (ADON) and Infection Preventionist (IP) were verbally notified of the IJ regarding failed to prevent infections disease (COVID-19) at the facility. The facility submitted an acceptable plan of correction and the facility showed they initiated and completed the plan of correction; the facility informed all the employees who were in contact with the COVID-19 positive employee (Employee 1) and did in-services for the ADM and staff. The IJ was removed on 12/4/20 at 3:15 p.m. Findings: During an interview with Employee 1 on 12/4/20 at 2:45, Employee 1 stated she had congestion and tiredness and body ache on 11/30/20 and went to the facility and started to work there, Employee 1 also stated she did the COVID test in the afternoon on 11/30/20 and left the facility, then she did the rapid COVID test as her physician ordered on [DATE] and the test result came back positive. During a review of the facility's documents title Registry staff screening form - please fill out the form completely date started on 11/28/20 and finished on 12/1/20 indicated Employee 1 did not fill out the screening form at the entrance when she started to work at the facility. During an interview with the MDSN (Minimum Data Set Nurse) on 12/4/20 at 12:30, MDSN reviewed the documents and confirmed Employee 1 did not fill out the screening form, MDSN was not able to find any other evidences that shows Employee 1 did the COVID-19 screening at the time of her entrance to the facility. During a review of Employee 1's COVID-19 rapid test result, indicated Employee 1' test related to 12/3/20 was positive. During a review of the facility's COVID-19 Mitigation plan Hayward Convalescent Hospital date 6/29/20 page 12 indicated .All staff/visitors will continue to have their temperatures checked and will have to attest for any of the s/s (Sing and Symptom) of COVID including distant travel/exposure to COVID-19 . they will complete the COVID screening questionier and will be instructed to follow-up with their PCP (Primary physician) .

Based on observation, interview and record review the facility failed to protect one of one sampled residents (1) from physical abuse by a certified nursing assistant (CNA 1). CNA 1 slapped Resident 1's hand and the side of his head in order to prevent him from touching the television, in the dining room during the evening meal. Resident retailiated by slapping CNA 1 and then CNA 1 slapped him again. Resident 1 has memory loss and did not remember the incident but it was witnessed by family members ( FM1 and 2) of another resident who said became very worried about staff beating up residents. treatment of [REDACTED]. Findings: The facility reported an incident on 6/17/13 wherein CNA 1 reportedly hit Resident 1 on his head and hand, on 6/16/13 which was reported by a " family member," who was visiting at the time of the incident. During an on-site investigation on 6/26/13 at 11:35 a.m. the Director of Nurses (DON) stated that Resident 2's family member (FM1) reported to the charge nurse LVN 1 around 5:45 p.m. on 6/16/13 that she saw CNA 1 slap the hand and head of Resident 1, then push and pull him out of the dining room. The DON stated that LVN 1 then took CNA 1 off the unit and sent her home. An observation of the dining room on the secured unit on 6/26/13 at 11:55 a.m. revealed one long table where residents were eating lunch, that was positioned perpendicular to the wall next to the hallway. Next to the wall and a foot or so away from the edge of the table was an upright piano. Above the piano was a television mounted on the wall and the control box was on top of the piano and under the television. The DON stated that the television/piano area was where the alleged incident happened. A review of Resident 1's medical record revealed that he was an [AGE] years old and had been a resident in the facility since 5/28/10. According to his most recent Minimum Data Set (MDS) assessment dated [DATE], he had a [DIAGNOSES REDACTED]. He had no behavioral symptoms during the assessment period. He was able to ambulate with supervision only and had no balance problems during transitions and walking. A care plan dated 11/14/11 and reviewed on 5/13 revealed the resident had a problem with impaired cognitive skills as exhibited by short term and long term memory loss and impaired decision making. One of the objectives developed was that the resident would be able to follow simple directions through verbal cueing. The interventions included "Provide appropriate cues to assist resident in following basic instructions/directions," and "Prompt resident with verbal reminders/cues as needed." During a telephone interview on 6/26/13 at 1 p.m. CNA 2 stated that she was in the dining room on 6/16/13 during dinner time, feeding a resident and heard some noises like slapping and turned around to see CNA 1 slapping Resident 1 on the face and his hat fell off. She saw a family member leave the dining room to tell the charge nurse (LVN 1). She said that CNA 1 had Resident 1's hat and Resident 1 followed the CNA out of the room to get his hat. She said the reason she wrote her first statement the evening of the incident to reflect that she did not see anything was because LVN 1 told everybody to write that. She then went home and it bothered her so she told the truth the next day to the administrator. She said that CNA 1 is the girlfriend of LVN 1 and she believes that was why LVN 1 told everybody to write that they didn't see anything. During an interview on 6/26/13 at 1:15 p.m. the Administrator stated that he interviewed CNA 2 on 6/17/13 and she had changed her story from the evening before so she also was suspended for 3 days for not telling the truth. When asked if he was aware of the relationship between LVN 1 and CNA 1,and replied that he was aware of their relationship and stated that they should not be working together. In a telephone interview on 6/27/13 at 10:20 a.m. FM 1 stated that on 6/16/13 she and another family member (Family Member 2) of Resident 2 were sitting in the back of the dining room with Resident 2. She saw a male resident standing in front of and touching the television and then the CNA (CNA 1) swatted his hand. The resident then swatted her hand back. CNA 1 then slapped the side of his head and his hat fell off. Family Member 1 stated she raised her voice saying, "Hey! Hey! What you gonna do?" a couple of times. Then CNA 1 grabbed the resident's clothes and took him out of the room. She went out of the room to see where they went but couldn't see them. FM 1 said that she then went to the charge nurse, LVN 1, and asked, "Is it customary for the staff to beat up the residents?" and told LVN 1 what she saw. Family Member 2 made a similar statement in a telephone interview on 7/17/13 and furnished a written statement via U.S. Mail received on 7/25/13 which revealed, "I, (Family Member 2), was visiting (Resident 2) at (The Facility). I was there with (Family Member 1). We were in the dining room at dinner time...and saw the male resident (1) at the TV and he was trying to turn it on. Then the CNA (1) came over to him and popped him on the hand and he popped her back and then she popped him and back and forth, then she popped him on the head and took his hat and pulled it down, then she pushed him in the corner. We shouted, "Hey, Hey, Hey" and asked what she was doing? Then she took him out of the dining room..." A review of the facility's undated abuse policy and procedure titled, "Reporting Abuse to Facility Management," revealed, "...Our facility will not condone resident abuse by anyone, including staff members..." The policy also included a definition of physical abuse which reads, "...Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment."