Every finding on record at San Luis Care Center

Based on observation, interview and record review, the facility failed to ensure food and ice were stored, prepared, distributed, and served in accordance with professional standards for food service safety when:1. [NAME] substances were found inside the bin in one of one ice machines located in the facility's kitchen.2. Food Service Worker (FSW) 4 was observed utilizing the kitchen sanitation bucket to sanitize food carts that did not contain the recommended concentration levels of quaternary ammonium (a group of chemicals used for killing bacteria, fungi, and viruses) for sanitization (to reduce the number of disease-causing pathogens).3. Expired items were found in the residents' food refrigerator in the facility's break room and there was no thermometer in the residents' food in the freezer in the facility's break room.These failures had the potential to cause the growth of microorganisms (organisms that are too small to be seen with the naked eye) and spread foodborne illness (disease or period of sickness caused by food contamination) to the 66 residents that were served meals from the kitchen.Findings:1. During an observation in the kitchen on 3/03/2026 at 11:46 a.m., FSW 3 was observed putting ice from the ice machine in a resident water pitcher and then giving to someone who came to the door. During concurrent observation in the kitchen and interview on 3/3/26 at 2:45 p.m. with Maintenance Director (MD), the facility's ice machine was observed to have a large area of a white substance throughout back of bin and ice was full and up to the top of the water trough in the bin. The MD confirmed the white substance and stated the facility had very hard water. The MD stated the ice machine is cleaned and sanitized once a month and when cleaned the white substance would come off and get removed.During an interview with the Dietary Manager (DM) on 3/5/26 at 11:40 a.m., DM stated there is only one ice machine in the facility. During a review of facility document titled Ice Machine- Cleaning Log, undated, the document indicated the ice machine was descaled (to remove [scale] a layer of hard white material from something) and sanitized on 2/20/26.During a telephone interview on 3/5/26 at 10:58 a.m. with Registered Dietitian (RD), the RD was informed of the white substance in the ice machine and asked if she looked at the inside of the ice machine. The RD stated she did not recall looking at the inside of the ice machine when she was onsite at the facility on 1/6/26 and 1/7/26.During a review of facility document titled Ice Machine- Manufacturer's Guide, no date, the document indicated in section 4- . De-scaling and sanitizing.if the ice machine requires more frequent de-scaling and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment.2. During a concurrent observation, interview and record review on 3/4/2026 at 8:42 a.m. with FSW 4 in the facility's kitchen, FSW 4 was observed wiping the food cart with a rag from a red sanitation bucket. FSW 4 stated the red bucket contained sanitizer used to minimize cross contamination. FSW 4 demonstrated the test strip used to test the level of the sanitizer in the red bucket. The strip was in the sanitizer for 18 seconds and when removed it was about 150 ppm (parts per million). FSW 4 stated the test strip was supposed to be dipped in sanitizer for 10 seconds. FSW 4 was asked to recheck the level again for 10 seconds and the test strip result was about 100 ppm -150 ppm. FSW 4 stated there was a need to change out the sanitizer since it needed to be between 200 ppm and 400 ppm. FSW 4 stated the sanitizer solution in the red bucket was last filled up at around 6 a.m. on 3/4/26.During an interview on 3/04/2026 at 4:25 p.m. with the DM, the DM stated the concentration for red sanitation bucket should have been at 200 ppm- 400ppm. The DM stated when the water is so dirty the concentration gets low. The DM stated it was important that the concentration level remained at 200 ppm - 400ppm so the germs could be killed, and for safety reasons.During a review of the facility's document titled, Clinical Systems- Dietary Services- General Sanitation of the Kitchen, dated 1/2023, the document indicated, . Intent: to provide guidance to the facilities related to local commerce state and federal standards and regulations regarding maintenance of a safe and sanitary dining services department. Guidelines . 1d. Equipment and food prep surfaces must be easily cleanable w/ approved chemicals .ii. Sanitation buckets should be kept within proper ppm (for example: 200-400 ppm for quaternary sanitizer) and checked every 2 hours to ensure ppm is maintained.3. During concurrent observation and interview on 3/4/26 at 2 p.m. with Licensed Vocational Nurse (LVN) 1 in the staff breakroom, the residents' refrigerator (fridge) was observed to have (4) [brand] blueberry and (2) strawberry yogurts with manufacturer's date 3/2/26 and (1) opened and unsealed meat wrapped around cheese labeled with a resident name. LVN 1 confirmed the dates were past due and the opened item that was unsealed. The residents' freezer was locked and could not be viewed. LVN 1 stated she was unaware who was responsible for checking the fridge. LVN 1 stated some of the food was labeled for activities so it would be best to ask them about it.During a concurrent observation and interview on 3/4/26 at 2:05 p.m. with the Activities Director (AD) in the staff breakroom, the residents' fridge and freezer were observed. The freezer was locked, the AD opened the freezer and there was no thermometer in the freezer, frozen fruit bars dated best by 2/28/26 were found in the freezer. The residents' fridge was observed to have (1) 32-ounce (oz - unit of measurement) container of orange juice dated opened 2/7/26, (12) 4 oz tapioca pudding dated 1/11/26, (1) 16 oz guacamole dated 2/7/26, (1) veggie tray best buy dated 2/23/26 written with delivered date 3/2/26, sliced pepper jack cheese dated 2/22/26, string cheese dated 1/15/26. The AD stated once food was opened, the facility followed a 3-day shelf life. The AD stated the facility could also use the manufacturer's best buy date and once that date had past then the food needed to be thrown out. The AD acknowledged the expired items and stated she and her staff were responsible for checking the dates of the items placed in the residents' fridge and freezer.During an interview on 3/4/26 at 2:21 p.m. in the nursing station, with the Infection Preventionist (IP), the IP stated the AD, and her assistants were responsible for ensuring food was kept within the recommended dates and did not expire. The IP stated food kept in the residents' fridge was good for 3 days only.During a telephone interview on 3/5/26 at 10:58 a.m. with the RD, the RD stated she did not recall looking into the residents' fridge and freezer when she was onsite at the facility on 1/6/26 and 1/7/26. The RD stated she was aware of the residents' fridge and freezer was in the facility break room. When informed of the expired items in the residents' fridge and freezer, the RD stated the DM should know when the staff are checking the residents' fridge and freezer and when expired items are removed. When informed there was no thermometer in the freezer, The RD stated that meant no one was checking the freezer.During a concurrent interview and record review on 3/4/26 at 2:18 p.m. in the nursing station, with the Director of Nursing (DON), the Temperature Log (TL) dated November 2025 through March 2026 were reviewed. The TL indicated there were some dates that had no temperature documented for the NOC shift and some temperatures were between 42 F - 44 F. The DON stated the residents' fridge temperature range should be within 36 - 46 F.During a concurrent interview, and record review on 3/4/26 at 2:21 p.m. in the nursing station, with the Infection Preventionist (IP), the TL for November 2025- March 2026 on the day (AM) and night (NOC) shifts were reviewed. The IP stated there was no log for the resident's freezer, the Licensed Nurse (LN)s only monitor the residents' refrigerator.During a concurrent interview and record review on 3/4/26 at 2:23 p.m. in the nursing station, with the IP, the TL dated November 2025 through March 2026 were reviewed. The TL sheet indicated .to maintain a desired refrigerator temperature of 36 - 46 F. Further review of the TL indicated in the month of November 2025, the temperature was above 41 F 16 times out of 30 recorded entries on the AM shift and 5 times out of 30 recorded entries on the NOC shift. The TL indicated in the month of December 2025, the temperature was above 41 F 13 times out of 31 recorded entries on the AM shift and 3 times out of 31 recorded entries on the NOC shift. The TL indicated in the month of January 2026, the log was not completed 3 times on the NOC shift; the temperature was above 41 F 16 times out of 31 recorded entries on the AM shift and 11 times out of 28 recorded entries on the NOC shift. The TL indicated in the month of February 2026, the log not completed blanks one (1) time; the temperature was above 41 F 19 times out of 28 recorded entries on the AM shift and 9 times out of 27 recorded entries on the NOC shift. The TL indicated in the month of March 2026, the temperature was above 41 F 2 times out of 4 recorded entries on the AM shift. The IP stated the residents' fridge temperature range should be within 36 - 46 F. The IP stated if temperatures are above 46 F, then the LNs will input a comment, and the food would not be good anymore since the facility would not know how long the food has been out of temperature. The IP stated it was the responsibility of the LNs to log and check fridge temperatures during AM and NOC shift. The IP stated the incomplete records on the TL meant the facility would not know when the fridge was out of range. The IP stated it was important that the temperature was documented to ensure the fridge was within range because if not it could cause food poisoning.During an interview on 3/4/26 at 3:14 p.m. with the DM in the kitchen, The DM was informed there was no thermometer in the residents' freezer. The DM stated she was not responsible for the residents' fridge and freezer in the facility's break room. The DM stated it was the responsibility of Activities to handle the resident's fridge and freezer. The DM stated she was not responsible for TL. The DM stated it was the responsibility of LNs to log the temperatures in the TL. When informed there was the TL indicated temperature should be between 36 - 46 F, the DM stated temperature of the fridge should be under 40 F. When informed there was expired items in the fridge, the DM stated facility staff should be given in-service training for that.During a telephone interview on 3/5/26 at 10:58 a.m. with RD, the RD stated she did not recall looking into the residents' fridge and freezer when she was onsite at the facility on 1/6/26 and 1/7/26. The RD stated she was aware of the residents' fridge and freezer was in the facility break room. When informed of the expired items in the residents' fridge and freezer, the RD stated the DM should know when the staff are checking the residents' fridge and freezer and when expired items are removed. When informed there was no thermometer in the freezer, The RD stated that meant no one was checking the freezer. The RD was informed the TL indicated temperatures should be between 36 - 46 F. The RD stated the TL states action that should be taken when temperature is out of range. The RD stated the forms for TL and the processes needed to be updated.During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services - Food brought by Family /Visitors, dated 7/2018, the P&P indicated, . Purpose: to enable the resident with the freedom to eat food brought in by family and visitors, if desired. 3. Food must be in tightly covered, resealable containers and labeled with the resident's name, item and date. Facility staff will discard the item when the used by date has passed .During a review of the facility's P&P titled, Food and Nutrition Services - Food Safety, dated 7/2018, the P&P indicated, . Purpose: to Provide food items to residents that are from approved sources and that are handled in a manner to prevent foodborne illness throughout the facilities food handling processes and in varying serving method. 9. Refrigerated foods: .a. Potentially hazardous food and time slash temperature controlled for safety foods will be maintained at or below 41 F, unless otherwise specified by law. b. Frozen foods will be maintained at a temperature to keep the food frozen solid Refrigerator temperatures will be monitored to verify the functioning of the equipment .

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals (define) were locked and labeled in accordance with current accepted professional standards of practice and facility procedures for one of five sampled residents (Resident 48) and two of three medication carts when: 1. [NAME] wing medication cart contained Resident 48's inhaler medication (pressurized canister that delivers a precise, pre-measured puff of medication directly into the lungs) Budesonide-Formoterol Fumarate Aerosol (treatment for asthma and chronic obstructive pulmonary disease [COPD-chronic lung disease causing difficulty in breathing]) was found to not have an open date and beyond use date (BUD- the last date you can safely use a medication).This failure had the potential for Resident 48's medication to be administered past the discard date which could result in loss of effectiveness of the medication leading to poor management of Resident 48's condition.2. Registered Nurse (RN) 1 left her medication cart unlocked, unsupervised, and not within her visual area in the west wing hallway outside of room [ROOM NUMBER] when she walked inside room [ROOM NUMBER] to administer medications to resident in bed C farthest from the door. This failure had the potential for passing residents, staff, and visitors to have access to medications in the medication cart and take medications which could lead to adverse reaction leading to serious health conditions.3 a. In one of two medication carts, two Controlled Drug Record (CDR - record of when and how many controlled medications were received) were not filled out.This failure had the potential for missing medications and drug diversion (drug diversion is the illegal transfer of prescription medicines from their rightful source to the street for misuse). b. One bottle of insulin (regulates blood sugar levels, preventing them from getting too high) did not have an open or expiration date.This failure had the potential for residents to receive the wrong and or expired medication. c. Two bottles of ear wax removal drops did not have resident labels and opened date.This failure had the potential for residents to receive the wrong and or expired medication. d. Open wound care supplies were stored with medications in the medication cartThis failure had the potential for residents to receive medication that could have been exposed to contagions (any disease or sickness that can be easily spread from one person to another), from being next to open wound care supplies. Findings: 1. During a concurrent observation and interview on [DATE] at 10:50 a.m. during initial tour in Resident 48's room, Resident 48 was observed sitting up in bed and appropriately dressed. Housekeeping Supervisor (HS) was in the room and stated Resident 48 was Spanish Speaking only and interpreted for Resident 48. Resident 48 stated he was happy and felt safe in the facility and was not sure how long he had been in the facility. During a concurrent observation and interview on [DATE] at 3:58 p.m. during medication administration in the west wing with RN 1, RN 1 prepared Resident 48's medications including metered dose inhaler (MDI) Budesonide-Formoterol Fumarate Aerosol. The MDI did not have open date and beyond use date. RN 1 stated she did not know why there was no open date and used by date. RN 1 stated the medication should have been labeled with the opened date and used by date when it was first opened. RN 1 had no answer when asked what happened when a medication was administered past its used by date. During a review of Resident 48's admission Record (AR- a document containing resident profile information), dated [DATE], the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses which included COPD, shortness of breath and muscle weakness. During a review of Resident 48's Order Summary Report, dated [DATE], the Order Summary Report indicated, . Budesonide-Formoterol Fumarate Inhalation Aerosol .2 [two]puff inhale orally two times a day for COPD Rinse mouth with water after use. Do not swallow . Order Date: [DATE] . During an interview on [DATE] at 2:45 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the MDI should be labeled with the opened date and used by date when it was first opened. LVN 3 stated it was to ensure all staff knew when to get rid of the medication and avoid administering medications past its used by date. LVN 3 stated administering medications past its used by date could the medications to be ineffective and residents may not receive the correct dose of medication which may not help the resident for its intended use. During an interview on [DATE] at 10:48 a.m. with LVN 2, LVN 2 stated the practice was to label the MDI with the opened date and used by date when first opening the medication. LVN 2 stated labeling the MDI with the used by date ensured medications were not administered after the used by date. LVN 2 stated medications lose their effectiveness past its used by date and when administered to a resident will not be as effective and not help improve the resident's condition. During an interview on [DATE] at 11:12 a.m. with LVN 1, LVN 1 stated the nurse opening the MDI should label the date the medication was opened and the used by date. LVN 1 stated once a MDI was opened we no longer go by the manufacturer expiration date. LVN 1 stated medications past its used by date did not have the same effectiveness when administered. During a review of facility's policy and procedure (P&P) titled, General Dose Preparation and Medication Administration, dated [DATE], the P&P indicated, . Facility staff should enter the date opened on the label of medications with shortened expiration dates . Facility staff may enter the expiration date based on date opened on the label of medications with shortened expiration dates . 2. During a concurrent observation and interview on [DATE] at 4:14 p.m. in the west wing during medication observation with RN 1, RN 1 prepared Resident 22's medications and entered Resident 22's room and left the medication cart unlocked and unsupervised. RN 1 stated when she left the medication cart open, residents and staff could access the medications, and take the medications which could cause residents to experience side effects of the medication like increase or decrease in their blood pressure. RN 1 stated she was too nervous, she forget to lock the medication cart. RN 1 stated the practice was to ensure the medication cart was locked at all times. During an interview on [DATE] at 11:45 a.m. with LVN 1, LVN 1 stated the practice was to make sure medication cart was locked at all times when not within our sight. LVN 1 stated there were residents walking by all the time and could access the medications and when taken could cause a reaction leading to a serious health condition. LVN 1 stated staff could also take the medications which could lead to drug diversion (illegal transfer of prescription drugs for personal use, sale, or profit). During an interview on [DATE] at 11:40 a.m. with the Director of Nursing (DON) the DON stated the nurse opening the MDI should label the date opened and used by date to ensure efficacy of the medication. The DON stated the medication should not be administered past its used by date because it is not as effective. The DON stated her expectation was for the licensed nurses to ensure to lock their medication carts at all times when they turned their back away from the medication cart. The DON stated there were residents walking by and could access the medications and when taken, could cause adverse reactions leading to serious health conditions. During an interview on [DATE] at 1:25 p.m. with the Administrator (ADM), the ADM stated, Some medications you have to put the date when it was first opened and used by date. The ADM stated labeling medications to ensure medications were not administered past its used by date. The ADM stated the medication concentration was not the same and was not as effective when past its used by date. The ADM stated she expected licensed nurses to ensure medication carts should be locked at all times. The ADM stated any residents walking by could get medications and when taken, could lead to adverse effects of the medications. During a review of facility's policy and procedure (P&P) titled, General Dose Preparation and Medication Administration, dated [DATE], the P&P indicated, .Facility should take all measures required by facility policy and applicable law, including, but not limited to the following . Facility should not leave medications or chemicals unattended . Facility should enter the date opened on the label of medications with shortened expiration dates .During medication administration, facility staff should take all measures required by facility policy and applicable law . Facility staff should ensure that medication carts are always locked when out of sight or unattended. 3. During a concurrent observation and interview on [DATE] at 8:45 a.m. with Licensed Vocational Nurse (LVN) 1, in medication cart two of two, a bottle of insulin did not have an opened or expiration date, two bottles of ear wax removal drops had no resident label or opened date and opened wound care supplies were stored with resident medications. LVN 1 stated, . If the bottles of medications get separated from the box, they could be given to the wrong resident or medication past the expiration date could be given to residents. The opened wound supplies could contaminate the medication in medication cart. The CDR must be filled out completely per policy and to keep inventory in control to prevent drug diversion . During an interview on [DATE] at 11:25 a.m. with the Director of Nursing (DON), the DON stated only medications should be stored in the medication cart, the wound care supplies have been opened and used on residents and could be contagious. The DON stated bottles of medications should be labeled with the resident's information and an opened and expiration date. During a review of the facility's P&P titled, Storage and Expiration Dating of Medications and Biologicals, dated [DATE], the P&P indicated, . Facility should ensure external use medications and biologicals are stored separately from internal use medications and biologicals . Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler).

Based on observation, interviews, and record review, the facility failed to ensure two Food Service Workers (FSW 2 and FSW 3) were competent to safely and effectively carry out the functions of food and nutrition services when:1. FSW 2 did not follow recipes during meal preparation of Turkey Sandwiches on 3/3/2026 and Chicken Enchiladas on 3/4/2026 and was not aware of what the use by date should be after mighty shakes (nutritional supplement) was thawed in the kitchen fridge on 3/1/26.2. FSW 3 was not aware of appropriate temperature for the dishwashing machine.These failures had the potential to result in residents' diet orders and facility menus not being followed which can affect residents' nutritional and medical status and to increase the growth of microorganisms and spread foodborne illness (disease or period of sickness caused by food contamination) to the 66 residents that were served meals from the kitchen.Findings:1.a. During a concurrent observation and interview on 3/3/26 at 3:04 p.m. with FSW 2 in the facility's kitchen, FSW 2 was observed preparing turkey sandwiches with 2 slices of cheese, 4 slices of deli turkey meat and two slices wheat bread. FSW 2 stated the sandwiches were for the regular diet.During a review of the dinner meal on 3/3/26, indicated deli Sandwich, pasta with ranch dressing, and mashed potatoes was to be served for the following diets: Regular, Consistent Carbohydrate Diet (CCD), Heart Healthy (Cardiac), soft and bite sized diets. During a review of the facility recipe titled Sandwich Turkey & Cheese [3] (Turkey & Cheese Sandwich), indicated for 50 servings to use cheese, American white sliced- Preparation step- To assemble sandwich, place 1 slice of cheese and 2 ounces (oz - unit of measurement) of turkey between 2 slices of bread.b. During an observation on 3/4/26 at 10:06 a.m. with FSW 2 in the facility's kitchen, FSW 2 was observed placing 60 x 3 ounces chicken enchiladas from box into a hotel pan, then 2 #10 cans of red sauce and one small can of green enchilada sauce were opened. The red sauce was poured over the chicken enchiladas. FSW 2 was observed grabbing 3 handfuls mozzarella cheese and then a handful of shredded cheddar cheese for each hotel pan of chicken enchiladas and all pans were placed in one of the facility's ovens.During a review of the lunch meal on 3/4/26, indicated Chicken enchiladas, Spanish rice, Whole kernel corn and sliced peaches was to be served for the following diets: Regular, Consistent Carbohydrate Diet (CCD), Heart Healthy (Cardiac), soft and bite sized diets. During a review of the facility recipe titled BVH Chicken Enchiladas (Chicken Enchiladas), indicated for 110 servings to use 7 pounds (lbs. - unit of measurement) of Cheese, [NAME] Shredded and 7 lbs. of cheese, cheddar shredded.Preparation step- Top with enchilada sauce and cheese. FSW 2 did not mix the water and vegetable base with the enchilada sauce. It was unclear how much cheese should be used for the approximate 60 servings for the facility.During a review of the facility recipe titled Enchilada Chicken [3] for 50 servings, indicated to mix water, tomato paste and seasonings together in a saucepan, heat then pour over enchiladas. Then to cover with 10.5 oz of shredded mozzarella cheese. It was unclear how much cheese should be used for the approximate 60 servings for the facility and what recipe FSW 2 should have used for the lunch meal. During an interview with the DM on 3/5/26 at 9:41 a.m., the DM stated she had only done a couple of in-services for kitchen staff since she started at the end of December and was trying to locate any from the past manager.During a review of kitchen in-services dated 1/21/26 and 2/6/26, the in-services did not show any topics about following recipes. During a telephone interview on 3/5/26 at 10:58 a.m. with Registered Dietitian (RD), the recipe for the turkey sandwich was discussed, the RD stated she would expect the dietary staff to following the recipe of one slice of cheese and 2oz of turkey. The RD stated she did not recall observing food production or FSW using the recipes while onsite in the facility on the 1/6/26 and 1/7/26. The RD stated FSW not referencing the recipes was odd. The RD stated the expectation from the FSW was to ensure the menus and recipes were followed.c. During concurrent observation and interview on 03/03/2026 at 10:06 a.m. with the Dietary Manager (DM) during the initial kitchen tour, the fridge in the kitchen had a box of mighty shakes- strawberry flavor with a pull out date of 3/1/26 and use by date of 3/22/26, there was a box of mighty shakes- chocolate flavor with no pull out date or use by date. The DM stated the pull out date should have been on the box. The DM stated the information sheet on fridge indicated the use by date was based on the manufacturer's instructions.During a concurrent observation, interview and record review on 03/03/2026 at 3:09 p.m. with FSW 2 and the DM in the facility's kitchen, the kitchen fridge was opened and the box of mighty shakes- strawberry flavor in fridge dated 3/1 with use by date 3/22 was reviewed. The DM stated, the carton should have stated 15 days after 3/1. FSW 2 stated she thought it should be 3 weeks. FSW 2 was referred to a carton of mighty shakes with manufacturers instruction. The manufacturer's instruction indicated .once thawed to use within 14 days. FSW 2 read the carton and stated, oh it states 14 days.During a review of the facility information sheet displayed on the front of the refrigerator dated 1/2023. The information sheet indicated . Food item- health shake (Thaw), use by date- 2weeks.During a concurrent interview and record review on 03/5/2026 at 9:01 a.m. with the Director of Staff Development (DSD), FSW 2's employee file (EF) was reviewed, the EF indicated FSW 2 was hired on 8/26/25. FSW 2 did not have competency or skills check completed. The DSD stated after one year of employment, there would be an evaluation of facility staff. The DSD stated the DM was responsible for the department training. The DSD stated her department had no record of any competency or training for the kitchen department and thought the DM would have them.During an interview with the DM on 3/5/26 at 9:41 AM, the DM stated when she hired staff, she would give them one week of training and then determine when they can work solo. DM stated she was not sure what was done in the past since she had been here since the end of December. DM stated she had been trying to locate if there was any documentation of staff competencies for any kitchen staff. DM stated she had only done a couple of in-services for kitchen staff since she started and was trying to locate any from the past manager. During a review of kitchen in-services dated 1/21/26 and 2/6/26, the in-service topics were on food temperatures and produce preparation. There were no in-services provided regarding following recipes or nutritional supplements storage dates. During a review of the facility's job description document titled, Nutrition Services Cook, dated 2022, the document indicated, .Summary/ Objective: prepare food in accordance with prescribed resident diet specifications, facility procedures and dietary and sanitary regulations under the supervision of the dietary services manager. Essential functions. Food preparation and serving- prepare and serve food and meals food in accordance with planned menu, diet plans, recipes, portion and temperature control procedures and facility policies.During the survey, there was no documentation provided for kitchen staff competencies for FSW 2. 2. During a concurrent observation and interview on 03/03/2026 at 2:38 p.m. with FSW 3 in the facility's kitchen, FSW 3 was observed was running the dishwashing machine. The temperature was 128 Fahrenheit ( F- a scale for measuring temperature). When asked what the temperature of the dish machine should be at, FSW 3 stated she was not sure what temperature the dish machine needed to be but would write it down on the log. When asked if it mattered what the temperature of the dish machine needed to be, FSW 3 stated she did not know. The temperature log for the dish machine was reviewed, the document indicated for low temp dish machine, temperature needed to be 120 F -140 F.During a concurrent interview and record review on 03/5/2026 at 9:01 a.m. with the Director of Staff Development (DSD), FSW 3's EF was reviewed, the EF indicated FSW 3 was hired on 8/26/25. FSW 3 did not have competency or skills check completed. The DSD stated after one year of employment, there would be an evaluation of facility staff. The DSD stated the DM was responsible for the department training. The DSD stated her department had no record of any competency or training for the kitchen department and thought the DM would have them.During a review of the facility's job description for FSW 3 titled, Nutrition Service Aide, signed and dated 8/26/2025, the document indicated, . Summary/ Objective: . assist in maintaining clean and sanitary condition in the kitchen.essential functions . assist in cleaning and sanitizing work areas, equipment.dishes and utensils .During an interview with the DM on 3/5/26 at 9:41 AM, the DM stated when she has hired staff, she will give them one week of training and then determines when they can work solo. DM stated she was not sure what was done in the past since she has been here since the end of December. DM stated she has been trying to locate if there was any documentation of staff competencies for any kitchen staff. DM stated she had only done a couple of in-services for kitchen staff since she started and was trying to locate any from the past manager. During a review of kitchen in-services dated 1/21/26 and 2/6/26, the in-service topics were on food temperatures and produce preparation. During the survey, there was no documentation provided for kitchen staff competencies for FSW 3. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services - Qualified Dietary Staff, dated 7/2018, the P&P indicated, . Purpose: to provide food and nutrition services by employing . qualified staff with appropriate competencies and skill sets. Policy: the facility will employ sufficient staff with the appropriate competencies and skill set to carry out the function of the food and nutrition service . Guidelines: .3 the facility will provide sufficient support staff to safely and effectively provide the functions of the food and nutrition services. 5. The dietitian or the other qualified nutrition professional will be responsible for tasks related to nutritional and diabetic needs of residents and the management of the food and nutrition services. These tasks include but are not limited to .e. food preparation service and storage .

Based on observation, interviews, and record review, the facility failed to ensure food maintained its nutritional value when the cooked asparagus prepared for the lunch meal on 3/05/26 was not palatable and lacked flavor.This failure had the potential to result in residents having a decrease in oral intake which could lead to weight loss. The facility census was 66.Findings:During an interview on 3/3/26 at 10:57 a.m. with Resident 62, Resident 62 stated the facility needed to upgrade their food choices. Resident 62 stated the food served did not taste like it should.During an interview on 3/3/26 at 11:23 a.m. with Resident 31, Resident 31 complained of the facility's food having no flavor.During a review of the lunch meal on 3/5/26, indicated Marinated pork loin, parslied potatoes, and red pepper asparagus was to be served for the following diets: Regular, Consistent Carbohydrate Diet (CCD), Heart Healthy (Cardiac), soft and bite sized diets. During a concurrent lunch meal test tray observation and interview on 3/5/26 at 12:46 p.m. with the Dietary Manager (DM) in 100 East Wing Hallway. The temperatures of the food were taken, and the regular and puree test tray were sampled. The regular and pureed asparagus tasted bland and lacked flavor. The DM acknowledged the asparagus lacked flavor and tasted bland.During an interview on 3/5/26 at 12:59 p.m. with FSW 1 and the DM, FSW 1 stated she was unable to recall the quantity of items used to flavor the asparagus. FSW 1 stated she eyeballed the salt and pepper to taste and used margarine. FSW 1 stated the quantity of items put on the asparagus was not measured. FSW 1 stated the asparagus was a frozen product and she did not want to use the oven since the facility had one working oven. FSW 1 stated the asparagus was prepared on the stove for about 30 minutes and then it was put on the steam table at 11am. FSW 1 stated she liked to start tray line or meal service around 11:40 a.m. or 11:45 a.m. FSW 1 stated the outcome of the asparagus could be due to the length of time it was cooked. The DM stated food should not be on the steam table longer than 30 minutes.During a review of the facility recipe titled Asparagus with Red Pepper (fzn) AV (Red Pepper Asparagus -TM), indicated for 50 servings to use 10 pounds of frozen cuts of asparagus with one cup of canned diced red peppers, with 1/2 cup of margarine. It indicated under notes, recommended seasonings include basil, chives, coriander, dill, garlic powder, ginger, marjoram, oregano, rosemary, tarragon, herbes de [NAME], salt free herb seasonings. Add 2 1/2 tablespoons seasoning of choice per 10 pounds.During an interview with the DM on 3/5/26 at 9:41 a.m., the DM stated she had only done a couple of in-services for kitchen staff since she started at the end of December and was trying to locate any from the past manager.During a review of kitchen in-services dated 1/21/26 and 2/6/26, the in-services did not show any topics about following recipes. During a review of the facility's job description document titled, Nutrition Services Cook, dated 2022, the document indicated, .Summary/ Objective: prepare food in accordance with prescribed resident diet specifications, facility procedures and dietary and sanitary regulations under the supervision of the dietary services manager. Essential functions. Food preparation and serving- prepare and serve food and meals food in accordance with planned menu, diet plans, recipes, portion and temperature control procedures and facility policies.During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services - Food and Drink, dated 7/2018, the P&P indicated, . Purpose: to provide residents with food and drink that is nutritive, appealing and meets their needs. Policy: the facility will prepare food and drinks in methods that conserve nutritive value, flavor and appearance. Food and drink will be palatable, attractive and at a safe, appetizing temperature. It further indicated under the section titled Guidelines 1. To maintain nutritive value of food, the food will not be . b. held for prolonged times on a steam table .

Based on observation, interviews and review of facility documents, the facility failed to ensure the puree vegetables were in proper form when there were stringy pieces of asparagus throughout the food mixture on the lunch meal test tray on Thursday, March 5, 2026. Failure to properly process the puree food can result in choking for the five residents (Residents 6, 22, 50, 55, 69) on a puree diet at the facility.Findings:During an observation of the lunch meal test tray for a puree and regular diet in the presence of the Dietary Manager (DM) on 3/5/26 at 12:46 p.m. on the 100 East wing hallway, once all the trays were passed to the residents. The puree and regular food items were tasted by the surveyors and the DM as well as the DM took temperatures of the foods at this time. The puree asparagus had multiple strings and thin pieces throughout the portion on the plate. During a concurrent interview with the DM, DM acknowledged the strings in the puree asparagus and stated they should not be there. During an interview with the Food Service Worker (FSW) 1 on 3/5/26 at 12:59 p.m., FSW 1 stated she uses frozen asparagus, cooks for 30 minutes then will add the broth to thin to the appropriate consistency. FSW 1 stated she is looking at the back of the spoon and to have the food stick to it. FSW 1 stated she always has trouble with having strands when she makes the pureed asparagus. During an interview with the DM on 3/05/2026 at 11:47 a.m., DM stated she would expect staff to test for consistency for International Dysphagia Diet Standardization Initiative (IDDSI). During a review of the lunch meal tray tickets dated 3/5/26, indicated there were five residents (Residents 6, 22, 50, 55, 69) receiving a level four puree texture and received the puree asparagus. During a review of the facility document titled Standards of Professional Practice: Diet Guide for the IDDSI for Level 4: Pureed Food, undated, indicated foods are to be smooth, and lump-free, not firm or sticky, requires no chewing or bolus formation, fall off the spoon as an intact spoonful, and hold shape on a plate. During a review of the facility recipe titled PU4 Asparagus with Red Pepper (fzn), indicated to measure desired number of servings into food processor. Blend until smooth. Use Fork Drip Test & Spoon Tilt Test to confirm texture is within IDDSI Level 4 specifications.During a review of the facility policy and procedures titled Food and Nutrition Services Menus and Therapeutic Diets dated 7/18, indicated the purpose is to have menus that are developed and prepared to meet resident choices while meeting their nutritional needs and in the appropriate form.

Based on observation, interview, and record review, the facility failed to establish and maintain infection prevention and control program for a safe, sanitary, and comfortable environment for three of 12 sampled residents (Residents' 46, 47, and 79) when:1.Handheld nebulizer (HHN) masks (a medical device accessory that covers the nose and mouth, allowing patients to inhale aerosolized medication directly into the lungs) for Resident 46 and Resident 47 were not labeled with the date it was first used and was observed placed directly on top of each resident's bedside table.These failures had the potential for Resident 46 and Resident 47 to be exposed to cross contamination (unintentional transfer of harmful germs or allergens from one surface or object to another) when the nebulizer masks were used by the residents.2. Physical Therapy Assistant (PTA) did not wear appropriate personal protective equipment (PPE-specialized clothing, equipment, and supplies worn by healthcare staff to protect residents and themselves from potential infectious hazards) while transferring Resident 79 from bed to wheelchair. Resident 79 was on an enhanced barrier precaution (EBP - measures used in healthcare settings to prevent the spread of infections) due to the presence of a urinary catheter (a tube that drains urine from the bladder into a bag) and a nephrostomy tube (a tube from the kidney to the outside of the body to drain urine when normal flow is blocked).This failure had the potential to cause Resident 79 a catheter-associated urinary tract infections (a urine or bladder infection that happens because of a urine catheter) and contamination of the nephrostomy site. Findings: 1. During a concurrent observation and interview on 3/3/26 at 11:35 a.m. during the initial tour in Resident 46's room, Resident 46's bedside tabletop had a hand held nebulizer mask with no date. Resident 46 stated she used the handheld nebulizer mask every day for her breathing. Resident 46 stated she was not sure where the mask should be placed and was not sure when they replaced it last. During a concurrent observation and interview on 3/3/26 at 11:40 a.m. during initial tour in Resident 47's room, Resident 47's bedside tabletop had a nebulizer mask with no date. Resident 47 was lying in bed and stated she remembered she used the nebulizer mask in the morning and used it every day for her breathing problem. During a review of Resident 46's admission Record (AR-a document containing resident profile information), undated, the AR indicated Resident 46 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure (a life-threatening, medical emergency where lungs suddenly cannot get enough oxygen into the blood or remove enough carbon dioxide), heart failure (heart muscle is too weak or stiff to pump blood efficiently), and shortness of breath. During a review of Resident 47's AR, undated, the AR indicated Resident 47 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty breathing), muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 47's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 1/13/26, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 3 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 47 had severe cognitive impairment. During a concurrent observation and interview on 3/3/26 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 observeded Resident 46 and Resident 47's HHN masks and stated Resident 46 and Resident 47's HHN mask did not have dates and were placed on top of their bedside tables. LVN 2 stated HHN masks should have been labeled with the date they were first used and stored in a bag and not placed directly on top of the bedside tables. LVN 2 stated HHN masks were replaced every week. LVN 2 stated, I am not sure if it was night shift licensed nurses or the infection preventionist. LVN 2 stated not having the HHN mask labeled and placed in a bag was an infection control issue. LVN 2 stated bacteria could build up in the HHN masks and tubing and when used, residents could inhale bacteria which could go straight into their lungs making them sicker. During an interview on 3/6/26 at 11:20 a.m. with LVN 1, LVN 1 stated the practice was to make sure HHN masks were labeled with the date they were replaced and stored in a bag. LVN 1 stated HHN masks should not be placed directly on top of a surface like the bedside table. LVN 1 stated HHN tubing and masks were changed every week and labeled with the date and placed in a bag because it was an infection control issue. During an interview on 3/6/26 at 11:47 a.m. with the Director of Nursing (DON), the DON stated her expectation was licensed nurses should change HHN masks weekly and should be bagged because the masks got dirty, it was an infection control. The DON stated the IP was responsible to make sure oxygen tubing, HHN masks and tubings' were replaced and labeled. The DON stated, The infection preventionist did not do his rounds this week. During a review of facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Non-Critical Resident Care Items, dated 10/18/22, the P&P indicated, .Single resident use items are for single resident use only. [NAME] with the resident's name and/or room number and discard upon transfer or discharge . Critical items consist of items that carry a high risk of infection if contaminated . Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., [for example] respiratory therapy equipment). Such device should be free from all microorganisms . Dedicated, single resident -use items are labeled with the resident name . 2. During an observation on 3/3/26 at 11:15 a.m. outside of Resident 79's room, an EBP sign and cart were placed outside prior to entry into the room. The cart was stocked with gowns and gloves for use before entering the room. During a concurrent observation and interview on 3/3/26 at 11:20 a.m. with the PTA inside Resident 79's room, the PTA transferred Resident 79 from bed to wheelchair and was wearing gloves but not wearing a gown. The PTA stated, Resident 79 is scheduled for a physical therapy today. The PTA stated they had not been informed about the EBP sign posted on the door and reported that the EBP sign is sometimes not updated. During an interview on 3/3/26 at 12:04 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 79 was on EBP due to the presence of a urinary catheter and a nephrostomy tube. LVN 2 stated, prior to working with Resident 79, the facility staff including the PTA, were required to wear PPE to protect the resident from germs. During an interview on 3/5/26 at 9:26 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated, hand hygiene must be performed before applying PPE, including a gown and gloves used for EBP, when assisting the residents with activities of daily living (the basic things a person needs to do every day to take care of themselves). During an interview on 3/5/26 at 12:03 p.m. with the Infection Preventionist (IP), the IP stated the EBP applied to all Licensed Nurses, Certified Nursing Assistants, Physical Therapists and Physical Therapy Assistants when providing care to residents, including transfers from bed to wheelchair. The IP stated the purpose of EBP was to prevent cross-contamination (germs spreading from one place or object to another) and ensure the residents' safety from infection. The IP stated the EBP sign posted outside Resident 79's room was updated to ensure facility staff were aware of the necessary precautions before entering the room. The IP stated the EBP sign is updated weekly and as needed. During an interview on 3/6/26 at 12:35 p.m. with the Director of Nursing (DON), the DON stated facility staff were expected to always follow the EBP to protect residents from infection and to prevent the spread of germs within the facility. During a review of the facility's policy and procedures (P&P) titled, INFECTION CONTROL: Standard Precautions, Enhanced Barrier Precautions, and Transmission-Based Precautions, dated 3/26/24, the P&P indicated, .EBP is employed when performing the following high-contact resident care activities: .when anticipating close physical contact while assisting with transfers and mobility.

Based on observation, interview, and record review, the facility failed to ensure essential equipment was maintained in safe operating condition when: one of two kitchen ovens were not working and unable to be used. This failure to have an operational oven could result in the food taking longer to cook resulting in delayed meal times, inconsistent food quality, and inefficient workflows. The facility census was 66. Findings:1. During an observation on 3/4/26 at 10:06 a.m., Food Service Worker (FSW) 2 was preparing three hotel pans of chicken enchiladas with red sauce and one quarter hotel pan with chicken enchiladas with green sauce. All pans were placed in one of the kitchen ovens. During an interview on 3/4/26 at 11:42 a.m. with FSW 2, FSW 2 stated only one oven was working and the nonworking oven has not worked for about five months. FSW 2 stated she was told it could not be fixed and now they just had to try to time things and just use the one oven. During an interview on 3/5/26 at 9:30 a.m. with the Maintenance Director (MD), the MD stated the oven pilot had went out last week but thought everything was working since then. The MD stated the staff will use their system to let him know about maintenance issues. The MD stated two months ago that he did the pilot assembly and then it was working. The MD stated he relied on the kitchen staff to let him know about things going wrong in the kitchen. The MD stated he would find receipts of pilot assembly from two months ago and the engines done a month ago. During a review of the facility document titled, work order #1502, dated 12/10/25, the work order indicated the right oven was out and pilot light was on. Under comments it indicated checked oven and found switch was not on, working properly and the timeline indicated it was completed on 12/12/25. During a review of the facility policy and procedures titled, Physical Environment Essential Equipment, Safe Operation Condition, dated 7/18, the policy indicated, The facility will maintain mechanical, electrical and patient care equipment in safe operating condition.

Based on observation, interview, and record review, the facility failed to provide a comfortable environment for four of 31 sampled residents (Residents 14, 41, 51, and 80), when vertical blinds had missing slats, horizontal blinds were broken, and resident room walls had scratches and missing paint. These failures created an environment that was not homelike and had the potential to decrease the residents mood and potentially lead to depression.Findings: During a concurrent observation and interview on 3/5/26 at 3:27 p.m. with Resident 41 in her room, Resident 41 was lying in bed on her back with the sun streaming on her face. Resident 41 stated, . the sun shines off the cars in the parking lot and right into my face from the hole in the blinds, it causes me to get a headache. The blinds have been broken since I was admitted .During a concurrent observation and interview on 3/5/26 at 3:28 p.m. with Resident 80's family member in her room, Resident 80's family member stated, In my home I would not have so many slats missing from the blinds, I would prefer [Resident 80] have complete blinds.During a concurrent observation and interview on 3/5/26 at 3:40 p.m. with the Maintenance Director (MD) in Resident 41's and Resident 80's room, the MD stated, in reference to Resident 41 and 80's room . This is not a home like environment, the blind slat should not be on the floor, and if I would not like to have the sun shining in my eyes . During a concurrent observation and interview on 3/5/26 at 3:45 p.m. with the MD, in Resident 14's, and Resident 51's room. The horizontal blinds were broken with missing slats, and the residents' room walls had scratches and missing paint. The MD stated, . the resident should not have to look at the wall and blinds that are not repaired. I will be repairing the blinds and the wall . During a concurrent observation and interview on 3/5/26 at 4:49 p.m. with Certified Nurse Assistant (CNA 4), CNA 4 stated I would not want my family to be in a room that had all the damage to the wall. During a concurrent observation and interview on 3/5/26 at 4:53 p.m. with CNA 5, CNA 5 stated, Missing blinds are a pet peeve of mine and if I was stuck in bed looking at scraped wall and missing blinds it would make me depressed.During a review of Resident 14's admission Record (AR), dated 3/6/26, the AR indicated Resident 14 was admitted to the facility on [DATE] from a Skilled Nursing Facility (SNF) with the diagnosis of Hemiplegia (the severe or total loss of voluntary movement [paralysis] on one vertical side of the body [left or right], weakness, pain, dysphagia (difficulty swallowing, causing pain or trouble moving food/liquids from the mouth to the stomach), and cognitive communication deficit (difficulty in communication).During a review of Resident 41's AR, dated 3/6/26, the AR indicated Resident 41 was admitted to the facility from an acute care hospital on 2/10/26 with the diagnosis of closed right femur (long bone in the thigh) fracture (define), right patella (knee) fracture, right humerus (long bone of upper arm) fracture?, and general weakness.During a review of Resident 51's AR, dated 3/6/26, the AR indicated Resident 51 was admitted to the facility from a SNF on 1/20/23 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a progressive, irreversible lung disease-primarily caused by smoking or pollution-that restricts airflow, making it difficult to breathe), muscle wasting, Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out simple tasks), and Type 2 Diabetes Mellitus (DM - a chronic metabolic disease characterized by high blood sugar (glucose) levels, occurring when the body cannot properly produce or use insulin).During a review of Resident 80's AR, dated 3/6/26, the AR indicated Resident 80 was admitted to the facility from an acute care hospital on 2/25/26 with the diagnosis of Neoplasm of the bone (an abnormal growth or lump of cells within the bone, essentially a bone tumor), Human Immunodeficiency Syndrome Virus (HIV- a virus that attacks the body's immune system, specifically CD4 cells [T cells]), and Sepsis (a life-threatening medical emergency caused by the body's extreme, overactive response to an infection).During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated 1/2018, the P&P indicated . 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home-like setting. These characteristics include: a clean, sanitary, and orderly environment .

Based on observation, interview, and record review, the facility failed to treat each resident with dignity and respect in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of three sampled residents (Resident 79), when Resident 79's urinary catheter (tube inserted into the bladder through the urethra [urine tube], to drain urine freely into a connected bag) bag was not placed in a dignity bag (a bag the catheter drainage bag is placed into, to cover the resident's urine from view).This failure resulted in Resident 79's urinary catheter bag to be uncovered in full view for others to see and having the potential for Resident 79 to feel his privacy and dignity were not respected.Findings:During a review of Resident 79's admission Record (AR), dated 03/6/26, the AR indicated, Resident 79 was admitted to the facility on [DATE] with diagnosis which included Acute kidney failure (kidney suddenly stop cleaning the blood), obstructive and reflux uropathy (blockage in the urine tubes), Hydronephrosis with renal and ureteral calculous obstruction (swollen kidney, kidney stones blocking the flow of urine), and other artificial openings of urinary tract status (surgically made opening to drain urine).During a review of Resident 79's Order Summary Report (OSR), dated 3/6/26, the OSR indicated, .Foley catheter to gravity drain. [catheter] size 16 .every shift. During a concurrent observation and interview on 3/5/26 at 9:26 a.m. with Certified Nurse Assistant (CNA) 3 in Resident 79's room, Resident 79's urinary catheter bag was hung on the side of the bed and uncovered. The urinary catheter bag was visible upon entry to Resident 79's room. CNA 3 stated Resident 79's catheter bag was not covered. CNA 3 stated, The catheter bag should be covered with a dignity bag at all times to provide privacy and dignity to the resident. During an interview on 3/5/26 at 10:58 a.m. with Licensed Vocation Nurse (LVN) 2, LVN 2 stated, a urinary bag must always remain covered when inside or outside the resident's room, to protect the resident's' privacy and maintain dignity.During an interview on 3/5/26 at 12:03 p.m. with the Infection preventionist (IP), the IP stated, a urinary bag cover must always remain in place to prevent exposure of the urine bag to other residents and visitors and to maintain resident privacy and dignity.During an interview on 3/6/26 at 9:25 a.m. with the Director of staff development (DSD), the DSD stated, a urinary bag cover was used to maintain residents' privacy, dignity and comfort while preventing embarrassment.During an interview on 3/6/26 at 12:25 p.m. with the Director of Nursing (DON), the DON stated, a urinary bag cover should be always applied as a best practice to maintain and promote residents' dignity.During a review of the facility's policy and procedure (P&P) titled, RESIDENT RIGHTS, dated 9/20/2022, the P&P indicated, .The resident has the right to be treated with respect and dignity.

Based on observation, interview, and record review, the facility failed to ensure a physician informed consent (the process in which residents are given information of the possible risk and benefits of psychoactive medications (change brain function, altering perception, mood, consciousness, and behavior) for the use of psychotropic medications (medication capable of affecting mind, emotions and behavior) was obtained for one of six sampled residents (Resident 32), when Resident 32 was administered lorazepam (medication used to treat anxiety (excessive, persistent fear or worry that interferes with daily life)) on 3/1/26 and 3/2/26 and informed consent was not obtained prior to medication administration.This failure resulted in Resident 32 to be administered psychotropic medication and not be fully informed of the risks and benefits and did not have the knowledge to make an informed decision which placed Resident 32 at potential risk for negative side effects. During a concurrent observation and interview on 3/3/26 at 10:06 a.m. during initial tour in Resident 32's room, Resident 32 was observed standing next to his bed with certified nursing assistant (CNA) 1, Resident 32's bed was in the lowest position and a fall mat was at bedside. Resident 32 did not answer question, CNA 1 stated Resident 32 was confused and Spanish Speaking only. During a review of Resident 32's admission Record (AR-a document containing resident profile information), dated 3/5/26, the AR indicated Resident 32 was admitted to the facility on [DATE] with diagnoses which included anxiety, dementia (a progressive state of decline in mental abilities) and repeated falls. During a review of Resident 32's Order Summary Report, dated 3/5/26, the Order Summary Report indicated, .[brand name] 2 (two) [milligram/milliliter-unit of measurement (MG/ML)] (LORazepam) Inject 1 (one) mg intramuscularly [into muscle tissue] every 12 hours as needed . Order Date: 2/25/26 . During a review of Resident 32's Medication Administration Record (MAR- a document that shows the medication ordered and taken by a resident), dated 2/1/26-2/28/26 and 3/1/26-3/31/26, the MAR indicated lorazepam was administered on 3/1/26 and 3/2/26. During a concurrent interview and record review on 3/5/26 at 9:25 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 32's clinical record, dated 3/5/26 was reviewed. LVN 2 stated Resident 32's lorazepam was ordered on 2/25/26. LVN 2 stated she did not find an informed consent for lorazepam. LVN 2 stated lorazepam should not have been administered without an informed consent. LVN 2 stated licensed nurses were responsible to make sure informed consent were signed prior to administering psychotropic medications. LVN 2 stated informed consent were important to educate residents and family of the side effects and benefits of the medications. During a concurrent interview and record review on 3/5/26 at 3:08 p.m. with the Unit Manager (UM), Resident 32's clinical record, undated was reviewed. The UM stated the clinical record indicated a consent for Resident 32's lorazepam was not found. The UM stated the licensed nurse who received the order should have made sure informed consent was signed prior to administering the medication. The UM stated lorazepam should not have been administered to Resident 32 without a signed informed consent. During a concurrent interview and record review on 3/6/26 at 11:32 a.m. with the Director of Nursing (DON), Resident 32's clinical record, undated was reviewed. The DON stated the clinical record indicated Resident 32's lorazepam was changed from oral to injection. The DON stated her expectation was for the licensed nurse to ensure the lorazepam informed consent was signed. The DON stated, The consent should have been signed before it was administered. The DON stated it was the right of the resident and family to be aware of the medications they are receiving and given a chance to decide whether they wanted to receive the medication. During an interview on 3/6/26 at 1:05 p.m. with the Administrator (ADM), the ADM stated her expectation was to ensure informed consent for psychotropic medications were signed prior to administering medications. The ADM stated informed consents explained the risks and benefits of medications, so residents and family could then decide whether they wanted the medication or not. During a review of facility's policy and procedure (P&P) titled, Freedom from Abuse, Neglect and Exploitation, Abuse, dated 11/17, the P&P indicated, .The facility will provide a safe environment and protect residents from abuse .This includes freedom from . physical or chemical restraint not required to treat the resident's medical symptoms . During a review of facility's P&P titled, Psychotropic Medication Use, dated 12/1/07, the P&P indicated, Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use . Facility staff should inform the resident and/or resident representative of the initiation, reason for use and the risks associated with the use of psychotropic medications .

Based on observation, interview, and record review, the facility failed to complete a new Preadmission screening and Resident Review (PASARR- a federal requirement to ensure resident with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level 1 screening for one of six sampled residents (Resident 6) when Resident 6's PASARR level 1 dated 9/9/24 completed prior to admission to the facility did not include diagnosis of psychosis (a severe mental condition in which thought, emotions are so affected that contact is lost with reality) and depression (a serious, persistent mood disorder) and use of psychotropic medication (drugs that affect the mind, emotions, and behavior).This failure had the potential for Resident 6 to not receive the appropriate services related to her diagnoses and medication used. Findings: During a concurrent observation, and interview, on 3/3/26 at 12:05 p.m. in the dining room with Resident 6, Resident 6 was observed sitting up in her wheelchair, appropriately dressed and answered questions. Resident 6 stated she did not remember how long she had been in the facility. Resident 6 stated she was happy and did not have any concerns. During a review of Resident 6's admission Record [AR- a document containing resident profile information], dated 3/5/26, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses which included unspecified psychosis, depression and hemiplegia [total paralysis of the arm, leg and trunk on the same side of the body] and hemiparesis [one-sided weakness or side weakness].During a review of Resident 6's Order Summary Report [OSR] undated, the OSR indicated, . [brand name] Sprinkles Oral Capsule . 125 [(MG) milligram-unit of measurement] (Divalproex Sodium-medication used to treat seizures). Give 2 capsules by mouth two times a day . yelling out . uncontrollable sobbing .Order Date: 3/14/25 . FLUoxetine [medication used to treat depression] . 60 MG . Give 1 tablet by mouth one time a day for sad facial expression, 2 tearfulness . Order Date: 3/11/25 During an interview on 3/4/26 at 2:41 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 6's care. CNA 1 stated Resident 6 have behaviors like crying and she does not even know why she was crying. CNA 1 stated she did not know if Resident 6 took medication for her crying.During a concurrent interview and record review on 3/5/26 at 9:15 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 6's clinical record, undated was reviewed. LVN 2 stated the clinical record indicated Resident 6 was admitted to the facility on [DATE]. LVN 2 stated Resident 6's divalproex sodium was ordered on 3/17/25 and her fluoxetine was ordered on 3/12/25. During an interview on 3/5/26 at 3:08 p.m. with the Unit Manager (UM), the UM stated, Director of Nursing (DON) and I review admission and ensure there was a PASARR completed prior to admission to the facility. The UM stated she was not sure when a new PASARR should be completed when there was a new order for a psychotropic medication. The UM stated a new PASARR assessment should be completed annually and when a resident was admitted to hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility. During a concurrent interview and record review on 3/6/26 at 9:22 a.m. with the DON, Resident 6's clinical record, undated was reviewed. The DON stated the clinical record indicated Resident 6 was ordered psychotropic medication after the PASARR was completed but was not sure whether a new PASARR should be completed. The DON stated new admission's PASARR were reviewed for any discrepancies but was not sure whether to complete another PASARR assessment and reached out to the company consultant. The DON stated, I was told not to do another PASARR assessment because there was one already completed. During a review of facility policy and procedure (P&P) titled, Resident Assessment Preadmission Screening and Resident Review (PASRR), dated 11/17, the P&P indicated, .Any resident with newly evident or possible serious [Mental Disorder](MD)], or [Intellectual Disability (ID)], or a related condition will be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review . During a review of professional reference from the California Department of Health Care Services (DHCS) (a government agency that provides healthcare services to low-income and disabled Californians) titled, Preadmission Screening and Resident Review, undated, (found at https://www.dhcs.ca.gov/services/MH/Pages/PASRR.aspx), the reference indicated .The (DHCS), PASRR Section is responsible for determining if individuals with serious mental illness (SMI) and/or intellectual/developmental disability (ID/DD) or related conditions (RC) require: Nursing facility services, considering the least restrictive setting, Specialized services. This is achieved by completing the PASRR process. The PASRR process consists of a Level I Screening, Level II Evaluation, and a final Determination. Level I Screening-The Screening is submitted online by the facility and is a tool that helps identify possible SMI and/or ID/DD/RC. Level II Evaluation- If the Screening is positive for possible SMI and/or ID/DD/RC, then a Level II Evaluation will be performed. The Level II Evaluation helps determine placement and specialized services. The Department of Health Care Services (DHCS) is responsible for SMI Level II Evaluations, which by law must be performed by a third-party contractor

Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of eight sampled residents (Resident 41), when Resident 41 did not have a care plan for their arm sling (a supportive device-usually a fabric pouch with a strap-used to hold an injured arm, wrist, or shoulder still against the body). This failure placed Resident 41 at risk for delayed healing by not identifying and monitoring for compliance with the arm sling. Findings: During a review of Resident 41's admission Record (AR-a document containing pertinent resident profile information), dated 3/6/26, the AR indicated Resident 41 was admitted to the facility on [DATE] with diagnoses which included fracture (define) of the right femur (long bone of the leg), fracture of the right patella (knee cap), fracture of the humerus (long bone of the arm), and unsteadiness on her feet. During a review of Resident 41's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment, dated 2/16/26, the MDS assessment indicated Resident 41's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 15 out of 15 which indicated Resident 41 had no cognitive deficit. During a concurrent observation and interview on 3/3/26 at 10:40 a.m. with Resident 41 in their room, Resident 41 was lying in her bed without her arm sling. Resident 41 stated she was in the facility for therapy after falling and having surgery on her fractured right leg and right shoulder. Resident 41 stated she was supposed to have her sling on but frequently took it off. During a review of Resident 41's Order Summary Report (OSR-a report of all orders for resident while in facility), dated 3/4/26, the OSR indicated Resident 41 had an order to monitor sling placement to the right upper extremity every shift and for proper placement. During a concurrent interview and record review on 3/4/26 at 1:30 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 41's Electronic Medical Record (EMR), dated 9/12/24 was reviewed. LVN 1 stated the EMR indicated a care plan for Resident 41's right arm sling was not found. LVN 1 stated a care plan was created to instruct nursing on how to care for the resident, if the care plan had missing information, the resident could be at risk for not receiving the care needed to heal. During a concurrent interview and record review on 3/5/26 at 2:00 p.m. with the Unit Manager (UM), Resident 41's care plan, dated 3/5/26 was reviewed. The UM stated she placed the care plan for the sling earlier that day. The UM stated that the intervention should have been placed in the care plan right after the order was placed to give staff directions for care of Resident 41. During an interview on 3/6/26 at 11:57 a.m. with the Director of Nurses (DON), the DON stated Resident 41 did not have a care plan for her sling. Resident 41 should have a care plan to alert nurses that Resident 41 should be wearing her sling. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 11/2017, the P&P indicated, .The care plan will be person-centered. It will drive the type of care and services that a resident receives . a comprehensive care is developed within seven (7) days of completing the resident assessment.

Based on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of quality of care for three out of six sampled residents (Residents' 11, 48, and 65) when:1.Licensed Vocational Nurse (LVN) 3 signed the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) prior to administering Resident 11 and Resident 65's received their medications. These failures resulted in inaccurate charting and placed Resident 11 and Resident 65 at risk to not receive the medications ordered.2.Registered Nurse (RN) 1 did not shake the inhaler (handheld, pressurized device that delivers a specific, measured dose of medication) before he gave it to Resident 48 to self administer.This failure had the potential to result in Resident 48 not receiving the accurate dose of medication which could lead to Resident 48 not experiencing relief of his condition.Findings: 1. During a concurrent observation and interview on 3/5/26 at 8:25 a.m. with Licensed Vocational Nurse (LVN) 2 in the west wing, LVN 2 was observed preparing Resident 11's medications and stated Resident 11 was the last resident she was administering medications to. LVN 2 exited Resident 11's room after administering Resident 11's medications, opened the medication cart and pulled out a medication cup with pills and stated, I have to give these five pills to Resident 65 in room [ROOM NUMBER]. LVN 2 did not sign or record in the eMAR she administered Resident 11 and Resident 65's medications after administering their medications. LVN 2 stated she documented she administered Resident 11's medication prior to administering her medications. LVN 2 stated she prepared Resident 65's medications earlier and documented she administered medications but Resident 65 did not take his medications. LVN 2 stated she had to go back to administer Resident 65's medications. LVN 2 stated it was her practice to click save in the eMAR indicating medication was administered prior to administering medications to residents. LVN 2 stated the acceptable practice was to administer medications first then document after medications were administered. LVN 2 stated documenting medications were administered prior to administering medications was not the acceptable practice, it could lead to a medication error. During a review of Resident 11's admission Record (AR-a document containing resident profile information), undated, the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (irregular heart rhythm, characterized by rapid chaotic electrical signals that causes the heart's upper chambers to quiver), muscle weakness, rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility) and carcinoma (cancer) of the skin. During a review of Resident 65's AR, undated, the AR indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and muscle weakness. During an interview on 3/6/26 at 10:55 a.m. with LVN 2, LVN 2 stated the practice was to pull out one medication at a time, administer the medication then go back in the eMAR and click save indicating the medication was administered. LVN 2 stated medications could not be documented as administered prior to administering medications to residents stating, it is not the right practice. During an interview on 3/6/26 at 11:20 a.m. with LVN 1, LVN 1 stated, I document a medication was administered after I administered the medication and not before. LVN 1 stated the practice in the facility was to ensure medications were administered first then documented to prevent a medication error. 2. During a concurrent observation and interview on 3/5/26 at 3:58 p.m. in the west wing during medication administration observation with RN 1, RN 1 prepared Resident 48's medication including a metered dose inhaler (MDI-handheld, pressurized device that delivers a specific, measured dose of medication) of Budesonide-Formoterol Fumarate Aerosol (used to help control asthma and improve lung function). RN 1 entered Resident 48's room and administered Resident 48's medication. RN 1 gave the MDI to Resident 48 without shaking and let Resident 48 self-administer two puffs of the MDI. RN 1 stated she did not shake the MDI because the MDI was already shaken every day. RN 1 stated she was not sure if Resident 48 self-administered the MDI because she had always given the MDI to Resident 48. RN 1 stated not shaking the MDI could result in not delivering the right dose or concentration of medication. During a review of Resident 48's admission Record (AR- a document containing resident profile information), dated 3/6/26, the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty inbreathing), shortness of breath and muscle weakness. During a review of Resident 48's Order Summary Report, dated 3/6/26, the Order Summary Report indicated, . Budesonide-Formoterol Fumarate Inhalation Aerosol .2 [two]puff inhale orally two times a day for COPD Rinse mouth with water after use. Do not swallow . Order Date: 05/24/2025 . During an interview on 3/5/26 at 2:30 p.m. with LVN 3, LVN 3 stated the MDI medication should be shaken well to ensure the medication was mixed thoroughly to administer the correct amount of medication. LVN 3 stated not shaking the medication well could lead to residents not experiencing relief because the proper dose or strength was not delivered. LVN 3 stated she was not sure if giving the MDI to Resident 48 to self-administer is considered self-administration. During an interview on 3/6/26 at 10:48 a.m. with LVN 2, LVN 2 stated MDI medications should be shaken well before administration to make sure medications were mixed properly. LVN 2 stated, To make sure resident received the accurate, consistent and effective dose with each spray. LVN 2 stated there was an instruction in the medication package to shake well. LVN 2 stated it was considered self-administration of medication when Resident 48 self-administered the MDI. During an interview on 3/6/26 at 11:23 a.m. with LVN 1, LVN 1 stated, I usually shake MDI before I hand over to residents. LVN 1 stated residents who had inhalers are alert and not sure if evaluation or assessment was needed to check if residents were competent to self-administer medication. LVN 1 stated it was considered self-administration when Resident 48 self-administered the MDI. LVN 1 stated she was not sure if Resident 48 was administering the MDI properly and receiving the correct dose of medication when the MDI was not shaken prior to administration. During a concurrent interview and record review on 3/6/26 at 11:35 a.m. with the Director of Nursing (DON), Resident 48's Self-Administration of Medication (SAM), dated 10/14/25 was reviewed. The DON stated her expectation was for licensed nurses to administer medications first before they saved in the eMAR. The DON stated nurses could place a checkmark next to each medication pulled but do not save because once they clicked save, it meant the medication was already administered. The DON stated, Nurses should know better. The DON stated the MDI should be shaken well to ensure medication was thoroughly mixed. The DON stated her expectation was for licensed nurses to shake medications well to ensure an accurate, consistent and effective dose was administered to the resident. The DON stated the SAM indicated Resident 48 could self-administer medications. The DON stated the evaluation should be renewed every 3 months and Resident 48's evaluation was due in January 2026 but was not completed. During an interview on 3/6/26 at 1:10 p.m. with the Administrator (ADM), the ADM stated it was not acceptable to sign the eMAR before administering medications. The ADM stated it could lead to a medication error because they may not administer the medication since it was already signed. The ADM stated she considered it as self-administration of a medication when a licensed nurse handed over the MDI to a resident. The ADM stated, The resident is pressing down the inhaler/actuation which controls the dose. The ADM stated her expectation was for the licensed nurses to do the right thing.During a review of the facility policy and procedure (P&P) titled, General Dose Preparation and Medication Administration, dated 12/01/07, the P&P indicated, .Facility should take all measures required by facility policy and applicable law .Only prepare medications for one resident at a time . Verify each time a medication is administered that it is the correct medication . Position the resident properly, if necessary . After medication administration, facility staff should take all measures required by facility policy and applicable law . Document necessary medication administration/treatment information [e.g., (for example) when medications are opened, when medications are given, injection site of a medication, if medication are refused, PRN medications, applicable site] on appropriate forms .During a review of the facility P&P titled, Pharmacy Services Medication Administration, dated 08/18, the P&P indicated, .Medications will be shaken according to manufacturer instruction . When administering a metered dose inhaler (MDI), staff will: a. Shake the container well. b. Position the inhaler in front of or in the resident's mouth .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services which ensured the administration of medications to meet residents needs were met for one of 10 sampled residents (Resident 31), when Resident 31's buspirone (medication used to treat anxiety (feeling of fear, dread, and uneasiness, often accompanied by physical symptoms)) medication was not available during medication pass on 3/5/26.This failure had the potential for Resident 31's anxiety behavior to increase which could result in serious medical conditions such as worsening of anxiety, panic episodes, insomnia, irritability, dizziness, headache, and nausea. Findings: During a concurrent observation and interview on 3/3/26 at 11:23 a.m. during initial tour in Resident 31's room, Resident 31 was lying in bed, watching television and talking with another resident in bed next to Resident 31's bed. Resident 31 was appropriately dressed and stated his only concern was the food. Resident 31 stated he felt safe in the facility and staff assisted him with all his care. During a concurrent observation and interview on 3/5/26 at 4:26 p.m. during medication administration in the west wing, Registered Nurse (RN) 1 was observed preparing Resident 31's medication. RN 1 did not administer Resident 31's buspirone. RN 1 stated she did not administer Resident 31's buspirone because it was not available. RN 1 stated she would call the pharmacy after she completed administering medications to all the residents in her wing. RN 1 stated it was the responsibility of licensed nurses to make sure routine medications were available to administer to residents. RN 1 did not answer what could happen to Resident 31 when he did not receive his buspirone. During a review of Resident 31's admission Record (AR-a document containing resident profile information), dated 3/6/26, the AR indicated Resident 31 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), depression (persistent, intense, and long-lasting low mood, loss of interest in activities, and feelings of sadness or worthlessness) and anxiety. During a review or Resident 31's Order Summary Report, dated 3/6/26, the Order Summary Report indicated, .busPIRone [hydrochlorothiazide (HCl)] Oral tablet 7.5 [milligram (MG)-unit of measurement] (Buspirone HCl) Give 1 tablet by mouth two times day for feeling nervous, restless . Order Date: 01/20/2023, Start Date: 01/20/2023 . During an interview on 3/6/26 at 11:15 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it was the responsibility of all licensed nurses to make sure routine medications were available to administer to residents. LVN 1 stated, We order medications before we run out. LVN 1 stated, The practice was to call pharmacy and Medical Director when a routine medication was not available to administer to resident. During an interview on 3/6/26 at 11:50 a.m. with the Director of Nursing (DON), the DON stated licensed nurses were responsible to make sure medications were available and ready to be administered to residents. The DON stated the practice in the facility was to reorder medications when the last seven days of available medications were left. The DON stated her expectation was for the licensed nurses to call the pharmacy and follow up on medication availability. During an interview on 3/6/26 at 1:15 p.m. with the Administrator (ADM), the ADM stated she was a medical doctor in her country and familiar with medications. The ADM stated Resident 31 not receiving the buspirone medication could lead to an episode of psychosis and delusions. The ADM stated her expectation was for the licensed nurses to order medications before they ran out and call the pharmacy and notify the medical doctor. During a review of facility policy and procedure (P&P) titled, Reordering, Changing, and Discontinuing Medication Orders, dated 12/01/07, the P&P indicated, .Facility should ensure all orders clearly reference the resident's first and last name in full . Non-controlled medications may not be refilled 12 months after the original order . Facilities are encouraged to reorder medications electronically or by fax whenever possible .Reorders can be written and submitted on the pharmacy's Refill Order . During a review of facility P&P titled, Delivery and Receipt of Routine Deliveries, dated 12/01/07, the P&P indicated, . Pharmacy and Facility should coordinate to determine delivery day(s) and time(s) as soon as possible after the execution of Pharmacy Services Agreement . Upon delivery by pharmacy, facility nurse or other authorized designee . Sign the delivery manifest (may be electronic signature if permitted by Applicable Law), note the time of arrival, and take responsibility for the receipt . During a review of facility policy and procedure (P&P) titled, Pharmacy Services Medication Management, dated 11/17, the P&P indicated, .the facility staff and physician should inform the resident about the risks related to the lack of the medication, and discuss appropriate alternatives, as per the resident care plan. The facility pharmacist is a valuable resource of information about medications including boxed warning or off-label utilization .

Based on observation, interviews and review of facility documents, the facility failed to ensure the Dietary Manager (DM) received frequently scheduled consultation from the Registered Dietitian (RD). Failure to have the RD provide frequent oversight and consultation with the DM of food and nutrition services can result in a lack of the RD identifying system issues regarding menus and recipes not being followed, food not in the proper form, and lack of competent staff and ensuring development of a prompt action plan to resolve the issues for the health and safety of the 66 residents admitted to the facility. Cross Reference F802, F803, F804, F805.Findings:During a series of observations and interviews that identified multiple failures to deliver food and nutrition services safely and effectively on 3/3/26 through 3/5/26 indicated the facility RD lacked familiarity with the food and nutrition service operation in relation to:a. During an observation on 3/3/26 at 12:01 p.m.of the lunch meal service, in the meal cart, Resident 15's lunch meal ticket showed a renal, consistent carbohydrate diet, regular texture and thin liquids with a scoop plate as the adaptive equipment. During a further review of Resident 15's meal ticket at the same time, indicated three ounces of pot roast, 1/2 cup white rice, 1/2 cup mixed vegetables. It was observed on Resident 15's lunch tray there was a scoop plate with three ounces of pot roast, 1/2 cup of mashed potatoes, and 1/2 cup mixed vegetables. During an observation with concurrent interview with the Food Service Worker (FSW) 1 when the kitchen meal cart was about to leave the kitchen on 3/3/26 at 12:13 p.m., FSW 1 observed Resident 15's lunch tray and meal ticket and confirmed the tray had the incorrect food item. FSW 1 stated the tray needed the rice and not the mashed potatoes. At the same time, the Dietary Manager (DM) confirmed that yes this was incorrect and needed the rice instead of the mashed potatoes. Cross Reference F803.b. During an observation of the lunch meal test tray for a puree and regular diet in the presence of the Dietary Manager (DM) on 3/5/26 at 12:46 p.m., on the nursing unit once all the trays were passed to the residents. The puree and regular food items tasted by the surveyors and the DM as well as the DM took temperatures of the foods at this time. The puree asparagus had multiple strings and thin pieces throughout the portion on the plate. During a concurrent interview with the DM, DM acknowledged the strings in the puree asparagus and stated they should not be there. During an interview with the Food Service Worker (FSW) 1 on 3/5/26 at 12:59 p.m., FSW 1 stated she uses frozen asparagus, cooks for 30 minutes then will add the broth to thin to the appropriate consistency. FSW 1 stated she is looking at the back of the spoon and to have the food stick to it. FSW 1 stated she always has trouble with having strands when she makes the pureed asparagus. During an interview with the DM on 3/05/2026 at 11:47 a.m., DM stated she would expect staff to test for consistency for International Dysphagia Diet Standardization Initiative (IDDSI). During a review of the facility document titled Standards of Professional Practice: Diet Guide for the IDDSI for Level 4: Pureed Food, undated, indicated foods are to be smooth, and lump-free, not firm or sticky, requires no chewing or bolus formation, fall off the spoon as an intact spoonful, and hold shape on a plate. During a review of the facility recipe titled PU4 Asparagus with Red Pepper (fzn), indicated to measure desired number of servings into food processor. Blend until smooth. Use Fork Drip Test & Spoon Tilt Test to confirm texture is within IDDSI Level 4 specifications. Cross Reference F805.c. During an observation of the lunch meal preparation on 3/4/26 at 10:06 a.m., FSW 2 placed 60, three ounce chicken enchiladas from a box into a full-size hotel pans. Then she poured red enchilada sauce over the enchiladas. Next FSW 2 grabbed three handfuls of shredded mozzarella cheese out of the bag and sprinkled on top of each hotel plan. Then she did the same with shredded cheddar cheese. During a concurrent interview at this time, FSW 2 stated she just tries to cover the enchiladas with sauce so they are soft and then she stated she puts cheese on top. FSW 2 stated she just guesses what quantity of cheese to place on the food.During a review of the facility recipe titled BVH Chicken Enchiladas for 110 servings, indicated to dilute three cans of enchilada sauce with water and vegetable base to cover bottom of hotel pans with sauce before adding enchiladas and then to top with sauce. It indicated to top with seven pounds of shredded [NAME] jack cheese and seven pounds of shredded cheddar cheese. FSW 2 did not mix the water and vegetable base with the enchilada sauce. It was unclear how much cheese should be used for the approximate 60 servings for the facility.During a review of the facility recipe titled Enchilada Chicken [3] for 50 servings, indicated to mix water, tomato paste and seasonings together in a saucepan, heat then pour over enchiladas. Then to cover with 10.5 ounces of shredded mozzarella cheese. It was unclear how much cheese should be used for the approximate 60 servings for the facility.During a review of the personnel file for FSW 2 indicated the date of hire was 8/26/25 and there was no documentation of the job competency for FSW 2. During a concurrent interview with the Director of Staff Development (DSD) on 3/5/26 at 9:01 AM, DSD stated after one year there will be an evaluation for the employee. The DSD stated the Dietary Manager (DM) is responsible for department training and they had no record of any competency or training for the department but thought maybe the DM would have that. During a interview with the DM on 3/5/26 at 9:41 a.m., the DM stated when she has hired staff she will give them one week of training and then determines when they can work solo. DM stated she was not sure what was done in the past since she has been here since the end of December. DM stated she has been trying to locate if there was any documentation of staff competencies for any kitchen staff. DM stated she had only done a couple of in-services for kitchen staff since she started and was trying to locate any from the past manager. During the course of the survey, there was no documentation provided for any kitchen in-services regarding following menus, recipes or food consistencies, or kitchen staff competencies. Cross Reference F802.d. During a review of the lunch meal on 3/5/26, indicated Marinated pork loin, parslied potatoes, and red pepper asparagus was to be served for the following diets: Regular, Consistent Carbohydrate Diet (CCD), Heart Healthy (Cardiac), soft and bite sized diets. During a concurrent lunch meal test tray observation and interview on 3/5/26 at 12:46 p.m. with the Dietary Manager (DM) in 100 East Wing Hallway. The temperatures of the food were taken, and the regular and puree test tray were sampled. The regular and pureed asparagus tasted bland and lacked flavor. The DM acknowledged the asparagus lacked flavor and tasted bland.During an interview on 3/5/26 at 12:59 p.m. with FSW 1 and the DM, FSW 1 stated she was unable to recall the quantity of items used to flavor the asparagus. FSW 1 stated she eyeballed the salt and pepper to taste and used margarine. FSW 1 stated the quantity of items put on the asparagus was not measured. FSW 1 stated the asparagus was a frozen product and she did not want to use oven since the facility had one working oven. FSW 1 stated the asparagus was prepared on the stove for about 30 minutes and then put it on the steam table at 11am. FSW 1 stated she liked to start tray line or meal service around 11:40 a.m. or 11:45 a.m. FSW 1 stated the outcome of the asparagus could be due to the length of time it was cooked. The DM stated food should not be on the steam table longer than 30 minutes. Cross Reference F804.During an interview with the RD on 3/05/2026 at 10:58 a.m., the RD stated she started working at the facility on 12/26/25 and had a site visit at the facility in January to meet the team and did kitchen inspection as well as a test tray. The RD stated she is based out of Washington State and works 8 hours per week remotely. RD stated she was onsite on 1/6 and 1/7/26. RD stated she will be conducting quarterly site visits to do sanitation inspection and test tray. RD stated when she was at the facility, she checked labels and dates, cleanliness, storage room, observe tray line and observe the kitchen staff wear hairnets and then conducted a test tray. RD stated she will send results to DM and administrator. RD stated she did not recall observing any food production but did a trayline (lunch meal service) observation to watch their flow. RD stated her expectation was that staff follow menus and match the meal ticket with the food items on the tray. RD stated she was not sure when she was onsite if she watched food production or the staff using recipes. RD stated most times the recipe books are out but was not sure if this building was one that did that. RD stated the DM might know if they are doing the tests for food consistency and it was her expectation for IDDSI does require testing of foods. RD stated she will come on site and do the kitchen audit on a quarterly basis. RD stated the DM has her email and phone and can reach out when she needs things. RD stated the DM and her both started at the facility around the same time. RD stated she has not done in-services or not scheduled that do routinely. RD stated she does not have any formal or documentation to show her frequently scheduled consultation to the DM. During a review of the RD job description, dated and electronically signed 9/4/25, indicated essential functions for Dietary Services was to provide oversight and ensures compliance with the provision of quality food services and nutritional care to residents, serve as a resource to the facilities.in-service education, perform standard reviews and nutrition and food service audits in the facility, act as a resource for the dietary services so that food services department is maintained in a clean, safe and sanitary manner, and to plan, organize, develop and direct.in accordance with current federal, state, and local standards, guidelines and regulators that govern the facility. It indicated under Continuing Education to assist in the orientation and training of other staff. During a review of the RD audit titled Kitchen/Food Service Operation dated 1/7/26, indicated the audit was for kitchen tour observations to identify any issues that may lead to food borne illness and if foods are prepared and stored under sanitary conditions. There was only one question that asked if food was prepared under sanitary conditions and in a manner that conserved nutritive value, flavor and appearance. The form had check marks indicating for a yes. There were no comments on the form. There was a test tray form dated 1/6/26 for lunch, however it did not show what type of diet was checked and tested. While the form identifies food temperatures, handling, accuracy, it does not indicate an area or question to ensure food is the proper consistency for the type of diet. There were other RD audits from the previous RD dated 9/18/25 and 11/28/25 that were more in-depth however only had a S to indicate satisfactory and the only comment was major improvements. During a review of the facility policy and procedures titled Food and Nutrition Services Qualified Dietary Staff, dated 7/18, indicated the facility will employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services. It indicated if the RD is not employed full-time, the facility will designate a director of food and nutrition services (DM) who will receive frequently scheduled consultation from a RD.

Based on observation, interviews, and review of facility documents, the facility failed to ensure menus were followed for a renal diet for one sampled resident (Resident 15) during the lunch meal service on Tuesday, March 3, 2026. This failure had the potential to result in the resident exceeding the micronutrients in the physician's prescribed therapeutic diet order which may compromise the nutritional and medical status of the resident.During an observation of the lunch meal service on 3/3/26 at 12:01 p.m., in the meal cart, a concurrent review of Resident 15's lunch meal ticket showed a renal, consistent carbohydrate diet, regular texture and thin liquids with a scoop plate as the adaptive equipment. During a further review of Resident 15's meal ticket at the same time, indicated three ounces of pot roast, 1/2 cup white rice, 1/2 cup mixed vegetables. It was observed on Resident 15's lunch tray there was a scoop plate with three ounces of pot roast, 1/2 cup of mashed potatoes, and 1/2 cup mixed vegetables. During an observation with concurrent interview with the Food Service Worker (FSW) 1 when the kitchen meal cart was about to leave the kitchen on 3/3/26 at 12:13 p.m., FSW 1 observed Resident 15's lunch tray and meal ticket and confirmed the tray had the incorrect food item. FSW 1 stated the tray needed the rice and not the mashed potatoes. At the same time, the Dietary Manager (DM) confirmed that yes this was incorrect and needed the rice instead of the mashed potatoes. During a review of the facility policy and procedures titled Food and Nutrition Services Menus and Therapeutic Diets, dated 7/18, indicated, The facility will follow menus.

Based on interviews and record review, the facility nursing staff failed to use the proper turning technique and ensure one of three sampled residents (Resident 1), received adequate supervision and assistance during pericare (cleaning a patient's genital and anal areas) to prevent falls when Resident 1 who was deemed fully dependent for toileting hygiene, experienced a fall on 9/7/25. The certified nursing assistant did not ensure implementation of effective intervention as the use of a draw sheet (sheet placed underneath a patient to assist with repositioning and transferring in a healthcare setting) or proper technique and positioning without draw sheet for Resident 1 in accordance with facility competency, training consistent with Resident 1's care's need. This failure resulted in Resident 1 sustaining an avoidable fall during pericare leading to a scalp laceration (cut or tear in the scalp, the outer layer of the head), traumatic brain injury (TBI - an injury to the brain caused by an external force) with Intracranial Hemorrhage (ICH- bleeding within the brain cavity), left rib fracture (broken rib), left pneumothorax (collapsed lung), and a manubrial fracture (break in the upper part of sternum, breast bone) requiring urgent transfer to an acute care hospital and admission to the Intensive Care Unit (ICU - unit in hospitals that provides round-the-clock monitoring and treatment for people with serious illnesses or injuries).During a review of Resident 1's 60-Day Physician recertification of Terminal illness, document signed by physician on 6/21/25, the document indicated Resident 1 was a [AGE] year-old female with primary hospice (comprehensive care program for terminally ill patients, focusing on comfort, quality of life, and symptom management rather than cure) diagnosis of Parkinson's (progressive disorder that affects movement, balance and coordination disease with comorbidities (medical condition that is simultaneously present with another disease or other conditions in a patient), conditions of hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormones, hormones essential for regulating metabolism, growth, and other bodily functions), hyperlipidemia (high level of fat in blood), depression (mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that can significantly impact daily life), dysphagia (difficulty swallowing food or liquids), Coronary Artery Disease (CAD - condition where the arteries that supply the heart with blood become narrowed or blocked, usually due to the buildup of fat) and pacemaker (implanted electronic device that sends electrical impulses to the heart to help it beat at a steady and appropriate rate). During a review of Resident 1's hospice note (HN) titled, [Skilled Nursing (SN)] For Routine Visit Summary, dated 8/28/25, the HN indicated, . [Resident 1] requires [one to one (1:1- one caretaker to one patient care model)] assist with meals . dependent in bathing, dressing, toileting, transferring, repositioning, and feeding. Patient bedridden [inability to get out of bed due to illness]. Requires changing and repositioning every two hours. Patient incontinent [unable to control your bladder or bowels, leading to leakage of urine or feces] of urine and feces. Contracture [permanent tightening and shortening of muscles leading to restricted movement in a joint] to right hand, and to [Bilateral (both) lower extremity] .Facility responsible for the 24-hour custodial care [assistance with daily activities like bathing, dressing, and eating, provided to individuals who cannot perform these tasks themselves] for the patient and will notify [company name] Hospice of changes in patient condition. During a review of the facility's document titled, COMPETENCY CHECK-MOVING A RESIDENT IN BED, dated January 2025, the document indicated, . Performance Criteria . MOVING RESIDENT TO SIDE OF BED . Stands on same side of bed to where resident will be moved . With a draw sheet: Rolls draw sheet up and grasps draw sheet with palms up. Puts one hand at resident's shoulders and the other at resident's hips. Applies on knee against side of bed, leans back, and pulls draw sheet and resident on the count of three. Without a draw sheet: Slides hands under head and shoulders and moves toward self. Slides hands under midsection and moves toward self. Slides hands under hips and legs and moves toward self .During a review of the document titled, [Emergency Medical Services (EMS)] Patient Care Report (3.5)x, dated 9/7/25, the document indicated, . Response Mode to Scene: Emergent (immediate response) . Lights and Sirens . Unit Arrived On Scene . 9/7/25 at 21:58 . unit left the Scene: 9/7/25 at 22:13 . Patient arrived at destination . 9/7/25 at 22:50 . arrived . patient laying supine on the linoleum floor with two pillows under her head, both saturated with blood. Per facility staff [unknown], [ Certified Nursing Assistant (CNA- a healthcare professional who provides basic patient care, such as assisting with daily activities, vital signs, and hygiene, under the supervision of a licensed nurse)] 's had patient in a standing position next to the bed when she slipped, fell, and hit her head causing a deep/ open head laceration [cut] approximately 2 [inches- unit of measurement] in length. Staff denies any LOC [loss of consciousness] but states patient immediately began vomiting and had 3 episodes of vomiting prior to EMS arrival. Manual C-spine [way to protect the person's neck and spine from moving] was held as wound was dressed with a pressure bandage and c-collar [support brace for neck and spinal cord] was placed . [Resident 1] was transported to [emergency room] .During a review of the Resident 1's History and Physical (H&P), dated 9/8/25 from Hospital A, the H&P indicated, Resident 1 was admitted on [DATE] after presenting to emergency department on transfer from care facility by EMS following a fall. The H&P indicated, .Assessment of New and Established Problems: [AGE] year-old female status post ground level fall with Scalp laceration, TBI, mild, with ICH, Left rib fracture, Left pneumothorax, Manubrial fracture . Plan and Recommendations: . Admit to ICU .During a record review on 9/12/25 at 1:42 p.m. with the Director of nursing (DON) and the Administrator of the facility (ADM), Resident 1's Medical Record (MR), with the admission date of 6/24/24 was reviewed. The review of progress note titled, Interdisciplinary Team [IDT - group of professionals including nurses, social workers, physical therapists, and others who collaborate to develop, implement, and evaluate a patient's comprehensive plan of care] note, dated 9/8/25, the IDT note indicated, . IDT for witnessed fall that occurs on 9/7/2025 around 10:00 PM. Discussed with IDT on 9/8/2025 at 9:00 AM. [CNA 1] informed Charge Nurse [CN 1]that resident had fallen in her room. Per [CNA 1], as she was performing a brief change for the resident had a bowel movement, she turned the resident on her right side, her feet dangled slightly off the bed, she stated to the resident do not move, as she pulled out the soiled brief from the resident and place it on the trash bag by her side, when she turned to resume care to the resident, she had fallen off the bed into the floor. [CNA 1] called another CNA [unknown] across the hallway to call and informed the [CN 1]. During a concurrent interview and record review on 9/12/25 at 1:55 p.m. with the DON, Resident 1's MR, dated 6/24/24 was reviewed. The DON stated she was present at the IDT meeting and the facility investigation indicated that CNA 1 was not being careful. The DON stated Resident 1 was in room [ROOM NUMBER] A, and the fall occurred on 9/7/24 at 10:00 p.m. The DON stated Resident 1's Brief Interview for Mental Status (BIMS - mandatory cognitive (the ability of the brain to think and reason) screening for residents, scored from 0-15, score of 13-15 indicating cognitively intact, score 8-12 moderate cognitive impairment, score 0-7 severe cognitive impairment ) was 0 and which indicated the resident was severely cognitive impaired. The DON stated Resident 1 was not restless, was not combative, was very light weight and was contracted [causes the joint to become stiff and fixed in a bent or flexed position, severely limiting a person's range of motion] in her extremities. The DON stated Resident 1 was fully dependent of care during toileting and repositioning. The DON stated CNA 1 cleaned Resident 1 and when CNA 1 turned to put the dirty brief in the trash, Resident 1 fell from the bed to the floor. The DON stated the facility investigation revealed CNA 1 did not have a draw sheet under the resident while turning and did not pull resident close to her as she should have based on her training and competency for repositioning of a resident in bed. The DON stated use of a draw sheet by CNA 1 and pulling Resident 1 close to her would have potentially prevented the fall. The DON stated Resident 1 was unable to hold on to assistive devices or support herself during the turning. The DON stated Resident 1's fall was preventable, and she expected CNA 1 to pay more attention, use assistance from another CNA if needed and follow her competency training (structured learning approach focused on developing specific, job-related knowledge and skills (competencies) that individuals must demonstrate before advancing). The DON stated the fall would have been potentially preventable if CNA 1 had followed the competency and training provided by the facility. The DON stated she was not sure why CNA 1 would ask the resident who was fully dependent for care and had a low BIMS score of 0 to Do not move and did not ensure safe positioning herself. The DON stated Resident 1 was also on an air pressure mattress (features a series of air cells that inflate and deflate in cycles to redistribute pressure across the body) which was provided by the Hospice company and was also one of the contributing factors to the fall. The DON stated she was unable to comment on the brand or type of mattress and since the incident, the facility notified the Hospice they were no longer using that particular air mattress and facility will arrange their own mattress. During a record review on 9/12/25 at 2:00 p.m. with the DON and the ADM, Resident 1's IDT note, dated 9/8/25 was reviewed. The IDT note indicated, . Assessment: [Licensed Vocational Nurse (CN 1)] and [Registered Nurse (RN)] immediately went into the room and found the resident on the right side of her bed, lying flat on her back with legs stretched out and arms crossed to her chest wearing only her shirt with no brief on. Upon assessment, blood was seen on the floor coming from the back of her head. There is an open laceration noted on the posterior [the back] part of her head. [CN 1] then placed a pressure dressing with gauze and bandage wrap. Resident was noted to be conscious and when asked what happened, she was able to answer and stated, I don't know. Pupils are [pupils are equal, round, reactive to light and accommodation (PERRLA)]. Vital signs checked and blood pressure was 134/75 within her normal limits. Resident was not moved due to head injury. A pillow with sheets was placed to her head to provide support. RN remained with the patient and [CN 1] called [NP] and informed him of the incident and ordered for the resident to be transferred out to acute [care hospital] for further evaluation and treatment. Per interview with the [CN 1], she stated that she was at the nurse's station doing her documentation, per her documentation, cause of fall was when the assigned CNA turned resident to her [resident 1] right side of the bed, CNA noted that resident did not have a draw sheet under her, as the CNA turned the resident, [Resident 1's] left leg fell forward [bringing] [Resident 1's] weight [down] and shifting her to fall off the bed and landed on the floor on her back. Resident's bed height was found at between waist and knee level Notification: MD notified of the incident and ordered to send resident out to [emergency room (ER)] for further evaluation and treatment. [Responsible person (RP)] was informed and [company name] Hospice. [Resident 1] was sent to [Hospital A] later on transferred to [Hospital B] . RP called the facility and stated that [Resident 1] is in [ Intensive Care Unit (ICU - is a hospital unit that provides specialized, round-the-clock care for critically ill patients with life-threatening injuries or diseases)], she has laceration on the back of her head with multiple internal hematoma [collections of blood in or around the brain], left rib 1-3 [indicates a serious injury requiring immediate medical attention] was fractured and punctured her lungs, and lumbar fracture [break in one of the five bones (called vertebrae) of lower back, part of spine supports most of body's weight] with internal bleeding. Root Cause Analysis: Resident's cause of fall was weakness and residents positioning during [Activities of Daily Living (ADL -which are the fundamental self-care tasks necessary for independent living, including bathing, dressing, eating, using the toilet, continence, and mobility)] care. During an interview on 9/12/05 at 2:41 p.m. with CN 1, CN 1 stated she had been working at the facility for almost two years and was familiar with Resident 1. CN 1 stated at the time of the incident she was at the nursing station and heard CNA 1 calling her name. CN 1 stated she was one of the first responders to Resident 1's room right after the fall. CN 1 stated she observed Resident 1 was lying flat on the right side of the bed. CN 1 stated CNA 1 informed CN 1 that CNA 1 was changing Resident 1's brief and Resident 1 slipped out of her hand. CN 1 stated Resident 1 fell to the right side of bed, Resident 1 was not wearing a brief and had a little bit of blood on floor next to Resident 1 and there was nothing on Resident 1's face. CN 1 stated she thought it was coming from Resident 1's head, she assessed Resident 1's vital signs and called to send Resident 1 out by ambulance to ER. CN 1 stated she notified the family and assisted the Emergency Medical Technician (EMT- a trained healthcare professional who provides immediate care to patients at the scene of an incident and transports them to a hospital). CN 1 stated CNA 1 turned Resident 1 and did not have a draw sheet under the resident as she should have one for repositioning residents. CN 1 stated CNA 1 was not able to pull [Resident 1] closer and when she turned [Resident 1], she lost her grip as she had a dirty brief in her other hand that she was putting in the trash. CN 1 stated, I would personally say yes [CNA] should have second person to assist with repositioning Resident 1. CN 1 stated Resident 1 should have a draw sheet under her while in bed. CN 1 stated this fall for Resident 1 happened around 10:00 p.m. and CNA 1 started her shift at 2:30 p.m. CN 1 stated she would have expected CNA 1 to have changed Resident 1's brief at least once or twice before and CNA 1 should have been aware Resident 1 did not have a draw sheet to securely reposition Resident 1 during pericare. CN 1 stated Resident 1 would not have moved unless she was being moved, Resident 1 was not combative and dependent on care. During a concurrent interview and record review on 9/12/25 at 2:59 p.m. with the Director of Staff Development (DSD), the facility's document titled, COMPETENCY CHECK-MOVING A RESIDENT IN BED, dated January 2025 was reviewed. The DSD stated she had been working as the DSD for two years. The DSD stated she assisted with the education and training of all staff. The DSD stated all CNAs received training on turning, positioning, and transfers of residents and during the training, CNAs were educated on when to ask for a second person for assistance while repositioning. The DSD stated she was familiar with Resident 1. The DSD stated Resident 1 required maximum assistance and may have required two people for assistance, however, one staff was sufficient for toileting needs. The DSD stated the facility used draw sheets and the purpose for the use of draw sheets was to help with repositioning, helped to safely turn the residents and assisted with safe mobility of the resident in bed by the CNA. The DSD stated she had reviewed the case and spoke with CNA 1. The DSD stated CNA 1 kept saying she was talking to Resident 1. The DSD stated she was unable to understand why CNA 1 would rely on Resident 1 and said, Don't move, to Resident 1. The DSD stated Resident 1 had a low BIMS and was not physically able to assist with repositioning or ensuring safety. The DSD also stated the IDT team and the facility leadership team reviewed the staffing for the day and the facility had sufficient staffing to accommodate another CNA to assist CNA 1 with turning Resident 1 safely. The DSD stated the document indicated the use of a draw sheet or following the process of positioning resident, without a draw sheet: Slides hands under head and shoulders and moves [resident] toward self [to avoid the potential for fall], as outlined in the competency would have potentially avoided the fall. The DSD stated it appeared Resident 1 was turned away instead of moving toward self by the CNA. The DSD stated she had provided in-services and training to all CNAs to ensure patient safety and avoid falls after Resident 1's fall. During an interview on 9/12/25 at 3:14 p.m. with the ADM, the ADM stated she had been at the facility in her role for two and half years. The ADM stated she was notified about Resident 1's fall by the DON the same day around 10:30 p.m. The ADM stated the following day, the DON and the ADM had a meeting with CNA 1 and also notified the family of Resident 1. The ADM stated the facility had an IDT meeting to discuss the root cause analysis (RCA - systematic approach to identifying the foundational causes of problems, rather than just addressing symptoms, to develop long-term solutions and prevent recurrence) and reported the incident to the regulatory authorities as required. The ADM stated CNA 1 should have positioned the patient closer to her during repositioning using a draw sheet or followed the process for repositioning residents without a draw sheet closer to her as mentioned in the competency and training. The ADM also stated the mattress topper should not have been used. The ADM stated the facility would be auditing and monitoring to ensure all residents' safety and reeducation was provided to CNAs. The ADM stated she expected staff to follow the facility policies, competency, and training and CNA 1 failed to follow facility competency and training and steps when moving Resident 1 safely. During a concurrent phone interview and record review on 9/15/25 at 1:45 p.m. with the DON, Resident 1's MDS RESIDENT ASSESSMENT AND CARE SCREENING, dated May 12, 2025, was reviewed. The MDS indicated . Section GG - Functional Abilities - . Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided . 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity . 01 C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy [define], include wiping the opening but not managing equipment . 01 G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear . The DON stated the assessment was the most recent assessment for Resident 1. The DON stated she was familiar with the MDS assessment. The DON stated the MDS assessment was completed quarterly and yearly assessment for change and to see any condition changes. The DON stated assessment was for the overall resident condition and different areas were assessed to address any change in resident condition and to make sure resident care needs were met. The DON stated the MDS looked at what residents required and the MDS assessment was done by the facility. The DON further stated the care plan and goals were established based on the residents assessment. The DON stated she reviewed and was familiar with Resident 1's assessment. The DON stated the MDS assessment for Resident 1 indicated Resident 1 scored dependent which indicated, helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 people for toileting need. The DON stated she was unable to explain whether Resident 1 required two people for toileting needs and would have to defer to the MDS consultant. The DON stated she would assist with arranging a call with the MDS consultant to explain the scoring, however, at times, the facility did have two staff helping with Resident 1. The DON stated Resident 1 was dependent and one CNA was sufficient at times, depending on the care needs. The CNO stated Resident 1 was dependent on CNA 1 and CNA 1 should not have relied on Resident 1 to assist during repositioning. During a concurrent phone interview and record review on 9/15/25 at 2:03 p.m. with the Clinical Reimburse Specialist consultant (CRS), Resident 1's MDS RESIDENT ASSESSMENT AND CARE SCREENING, dated May 12, 2025, was reviewed. The CRS stated she reviewed the assessment for Resident 1 and for toileting needs, Resident 1 was scored as dependent. The CRS stated if one helper did all the effort required to reposition Resident 1, then one person was sufficient, otherwise assistance of two or more helpers was required to complete the activity. The CRS stated the MDS assessment was used to establish resident care needs and plan of care. During a phone interview on 9/16/25 at 10:40 a.m. with CNA 1, CNA 1 stated she had been working at the facility for two years. CNA 1 stated she was working with Resident 1 when Resident 1 had a fall at the facility. CNA 1 stated Resident 1 was her last patient of the night to be checked if a brief change was required. CNA 1 stated she knocked on Resident 1's door and explained she was there to change Resident 1. CNA 1 stated, I closed the curtain, I gathered my stuff, bags, wipes, and brief. I checked her, she had a bowel movement. I explained I am going to change her. I proceeded with her, her foot was dangling. I began to turn her, and I pivoted to turn to throw away the soiled brief and next thing she fell to the floor. CNA 1 stated she was working by herself with Resident 1. CNA 1 stated she did not recall pulling Resident 1 closer to herself. CNA 1 stated she was still in shock and could not recall all the details, however, she did recall changing Resident 1's brief earlier in the day around 4:30 p.m. CNA 1 stated she recalled turning Resident 1 away from herself before the fall, and she fell while turning. CNA 1 stated she was on the opposite side [away from the side resident was facing] of Resident 1 and Resident 1 was facing the wall and the sliding door away from her. CNA 1 stated Resident 1 was very stiff and was not moving at all. CNA 1 stated Resident 1 did not have chucks [disposable absorbent under pads to protect the bed from spills or leakage often due to incontinence] or a draw sheet under her. CNA 1 stated Resident 1 should have chucks or a draw sheet as she was dependent. CNA 1 stated she did not recall seeing Resident 1 earlier without a draw sheet. CNA 1 stated Resident 1 was also on an inflatable bubbly mattress and it was set to a certain pressure. CNA 1 stated she should have called for help. CNA 1 stated if another person was present during repositioning, it would have helped to prevent the fall. CNA 1 stated the use of a draw sheet during repositioning would have helped prevent the fall for Resident 1. CNA 1 stated the facility normally had one person assisting Resident 1 with repositioning. CNA 1 stated she never had any residents fall during her care and this was the first time any resident under her care experienced a fall and she had learned from this experience. During a review of the facility's policy and procedure (P&P) titled, QUALITY OF CARE Accident Hazards / Supervision / Devices, dated 7/2018, the P&P indicated, .Purpose .To provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents .The facility will provide an environment that is as free of accident hazards as is possible and provide supervision and assistance devices to residents to avoid preventable accidents .Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment .interventions will be modified when necessary .individualized interventions will be developed to reduce the potential for accidents .Staff will be trained on the use of assistive devices and transfer equipment .The devices and transfer techniques will be reflected in the resident's comprehensive care plan .During a review of the facility's document titled, JOB DESCRIPTION NURSING ASSISTANT - CERTIFIED, undated, the document indicated, . Essential Functions . Observe and practice safety according to facility policy and procedure . Demonstrate and able to explain proper body mechanics in all patient handling interactions & processes . Perform the following according to policy and procedure . Apply proper lifting and transferring techniques . Safety: Know and follow all Company policies, regulations and requirements . Demonstrate safe practices in regard to resident's comfort and safety by applying knowledge of proper body alignment for self and resident .

Based on interview, record review, and facility policy review, the facility failed to provide two of three residents (Resident (R)47 and R62) or their responsible party, reviewed for hospital transfers out of a total sample of 36 residents a written bed hold when R47 and R62 was transferred to the hospital. This failure had the potential to cause confusion or distress regarding return to the same room after hospitalization . Findings include: Review of facility's policy titled Admission, Transfer and Discharge Notice of Bed Hold Policy Before/Upon Transfer revision date 11/2018 indicated, .The facility will provide written information to the resident or resident representative specifying the duration of the state bed-hold policy, if any, during which time the resident is permitted to return and resume residence in the facility.This information will be provided to the resident and the resident representative before a transfer or therapeutic leave and at the time of transfer of a resident for hospitalization or therapeutic leave. 1. Review of R47's undated Face sheet located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R47's Notice of Purposed Transfer/Discharge, revealed R47 was transferred to hospital on 03/24/24. The EMR lacked evidence that the facility provided R47 or the resident representative a copy of the facility's bed hold policy upon transfer to the hospital. Review of R47's Notice of Purposed Transfer/Discharge, revealed R47 was transferred to the hospital on 04/14/24. Review of R47's California Bed Hold Policy, dated 04/14/24, revealed R47s representative was contacted via phone on 04/15/24. The EMR lacked evidence that the facility provided R47 or the resident representative a copy of the facility's bed hold policy upon transfer to the hospital. 2. Review of R62's undated Face sheet located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R62's Skilled Nursing Facility to Hospital form revealed R62 was transferred to hospital on 06/20/24. The EMR lacked evidence that the facility provided R62 or the resident representative a copy of the facility's bed hold policy upon transfer to the hospital. Interview with the Business Office Manager (BOM) on 08/08/24 at 10:49 AM, the BOM stated they do consent for bed holds over the phone and she will sign. BOM stated they had residents and/or residents representative sign the bed hold policy upon admission but not upon transfer. BOM stated they did not document or confirm when or if a resident or representative was provided a written bed hold. BOM confirmed R62 was not provided a bed hold upon transfer to the hospital.

Based on interview, record review, and facility policy review, the facility failed to provide three of three residents (Resident (R)41, R47 and R62) reviewed for hospital transfers out of a total sample of 36 residents' notification to the ombudsman when R41, R47 and R62 transferred to the hospital. This failure placed the resident and their representative at risk of having incomplete information, misunderstanding the reason of transfer/discharge, and the discharge appeal process. Findings include: Review of the facility's policy titled Admission, Transfer and Discharge Notice Requirements Before Transfer/discharge date d 07/2018, read in part .10. Notifications to the Office of the State LTC [Long Term Care] Ombudsman will occur before or as close as possible to the actual time of a facility-initiated transfer/discharge. 1.Review of R41's undated Face sheet located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R41's Notice of Purposed Transfer/Discharge, revealed R41 was transferred to hospital on 02/10/24. 2. Review of R47's undated Face sheet located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R47's Notice of Purposed Transfer/Discharge, revealed R47 was transferred to hospital on 03/24/24. Review of R47's Notice of Purposed Transfer/Discharge, revealed R47 was transferred to hospital on 04/14/24. Review of R47's Notice of Purposed Transfer/Discharge, revealed R47 was transferred to hospital on 06/20/24. 2. Review of R62's undated Face sheet located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE]. Review of R62's Skilled Nursing Facility to Hospital form revealed R62 was transferred to hospital on 06/20/24. During an interview on 08/06/24 at 1:43 PM, Social Services (SS) confirmed the facility failed to provide the written notice of transfer/discharge form to the ombudsman for R41, R47 and R61 after they were transferred to the hospital. The SS confirmed was sending the notifications to a fax number they believed belonged to the local ombudsman. SS confirmed they spoke with the ombudsman who confirmed they had not received any transfer notifications from SS. SS stated the ombudsman provided their email and all transfers will be emailed and confirmed receipt from ombudsman going forward. SS stated they thought the ombudsman was receiving the notifications through fax but confirmed they never received any confirmations forms.

Based on observation, interview, and record review, the facility failed to revise the care plan to include refusals for weekly weights for one resident (Resident (R)41) out of a sample of 36 residents. Refer to F692. Findings include: Review of R41's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] with medical diagnoses that included Hydronephrosis with Renal and Ureteral Calculous Obstruction, Dysphagia, Anemia and Muscle Weakness. Review of R41's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/24, located in the resident's EMR under the MDS tab indicated the facility assessed R41 to have a Brief Interview for Mental Status (BIMS) score was 12 out of 15, indicating R41 was cognitively alert. Review of R41's Care Plan, located in the resident's EMR section titled Care Plans, revealed the resident had a care plan with revision date of 08/01/24. The care plan identified the resident had focus for R41 was at risk for altered nutrition/hydration status and/or weight fluctuations. Supplements: health shakes three times a day and multivitamins with minerals. Review of care plan did not have any indication of R41 refusing weekly weights. Interview on 08/08/24 at 11:40 AM with Licensed Vocational Nurse (LVN) 2 revealed they have weekly meetings with the Registered Dietician to discuss any nutrition concerns. LVN2 stated R41's last nutrition review was 05/31/24 and RD recommended multi vitamins, health shake and continue weekly weights. LVN2 stated they are responsible for ensuring R41's care plan was updated with all dietician recommendations. LVN2 stated R41 sometimes refuses weights but confirmed there was only one note from May 2024 through July 2024 indicating R41 refused to be weighed. LVN2 stated they were responsible for ensuring R41's care plan was updated with interventions for refusing weekly weights. Interview on 08/08/24 at 12:04 PM with Director of Nursing (DON), revealed LVN2 was responsible for initiating R41's weekly weights and other nutrition interventions are implemented and entered on their comprehensive care plan. DON stated if a resident is refusing interventions and still triggering for weight loss then staff are to let the RD and Physician know so they can attempt to go over the risk verse benefits with resident.

Based on observation, interview, and record review, the facility failed to ensure safety and protection for one of three sampled residents (Resident 2) was free from abuse and neglect when Resident 1 had a known history of sexual behaviors that was care planned and interventions were not implemented for Resident 1. On 12/30/23, Certified Nursing Assistant (CNA) 2 noticed Resident 1 in the dining room unsupervised, CNA 2 neglected to implement care planned intervention leaving Resident 1 unattended. Resident 1 touched Resident 2 ' s breast in front of her husband during a visit. This failure resulted in the lack of supervision of Resident 1 in the dining room with a female resident present and resulted in the violation of Resident 2 ' s dignity, which could have resulted in humiliation, and psychosocial harm for a reasonable person. Resident 2 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions) and she did not like it when her breast was touched. Findings: During a review of Resident 1's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included Alzheimer ' s (affects memory, thinking and behavior) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 10 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired ). The BIMS assessment indicated Resident 1 had moderate cognitive impairment. During a concurrent observation and interview on 1/17/24 at 1:20 p.m. with Resident 2, in Resident 2 ' s room, Resident 2 was lying in bed. Resident 2 stated she did not know the resident that touched her on her breast and stated, I didn ' t like it one bit I am a girl. During a review of Resident 2's Admission Record undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Parkinsonism (disorder affecting the nervous system) and major depressive disorder (feeling of sadness and loss of interest). During a review of Resident 2's MDS assessment dated [DATE], indicated Resident 2's BIMS assessment score was 99. The BIMS assessment indicated Resident 2 had severe cognitive impairment. During an interview on 1/17/24 at 1:32 p.m. with Resident 4, Resident 4 stated she had witnessed Resident 1 act inappropriately with his genitals (sexual reproductive organs located outside the body) in front of residents in the past. Resident 4 stated she had also seen Resident 1 touch another resident ' s breast couple months ago. During a review of Resident 4's MDS assessment dated [DATE], indicated Resident 4's BIMS assessment score was 15. The BIMS assessment indicated Resident 4 was cognitively intact. During an interview on 1/17/24 at 1:51 p.m. with Activities Director (AD), AD stated there was care planned intervention developed on 6/2023 due to Residents 1 ' s inappropriate behavior with females. The plan was to supervise Resident 1 when he left his room and that she told the activities staff to ensure Resident 1 was not left alone in the dining room. AD stated Resident 1 could propel himself in his wheelchair but staff would bring him to the dining room at times and that no one should bring him to the dining unless staff were present. During an interview on 1/17/24 at 1:58 p.m. with Activities/Certified Nursing Assistant (ACNA), ACNA stated on 12/30/23 at 9:30 a.m. she was offering coffee to residents in their rooms and was going to have coffee in the dining room at 10 a.m. ACNA stated Resident 1 has had past inappropriate behaviors with her such as asking her to go to bed with him. ACNA stated on 12/30/23, Resident 2 ' s husband informed her that Resident 1 touched his wife ' s breast. ACNA stated she was not in the dining room at the time the incident on 12/20/23 , and that Resident 1 should not have been left unattended in the dining room due to his inappropriate behaviors with females. ACNA stated she had witnessed Resident 1 touch another resident ' s breast couple months ago in the dining room prior to the incident on 12/30/23. During an interview on 1/17/24 at 2:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on 12/30/23 Resident 3 informed him that Resident 1 touched Resident 2 ' s breast while Resident 2 was sitting with her husband. CNA 1 stated he was aware of Resident 1 ' s inappropriate sexual behaviors and that Resident 1 had touched his butt in the past. CNA 1 stated Resident 1 should be monitored when in the dining room because Resident 1 had inappropriate sexual behaviors and does not control his impulses. CNA 1 stated prior to the incident on 12/30/23 he knew the care planned intervention to not allow Resident 1 in the dining room unsupervised. During an interview on 1/17/24 at 2:23 p.m. with Resident 5, Resident 5 stated Resident 2 was a pervert [sexual behaviors that are considered particularly abnormal] and that he would make sexual comments or expose his genitals. During a review of Resident 5's MDS assessment dated [DATE], indicated Resident 5's BIMS assessment scored was 13. The BIMS assessment indicated Resident 5 was cognitively intact. During a concurrent interview and record review on 1/17/24 at 2:41 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2 ' s Progress Notes (PN), dated 12/30/23 was reviewed. The PN indicated, .moved Male Resident back to [room number] because he touched this resident's left breast . The husband reported to the CNA while visibly upset that the Male Resident touched the left breast of this resident, his wife. Upon seeing the incident, the Husband told the Male Resident to ' Stop, that is my wife ' . The Male Resident then answered back to the husband, ' I do what I f----[profanity] please and it is not your business. ' . [Resident 2] stated that ' that person touched me ' , while touching her left breast . This CN [charge nurse] spoke with [Resident 2] and asked her what had happened. She stated that ' that person touched me ' , while touching her left breast . LVN 1 stated Resident 1 has a history of making sexual comments and that it was common for Resident 1 to make comments such as nice [butt] and nice body. During an interview on 1/17/24 at 2:49 p.m. with Resident 3, Resident 3 stated he was in the dining room on 12/30/23 when Resident 1 touched resident 2 ' s breast in front of Resident 2 ' s husband. Resident 3 stated, it was not right I did not like seeing that at all and that Resident 1 is always doing something perverted. Resident 3 stated as soon as Resident 1 is left unattended he will act up and do something inappropriate such as exposing his genitals or touching females. During a review of Resident 3's MDS Assessment, dated 12/9/23, the MDS assessment indicated, Resident 3 ' s BIMS assessment scored was 15. The BIMS assessment indicated Resident 3 was cognitively intact. During an interview on 1/17/24 at 2:57 p.m. with Social Services (SS), SS stated she followed up with Resident 2 on 1/2/24. SS stated Resident 2 was confused and did not remember the inappropriate touching that occurred on 12/30/23. During a concurrent interview and record review on 1/17/24 at 3:28 p.m. with Licensed Vocational Nurse Unit Manager (LVNUM), Resident 1 ' s PN dated 5/18/23 was reviewed. The PN indicated, . Activities notified nurse resident asking another resident to show him her breasts in the dining area. Resident was then taken back to his room . Resident 1 ' s Psychiatric Assessment (PA) dated 6/20/23 was reviewed. The PA indicated, .Staff reported . had inappropriate sexual behavior towards the female, but no grabbing or touching . The PN dated 7/20/23 was reviewed, the PN indicated, .[Resident 1] was trying to grab RSA [recreational assistant]breast and he also was trying to touch the bottom of a resident ' s family member . LVNUM stated Resident 1 had a care plan intervention to only sit with male residents and not to be left alone with female peers. LVNUM stated Resident 1 had known inappropriate sexual behaviors. During a concurrent interview and record review on 1/17/24 at 3:41 p.m. with AD, Resident 1 ' s Care Plan (CP) dated 6/5/23 was reviewed. The CP indicated, .During group programs [Resident 1] is encouraged to sit with only males residents .[Resident 1] is not left alone with female peers when group programs are over encouraging [Resident 1] to move to small dining room to watch his favorite tv programs westerns . AD stated when Resident 1 had inappropriate behavior, the plan was to put him at a table by himself in the dining room because he was inappropriate with females. AD stated she would ensure that staff were present when she would conduct activity in the dining room and not leave Resident 1 alone. During an interview on 1/30/24 at 9:40 a.m. with CNA 2, CNA 2 stated Resident 1 was able to propel himself with the wheelchair around the facility. CNA 2 stated Resident 1 had inappropriate behavior and would touch female staff. CNA 2 stated on 12/30/23 she saw Resident 1 in the dining room and without staff in the dining room. CNA 2 stated the inappropriate touch could have been avoided if there was staff present in the dining room. CNA 2 stated she should have ensured staff were present in the dining room but didn ' t. During a telephone interview on 1/30/24 at 10a.m. with Family (FM), FM stated he was seated in the dining room on 12/30/23 with his wife. FM stated there was no staff present, a resident went to his wife and touched her breast. FM stated, he told the resident, get your hands off my wife. FM stated Resident 1 responded by telling FM that Resident 1 can do as he [explicit language] pleased. FM stated that he did not want anyone to touch his wife inappropriately. During a concurrent interview and record review on 1/30/24 at 12:30 p.m. with Administrator (ADM), the facility policy and procedure (P&P) titled Comprehensive Care Plans dated 11/2017 was reviewed. The policy indicated, .The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, physical, mental, and psychosocial needs .Interventions identified by the comprehensive care plan will be provided by qualified, competent persons .Resident care needs and care plan interventions will be communicated to direct care staff . ADM stated staff should follow the care plan and should have not left Resident 1 alone in the dining room. ADM stated she would not want this to happen to her herself or her family member. ADM stated care planned interventions should be implemented and Resident 1 should have been supervised because of his inappropriate behaviors with females. During a review of the facility P&P titled Freedom From Abuse, Neglect and Exploitation, dated 11/2017 , the P&P indicated, The facility will provide a safe resident environment and protect residents from abuse .Definition of Sexual Abuse: Non-consensual sexual contact of any type with a resident .Cognitive impairment or mental disorder does not preclude a resident from being abusive .Facility will assess the resident and care plan intervention to address resident behaviors that may indicate for abusive .sexual .Resident outcomes that will be considered in instances of sexual abuse may include, but not limited to .depression .anxiety .fear of being alone .fear of the dark .nightmares .disturbed sleep .

Based on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1) when Resident 1 with known inappropriate sexual behaviors was left unattended on 12/30/23 in the dining room. On 12/30/23, Certified Nursing Assistant (CNA) 2 noticed Resident 1 in the dining room unsupervised, CNA 2 did not implement care planned intervention to not leave Resident 1 alone with female peers. CNA 2 left Resident 1 unattended, Resident 1 touched Resident 2 ' s breast. This failure resulted in the lack of supervision of Resident 1 in the dining room with a female resident present and resulted in the violation of Resident 2 ' s dignity, which could have resulted in humiliation, and psychosocial harm for a reasonable person. Resident 2 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions) and she did not like it when her breast was touched. Findings: During a review of Resident 1's Admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included Alzheimer ' s (affects memory, thinking and behavior) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 10 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired ). The BIMS assessment indicated Resident 1 had moderate cognitive impairment. During a concurrent observation and interview on 1/17/24 at 1:20 p.m. with Resident 2, in Resident 2 ' s room, Resident 2 was lying in bed. Resident 2 stated she did not know the resident that touched her on her breast and stated, I didn ' t like it one bit I am a girl. During a review of Resident 2's Admission Record undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included Parkinsonism (disorder affecting the nervous system) and major depressive disorder (feeling of sadness and loss of interest). During a review of Resident 2's MDS assessment dated [DATE], indicated Resident 2's BIMS assessment score was 99. The BIMS assessment indicated Resident 2 had severe cognitive impairment. During an interview on 1/17/24 at 1:32 p.m. with Resident 4, Resident 4 stated she had witnessed Resident 1 act inappropriately with his genitals (sexual reproductive organs located outside the body) in front of residents in the past. Resident 4 stated she had also seen Resident 1 touch another resident ' s breast couple months ago. During a review of Resident 4's MDS assessment dated [DATE], indicated Resident 4's BIMS assessment score was 15. The BIMS assessment indicated Resident 4 was cognitively intact. During an interview on 1/17/24 at 1:51 p.m. with Activities Director (AD), AD stated there was care planned intervention developed on 6/2023 due to Residents 1 ' s inappropriate behavior with females. The plan was to supervise Resident 1 when he left his room and that she told the activities staff to ensure Resident 1 was not left alone in the dining room. AD stated Resident 1 could propel himself in his wheelchair but staff would bring him to the dining room at times and that no one should bring him to the dining unless staff were present. During an interview on 1/17/24 at 1:58 p.m. with Activities/Certified Nursing Assistant (ACNA), ACNA stated on 12/30/23 at 9:30 a.m. she was offering coffee to residents in their rooms and was going to have coffee in the dining room at 10 a.m. ACNA stated Resident 1 has had past inappropriate behaviors with her such as asking her to go to bed with him. ACNA stated on 12/30/23, Resident 2 ' s husband informed her that Resident 1 touched his wife ' s breast. ACNA stated she was not in the dining room at the time the incident on 12/20/23 , and that Resident 1 should not have been left unattended in the dining room due to his inappropriate behaviors with females. ACNA stated she had witnessed Resident 1 touch another resident ' s breast couple months ago in the dining room prior to the incident on 12/30/23. During an interview on 1/17/24 at 2:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on 12/30/23 Resident 3 informed him that Resident 1 touched Resident 2 ' s breast while Resident 2 was sitting with her husband. CNA 1 stated he was aware of Resident 1 ' s inappropriate sexual behaviors and that Resident 1 had touched his butt in the past. CNA 1 stated Resident 1 should be monitored when in the dining room because Resident 1 had inappropriate sexual behaviors and does not control his impulses. CNA 1 stated prior to the incident on 12/30/23 he knew the care planned intervention to not allow Resident 1 in the dining room unsupervised. During an interview on 1/17/24 at 2:23 p.m. with Resident 5, Resident 5 stated Resident 2 was a pervert [sexual behaviors that are considered particularly abnormal] and that he would make sexual comments or expose his genitals. During a review of Resident 5's MDS assessment dated [DATE], indicated Resident 5's BIMS assessment scored was 13. The BIMS assessment indicated Resident 5 was cognitively intact. During a concurrent interview and record review on 1/17/24 at 2:41 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2 ' s Progress Notes (PN), dated 12/30/23 was reviewed. The PN indicated, .moved Male Resident back to [room number] because he touched this resident's left breast . The husband reported to the CNA while visibly upset that the Male Resident touched the left breast of this resident, his wife. Upon seeing the incident, the Husband told the Male Resident to ' Stop, that is my wife ' . The Male Resident then answered back to the husband, ' I do what I f----[profanity] please and it is not your business. ' . [Resident 2] stated that ' that person touched me ' , while touching her left breast . This CN [charge nurse] spoke with [Resident 2] and asked her what had happened. She stated that ' that person touched me ' , while touching her left breast . LVN 1 stated Resident 1 has a history of making sexual comments and that it was common for Resident 1 to make comments such as nice [butt] and nice body. During an interview on 1/17/24 at 2:49 p.m. with Resident 3, Resident 3 stated he was in the dining room on 12/30/23 when Resident 1 touched resident 2 ' s breast in front of Resident 2 ' s husband. Resident 3 stated, it was not right I did not like seeing that at all and that Resident 1 is always doing something perverted. Resident 3 stated as soon as Resident 1 is left unattended he will act up and do something inappropriate such as exposing his genitals or touching females. During a review of Resident 3's MDS Assessment, dated 12/9/23, the MDS assessment indicated, Resident 3 ' s BIMS assessment scored was 15. The BIMS assessment indicated Resident 3 was cognitively intact. During an interview on 1/17/24 at 2:57 p.m. with Social Services (SS), SS stated she followed up with Resident 2 on 1/2/24. SS stated Resident 2 was confused and did not remember the inappropriate touching that occurred on 12/30/23. During a concurrent interview and record review on 1/17/24 at 3:28 p.m. with Licensed Vocational Nurse Unit Manager (LVNUM), Resident 1 ' s PN dated 5/18/23 was reviewed. The PN indicated, . Activities notified nurse resident asking another resident to show him her breasts in the dining area. Resident was then taken back to his room . Resident 1 ' s Psychiatric Assessment (PA) dated 6/20/23 was reviewed. The PA indicated, .Staff reported . had inappropriate sexual behavior towards the female, but no grabbing or touching . The PN dated 7/20/23 was reviewed, the PN indicated, .[Resident 1] was trying to grab RSA [recreational assistant]breast and he also was trying to touch the bottom of a resident ' s family member . LVNUM stated Resident 1 had a care plan intervention to only sit with male residents and not to be left alone with female peers. LVNUM stated Resident 1 had known inappropriate sexual behaviors. During a concurrent interview and record review on 1/17/24 at 3:41 p.m. with AD, Resident 1 ' s Care Plan (CP) dated 6/5/23 was reviewed. The CP indicated, .During group programs [Resident 1] is encouraged to sit with only males residents .[Resident 1] is not left alone with female peers when group programs are over encouraging [Resident 1] to move to small dining room to watch his favorite tv programs westerns . AD stated when Resident 1 had inappropriate behavior, the plan was to put him at a table by himself in the dining room because he was inappropriate with females. AD stated she would ensure that staff were present when she would conduct activity in the dining room and not leave Resident 1 alone. During an interview on 1/30/24 at 9:40 a.m. with CNA 2, CNA 2 stated Resident 1 was able to propel himself with the wheelchair around the facility. CNA 2 stated Resident 1 had inappropriate behavior and would touch female staff. CNA 2 stated on 12/30/23 she saw Resident 1 in the dining room and without staff in the dining room. CNA 2 stated the inappropriate touch could have been avoided if there was staff present in the dining room. CNA 2 stated she should have ensured staff were present in the dining room but didn ' t. During a telephone interview on 1/30/24 at 10a.m. with Family (FM), FM stated he was seated in the dining room on 12/30/23 with his wife. FM stated there was no staff present, a resident went to his wife and touched her breast. FM stated, he told the resident, get your hands off my wife. FM stated Resident 1 responded by telling FM that Resident 1 can do as he [explicit language] pleased. FM stated that he did not want anyone to touch his wife inappropriately. During a concurrent interview and record review on 1/30/24 at 12:30 p.m. with Administrator (ADM), the facility policy and procedure (P&P) titled Comprehensive Care Plans dated 11/2017 was reviewed. The policy indicated, .The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, physical, mental, and psychosocial needs .Interventions identified by the comprehensive care plan will be provided by qualified, competent persons .Resident care needs and care plan interventions will be communicated to direct care staff . ADM stated staff should follow the care plan and should have not left Resident 1 alone in the dining room. ADM stated she would not want this to happen to her herself or her family member. ADM stated care planned interventions should be implemented and Resident 1 should have been supervised because of his inappropriate behaviors with females. During a review of the facility P&P titled Freedom From Abuse, Neglect and Exploitation, dated 11/2017 , the P&P indicated, The facility will provide a safe resident environment and protect residents from abuse .Definition of Sexual Abuse: Non-consensual sexual contact of any type with a resident .Cognitive impairment or mental disorder does not preclude a resident from being abusive .Facility will assess the resident and care plan intervention to address resident behaviors that may indicate for abusive .sexual .Resident outcomes that will be considered in instances of sexual abuse may include, but not limited to .depression .anxiety .fear of being alone .fear of the dark .nightmares .disturbed sleep .

Based on interview and record review, the facility failed to develop and implement a fall risk care plan for one of three sampled residents (Resident 352) when: Resident 352's fall risk was determined to be high risk for falls on 4/5/19 and care plan interventions were not developed to keep her safe, free from falls and fall related injuries. This failure resulted in Resident 352's fall, a laceration to the bridge of her nose, a hematoma (a solid swelling of clotted blood within the tissues), discoloration to the left side of her head, pain and a left [MEDICAL CONDITION] which required surgical repair for the [MEDICAL CONDITION] and a nine-day hospitalization . Findings: During an interview with Licensed Vocational Nurse (LVN) 3, on 5/23/19, at 8:25 a.m., LVN 3 stated Certified Nursing Assistant (CNA) 3 notified him of Resident 352's fall on 4/9/19 at 10:45 p.m., during the night. LVN 3 stated he went to Resident 352's room and found her on the floor facing down without wearing a gown and without socks (hospital gown wrapped around lower part of her body). LVN 3 stated Resident 352 was full of blood (hair, face, and hands) and a laceration was noted on the bridge of her nose. LVN 3 stated Resident 352 was admitted to the facility on [DATE] and was a low fall risk. LVN 3 stated, (Resident 352) was very confused, wanted to get up and go to the restroom. (Resident 352) was (frequently) reminded that she just went to the bathroom. LVN 3 stated he did not review the fall risk assessment and was not aware Resident 352 was a high risk for falls. During an interview with CNA 3, on 5/23/19, at 8:50 a.m., CNA 3 stated, It was during shift change .when I saw (Resident 352) on the floor with her face down at the foot of the bed. She spilled her drinks and urinated on the floor. (Resident 352) was very consistent in saying I want to pee all of the time but would not pee (when taken to the restroom). CNA 3 stated Resident 352 frequently requested to use the restroom and would not urinate after being taken to the restroom. CNA 3 stated Resident 352 was confused and exhibited anxiety by frequent requests to use the restroom. CNA 3 stated she did not know Resident 352's fall risk score. CNA 3 stated she did not have information about Resident 352's fall risk and was not informed by the licensed nurses or CNA's who previously cared for Resident 352 of her risk. During a review of Resident 352's face sheet (a document with personal identifiable and medical information) undated indicated Resident 352 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 352, the Minimum Data Set (assessment of healthcare and functional needs) assessment dated [DATE], indicated Resident 352 had short and long term memory impairment. The MDS document indicated Resident 352 was moderately impaired in decision making during activities of daily living and required cues and supervision. During a review of the clinical record for Resident 352, Resident 352's initial nursing admission assessment dated [DATE], indicated Resident 352 required limited assistance (guided maneuvering of limbs) of one staff member for toilet use. During a review of the clinical record for Resident 352, the nurse's progress notes dated 4/9/19, at 10:45 p.m., indicated, CNA notified (Charge Nurse) that (Resident 352) had fallen in her room. Upon entering room noted that (Resident 352) was on the floor near her bed. (Resident 352) had her gown wrapped around the lower part of her body. (Resident 352) was noted to be bleeding from a laceration on her nose. A hematoma and discoloration to the left side of her head was noted at that time also. (Resident 352) complained of pain . During a concurrent interview and record review with the Registered Nurse (RN), on 5/24/19, at 2:31 p.m., the RN reviewed Resident 352's initial fall risk assessment on admitted d 4/5/19, and stated the score was 10 which indicated Resident 352 was at high fall risk. The RN reviewed Resident 352's care plan and stated there was a fall risk care plan dated 4/10/19 developed after Resident 352's fall with injury. The RN stated she could not find a baseline care plan initiated within 48 hours of Resident 352's admission which would have reflected Resident 352's fall risk and fall risk interventions. The RN stated the second shift (the evening shift) nurse was responsible to complete the baseline care plan. The RN stated, I was the first shift nurse and I did not complete the fall risk assessment because it was not assigned to me. The RN stated she had not reviewed Resident 352's fall risk assessment prior to Resident 352's fall and consequently she was not aware of Resident 352's high risk for falls. The RN stated if she would have been aware then she would have ensured Resident 352's safety was maintained by implementing care plan interventions which addressed Resident 352's fall risk within 48 hours from her admission to the facility. The RN stated, I don't have any specific monitoring for her. The RN stated Resident 352's was extremely confused. The RN stated, I told (Unit Manager) (UM) of her behavior (anxiousness) and confusion but I did not follow up (checked) with the (UM). The RN reviewed Resident 352's care plan and was unable to find a care plan that addressed Resident 352's confusion and behaviors which could increase Resident 352's fall risk. During a concurrent interview and record review with the UM, on 5/24/19, at 3:18 p.m., the UM reviewed Resident 352's date of admission and stated Resident 352 was admitted to the facility on [DATE]. The UM stated, We have interdisciplinary team (IDT) (a group composed of a licensed nurse, a physician, a social worker and dietician) that goes over (care plans) in the stand-up meeting every day. The UM stated the IDT missed Resident 352's care plan initiation for fall risk within 48 hours of admission. The UM stated the care plan was very important in the care of all residents because it painted a picture of the care and interventions they required. The UM stated Resident 352's fall could have been avoided and it was not. During a concurrent interview and record review with the Director of Nursing (DON), on 5/28/19 at 11:18 a.m., the DON reviewed Resident 352's clinical record and stated Resident 352 was admitted to the facility on [DATE]. The DON stated there was no baseline care plan documented within 48 hours of admission that indicated Resident 352 was a high fall risk. The DON reviewed Resident 352's initial fall risk assessment dated [DATE] and stated the fall risk score was 10 which indicated Resident 352 was a high risk for fall. The DON stated, (Resident 352) was admitted on a Friday (4/5/19) it was the weekend and nobody audited the (for the completion of Resident 352's) care plans. It should have been audited on Monday (4/8/19) but it was missed. During a telephone interview with the MD on 5/28/19, at 4:10 p.m., The MD stated he was aware Resident 352 fell on [DATE]. The MD stated he ordered x-ray on 4/10/19. The MD stated, When I order x-ray, it was stat (needed immediately) especially after (Resident 352) fell and resident had [MEDICAL CONDITION]. The MD stated when Resident 352 verbalized 8 out of 10 left lower leg pain he was not notified by the nurse and he should have been notified. MD stated, I would like to be notified for any change of condition especially for 8/10 pain, elevated temperature, cannot move extremities especially after a fall. An x-ray is always a stat order for a resident with a history of fall. If I was notified about the change of condition, I would have ordered to send (Resident 352) right away to acute hospital. I will consider to send the resident to hospital since resident has history of fall and a case of [MEDICAL CONDITION]. During a review of the hospital clinical record for Resident 352, the Emergency Department, Physician, and discharge Notes dated 4/11/19 through 4/19/19, indicated, (Resident 352) . with hip pain and swelling .received 100 mcg (micrograms - unit of measurement) [MEDICATION NAME] (strong pain medication) in route (in the ambulance, on the way to the hospital) . x- ray confirmed . left intertrochanteric (hip bone) fracture (brake), with dislocation, positive ST (soft tissue) swelling . (received blood transfusion) . patient [DIAGNOSES REDACTED]. patient has not improved despite aggressive medical management . Patient placed on palliative care (specialized medical care for patients with life-limiting medical conditions) . 4/19/19 discharged to (name) hospice (end of life care) . During a review of the facility policy and procedure titled, Comprehensive Care Plan, Baseline Care Plan dated 11/17, indicated, Purpose: Facility will complete and implement a baseline care plan within 48 hours of a resident's admission. The care plan is intended to promote continuity of care and communication among staff, increase resident safety, minimize potential adverse events that may occur right after admission. Policy: Facilities are required to develop a baseline care plan within the first 48 hours of admission which provides for the provision of effective and person-centered care to each resident and their representative. The care plan is a balance between conditions and risks affecting resident's health and safety, and the resident's goals and choices . During a review of the facility policy and procedure titled, Falls and Fall Risk, Managing dated 12/07, indicated, Policy Statement: 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 . 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions .