Every finding on record at Seneca District Hospital D/P SNF

Based on interview and record review, this requirement was not met when the facility failed to obtain the services of a registered nurse for eight consecutive hours, seven days a week. This had the potential to adversely affect residents' care, which could lead to potential negative clinical outcomes.Findings:During a concurrent interview and record review on 12/10/25 at 8:29 a.m. with the Director of Nursing (DON), of the facility's Registered Nurse (RN) staffing/schedule documentation from the period of 4/1/25 to 4/30/25 and 5/1/25 to 5/31/25 the documentation indicated that no RN was scheduled to work 4/16/25, 4/17/25, 4/18/25, and 5/26/25 when the DON was off. The DON confirmed that RN coverage was provided by RN E (a nurse from the hospital side of the facility down the hallway) on 4/16/25, 4/17/25, and 4/18/25 and that RN coverage was provided by RN F (a nurse from the hospital side of the facility down the hallway) on 5/26/25. The DON indicated that if the Licensed Vocational Nurses (LVNs) needed help they could get an RN from the hospital down the hall. The DON indicated that the facility would need to apply for the federal waiver for RN coverage.During the during the resident council meeting (a meeting for residents to voice their concerns regarding living in a facility) on 12/9/25 at 1:54 p.m., there were no complaints about staffing issues.

Based on observation, interview, and record review, the facility failed to implement and maintain infection control practices to prevent the transmission of infection when: 1. Staff failed to ensure proper hand hygiene and clean administration technique during the administration of eye drops to for one of 16 sample residents (Resident 8). 2. The facility failed to ensure the ice machine used by residents was maintained in a clean and sanitary condition, free from contamination. These deficient practices had the potential to put the residents at risk for unwanted infections, and negatively impact their quality of life.Findings: 1. During a review of the facility's policy and procedure titled, Medication Administration, dated 5/29/2025, indicated, that standard universal precautions, which include hand washing using soap and water or the hospital supplied hand antiseptic cleaner will be completed prior to and following all medication passes and after physical contact with residents. During a review of Resident 8's admission Record indicated that Resident 8 was admitted on [DATE] with diagnoses that included aphasia (a disorder that makes it difficult to speak), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), high blood pressure, memory loss, and hypertensive retinopathy (damage to the eye caused by high blood pressure). During a review of Resident 8's medication order record, with a start date of 6/5/23, the order indicated Resident 8 was to receive Dorzolamide-Timolol Ophthalmic (an eye drop medication), 1 drop in the left eye, twice daily. During a concurrent observation and interview on 12/11/25 at 9:42 am, with Licensed Nurse (LN) B, LN B was observed administering medication to Resident 8 and administering eye medication without performing hand hygiene (washing hands), changing gloves, or ensuring Resident 8's eye was clean before putting the eye drops in. LN B confirmed that hand hygiene should have been performed and that the eye should have been cleaned prior to medication administration. During an interview on 12/11/25 at 9:55 am, with the Director of Nursing (DON), DON confirmed that proper hand hygiene is required prior to medication administration and that the eye should be cleaned before administering eye drops. 2. A review of a facility ice machine service manual titled, HID312, HID525 and HID540 dated March 2025, indicated that the ice machine was to be cleansed with a scale (mineral build-up that can harbor bacteria), remover mixed with water every 6 months. During a concurrent observation and interview on 12/11/2025 at 9:05 am, the Maintenance Director (Main) D, confirmed the presence of a visible white and black substance present along the interior surface of the ice machine dispenser and that the ice came into direct contact with that substance during dispensing. Main D stated they follow the manufacturer's instructions to clean the ice machine every six months, but that area of the machine had never been cleaned.

Based on observation, interview and record review the facility failed to develop and revise care plans to meet the medical needs for two of eight residents sampled (Resident 7 and Resident 6) when:1. Resident 7's bladder incontinence (inability to hold urine) was not reflected on her care plan.2. Resident 6 had no care plan developed that addressed her heart condition.These failures had the potential to result in negative clinical outcomes for Resident 6 and Resident 7, by not receiving the care and services they needed.Findings: A review of the facility's Policy and Procedure titled, Comprehensive Care Policy effective 3/27/25, indicated the facility shall ensure a comprehensive care plan will be implemented for each skilled nursing facility resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. 6. The care plan will include the following information: b. All identified medical, physical and psychosocial problems, concerns and needs specific to the resident. Purpose: The purpose of this policy is to properly identify a resident's needs, with the help of IDT, to implement a plan of action to further improve a resident's quality of life. A review of Resident 7's admission Record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included dementia, urinary frequency (having to urinate frequently), and high blood pressure. A review of Resident 7's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 7/10/25, indicated Resident 7 had a Brief Interview for Mental Status (BIMS, cognitive screening tool scored from 0 to 15) with a score of 9 (moderate cognitive impairment). MDS section H indicated that Resident 7 was always continent (full control) of her bladder. A comparison MDS of section H dated 10/08/25, indicated Resident 7 was occasionally incontinent, a decline from the previous MDS on 7/10/25. During interview on 12/10/25 at 4:52 pm, with Certified Nursing Assistant (CNA) C, CNA C stated Resident 7 gets up and uses the bathroom frequently. CNA C stated Resident 7 was toileted every two hours, but needs to go more frequently than that. During an interview and concurrent review of Resident 7's care plans and MDS assessments on 12/11/25 at 10:19 am, with Minimum Data Set Nurse (MDS) A, MDS A confirmed Resident 7 had a decline in her ability to control her urinary continence and the care plan had not been revised to reflect that. During an interview and record review of Resident 7's care plans on 12/11/25 at 10:40 am, the Director of Nursing (DON) confirmed Resident 7's bladder care plan had not reflected her current status and should have been revised to include that Resident 7 has incontinent episodes. 2. Review of Resident 6's medical record indicated that she was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (a cardiac condition which causes an irregular and often very fast heartbeat that can cause poor blood flow) and hypertension (HTN-high blood pressure: a major risk factor for worsening cardiac conditions). Review of Resident 6's MDS, dated [DATE], and completed by the Director of Nursing (DON), indicated that Resident 6 had a BIMS score of 12 indicating moderate cognitive impairment. During a concurrent interview and record review of Resident 6's care plan on 12/10/25 at 12:53 pm, with the DON, the DON confirmed that there was not a cardiac care plan developed for Resident 6, and there should have been.

Based on observation, interview, and record review, the facility failed to ensure controlled medications (medications with high potential for abuse and addiction) verification process was accurately completed for one of four medication carts when the medication verification documentation was not signed with two (2) licensed nurses. This failure had the potential to cause the diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff, compromising the facility's ability to ensure safe and appropriate medication management for its patients. Findings: During a review of the facility's policy and procedure titled, Medication Administration, dated 5/29/2025, indicated, that controlled substances will be counted at the change of each shift by the licensed on-coming and off-coming nurses and that each nurse will be responsible for assuring the completion of the record. During a concurrent interview and record review on 12/10/25 at 11:27 am with Licensed Nurse (LN) B, the facility's narcotic reconciliation (the comparison of controlled medication counts against medication records) record titled Narcotic End of Shift-Date, found on the facility medication cart was reviewed. The record indicated that documentation was not completed on 8/13/25, 9/17/25, 10/14/25, 10/20/25, 10/28/25, 11/11/25, and 12/2/25. LN B confirmed that the documentation was incomplete, and that controlled medication reconciliation must be completed at the change of each shift and documented. During an interview on 12/10/25 at 3:15 pm with the Director of Nursing (DON), the DON confirmed that the expectation is that controlled medication is reconciled at the end and beginning of each shift and confirmation is documented.

Based on observation, interview, and record review, the facility failed to report physical and verbal abuse, and an injury of unknown origin within two hours to the state and federal entities (California Department Public Health, CDPH, the Ombudsman, [a person appointed by the government who ensures that residents are treated fairly and that their rights are protected], and the Sheriff's office) for two of two residents (Resident 1 and 2) reviewed for abuse, when:1. On 10/1/25 at 9:30 pm, Certified Nursing Assistant (CNA) 1 witnessed CNA 2 roughly turning, slapping and holding down Resident 1's hands and arms and causing a skin tear to Resident 1's left wrist during patient care. CNA 1 did not report the abuse of Resident 1 to state and federal entities and waited until 10/2/25 at 3:45 pm, (18 hours later) before reporting abuse to Licensed Nurse (LN) A.2. On 10/1/25 at10:30 pm, CNA 1 witnessed CNA 2 intentionally placing a pillow over Resident 2's face and verbally tell her to shut up. CNA 1 did not report this to state and federal entities and waited until 10/3/25 at 9:03 am (35 hours later), to notify the Director of Nursing (DON).3. On 10/2/25 at 3:30 pm, CNA 1 reported to LN A the witnessed abuse (roughly turning, slapping and holding down Resident 1's hands and arms and causing a skin tear) of Resident 1 by CNA 2 on 10/1/25 at 9:30 pm. LN A did not report the suspected abuse to state and federal entities.4. At the beginning of August 2025 LN B overheard unidentified staff talking about how CNA 2 was rough with residents during patient cares and LN B did not notify anyone.5. On 10/1/25 at noon, a bruise of unknown origin was discovered on Resident 1's left arm by LN B, and it was not reported to the state and federal entities and there was no investigation to determine the cause of the bruise.6. The facility's Policy and Procedure (P&P) titled Abuse Prevention and Reporting revised 3/27/25, did not correctly indicate the CDPH and Ombudsman should be notified within two hours of known abuse.Refer to F600The failure to report these events immediately to a supervisor and within two hours to the appropriate state and federal entities allowed for the continued abuse, mental anguish, a skin tear and bruising for Resident 1 and verbal and physical abuse for Resident 2. Findings:During a record review of the facility's checklist titled Unusual Occurrence Alleged Abuse Reporting SNF Checklist (undated), indicated Unusual Occurrence is defined as: Any incident or event, especially one which happens without being designed or expected as an unusual occurrence or the ordinary occurrences of life. The checklist indicated that the person reporting the allegation is ultimately responsible for making sure the Sheriff, CDPH, and Ombudsman are verbally notified within 2 hours.1. During a record review of Resident 1's admission record, printed 10/3/25, indicated Resident 1 was admitted on [DATE] with diagnoses that included Alzheimer's dementia (a progressive, irreversible brain disorder that causes memory loss, confusion, and a decline in mental ability) and acute back pain. Resident 1 was unable to make her own health care decisions.During a review of Residents 1's Quarterly Minimum Data Set (MDS, a data driven clinical assessment) dated 7/30/25, section C -(Cognitive patterns, the ability to think clearly, reason and remember) indicated a Brief Interview for Mental Status (BIMS, a test for memory and thinking ability with scores from 00 having severe cognitive impairment to a score of 15 memory intact) was conducted, and Resident 1 scored a 4 indicating severe cognitive impairment. Section E- (Behavior assessment) indicated Resident 1 did not exhibit physical or verbal behavioral symptoms (i.e. hitting, pushing, screaming or cursing) directed toward others and did not have episodes of refusing care. Section GG-Functional Abilities indicated Resident 1 was dependent on staff for toileting. Section H -Bowel and Bladder indicated Resident 1 was incontinent (having no control with) bowel and bladder and wore briefs (disposable underwear that collects urine and feces) that required the staff to change.During an interview with CNA 1 on 10/8/25 at 3:16 pm, CNA 1 stated that during patient care for Resident 1 she had witnessed CNA 2 grab Resident 1's hands and arms and push them into Resident 1's chest. CNA 1 continued to say CNA 2 turned Resident 1 roughly and quickly when they were changing her brief. CNA 1 stated she had witnessed this treatment of Resident 1 by CNA 2 since September 1, 2025, but on 10/1/25 it was the worst she had seen. CNA 1 indicated that on 10/1/25 at 9:30 pm, Resident 1 obtained a skin tear when CNA 2 grabbed Resident 1's arm and rolled her roughly. CNA 1 indicated she reported the rough treatment of Resident 1 by CNA 2 to LN A on 10/2/25 at 3:45 pm (18 hours after the incident.) CNA 1 confirmed that she should have reported it right away.2. During a record review of Resident 2's admission record, printed 10/3/25, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, chronic (on going) pain, joint pain of the leg, and anxiety disorder. Resident 2 was unable to make her own health care decisions.During a record review of Resident 2's Quarterly MDS dated [DATE], section C indicated a BIMS was conducted, and Resident 2 scored a 9 indicating moderate cognitive impairment. Section E indicated Resident 2 had daily behaviors that included yelling and screaming and making disruptive sounds. Section GG- indicated that both legs were impaired, Resident 2 was unable to feed herself, required maximal assistance (helper does more than half the effort) with going to the bathroom, upper and lower body dressing, personal hygiene (washing and drying face), and rolling from left to right while in bed. Resident 2 was unable to stand or transfer in and out of bed without total assistance from staff. Section H indicated Resident 2 was incontinent with bowel and bladder and wore briefs that required the staff to change.During an observation and interview with Resident 2 laying on her bed in her room on 10/3/25 at 2:58 pm, Resident 2 was lying on her back, facing the ceiling. Resident 2 had three pillows placed behind and to both sides of her head. The covers were pulled up to her chest. Resident 2 was talking continually and not making any sense. Resident 2 did not answer questions that were asked of her. Resident 2 continued to say words that did not make sense. During a phone interview with CNA 1 on 10/8/25 at 3:16 pm, CNA 1 stated CNA 2 always says shut up, knock it off, and stop screaming to Resident 2. I noticed CNA 2 saying these things to Resident 2 since the beginning of September 2025. On 10/1/25 at 10:30 pm, we were changing Resident 2's brief while she was in bed. Resident 2 was screaming, and CNA 2 put a pillow over Resident 2's face and said, try screaming, stop screaming [Resident's name]! Resident 2 was unable to remove the pillow by herself, so I removed it. CNA 1 continued to state that when they were done changing and positioning Resident 2, CNA 2 threw blankets over Resident 2's face. CNA 1 said I was so afraid, and I know I should have said something that night. I knew it was wrong. I should have reported it right away, but I was scared. CNA 1 said she notified the DON on 10/3/25 at 9:03 am. (35 hours after the incident)3. During an interview on 10/3/25 at 2:30 pm, DON stated she opened and read an email from LN A the morning of 10/3/25 at 8:00 am. DON said the email indicated CNA 1 had witnessed CNA 2 abuse residents. DON said LN A had sent the email to her on 10/2/25 at 6:58 pm.During an interview with LN A on 10/3/25 at 3:29 pm, LN A stated that on 10/2/25 in the evening, CNA 1 told him that CNA 2 took Resident 1's hands and slapped them on her chest and slapped her arms and caused a skin tear to Resident 1's left wrist because of the rough treatment. LN A stated, Since I did not witness the abuse, I am not the one to fill out an abuse report. LN A confirmed that he sent an email to his DON about the reported abuse but did not call anyone or fill out any forms.During an interview with DON on 10/3/25 at 4:20 pm, DON stated that witnessed or suspected abuse at any time should be reported to herself immediately, CDPH, Ombudsman and the Sherrif office within two hours and this was not done by LN A or CNA 1, and it should have been.4. During an interview with LN B on 10/3/25 at 3:03 pm, LN B stated that at the beginning of August 2025 she heard two unidentified CNA's talking about how CNA 2 was very verbally aggressive or dominate with her speech with residents. LN B stated she did not report this to anyone.5. During an interview on 10/3/25 at 3:03 pm, LN B said she noticed a bruise on Resident 1's left forearm on 10/1/25 in the morning. LN B stated the bruise measured 9 centimeters (cm, a measurement of length) X 3 cm. LN B stated she did not know how the bruise happened and did not do an investigation concerning the bruise but just assumed she had hit the bed rail.During an interview on 10/3/25 at 3:07 pm, DON confirmed that Resident 1 had a obtained a bruise on her left forearm that was unwitnessed. DON stated that she assumed it came from Resident 1 hitting her arm on the bed railing but that there had been no investigation done to determine this. DON confirmed that the bruise should have been reported to the state and federal agencies, and an investigation should have been carried out to determine root cause.During a concurrent observation and interview with Resident 1 and the DON in the DON's office on 10/3/25 at 3:20 pm, Resident 1's left forearm was observed to have a bandage wrapped around the left hand and up to half of the left forearm. The DON removed the bandage, and a purple and reddish bruise was noted on the top of her forearm about 3 to 4 inches (approximately 9 cm) long and a skin tear was on the bruised area. The DON indicated it was not normal for Resident 1 to get bruises.6. During a concurrent interview with the DON and policy review on 10/6/25 at 2:21 pm, the facility's P&P titled Abuse Prevention and Reporting revised 3/27/25 was reviewed. The P&P did not indicate that all suspected Abuse was required to be reported to the CDPH within 2 hours. The DON confirmed that their policy was incorrect and needed to be revised to indicate that all suspected abuse was to be reported to the CDPH, local Sheriff's office and the Ombudsman within 2 hours.

Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from physical abuse and verbal abuse by Certified Nursing Assistant (CNA) 2 for two of two residents (Resident 1 and 2) sampled for abuse when:1. CNA 2 roughly turned, slapped, and held down Resident 1's hands and arms during patient care. This resulted in Resident 1 receiving a skin tear to her left wrist on 10/1/25 at 9:30 pm and caused Resident 1 to yell and scream at CNA 2 whenever she was in the room. The treatment of Resident 1 by CNA 2 had the potential to have caused the bruise that was discovered on Resident 1's left arm on 10/1/25. 2. CNA 2 intentionally placed a pillow over Resident 2's face and verbally told her to shut up. This had the potential for Resident 2 to experience fear and anxiety when CNA 2 was doing her cares and a decline in her mental and emotional wellbeing.This failure had the potential to result in negative psychosocial outcomes for Residents 1 and 2.Findings:A review of the facility's policy and procedures (P&P) titled Abuse Prevention and Reporting revised 3/27/25, indicated [Facility's name] shall ensure an abuse-free environment for the residents of the Skilled Nursing Facility (SNF) by establishing an effective abuse prevention program and shall report suspected or known resident abuse per all state and federal regulations. The P&P defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. d. Mental abuse includes, but is not limited to, humiliation, harassment and threats of punishment or deprivation. e. Physical abuse includes, but not limited to, hitting, slapping, pinching, and kicking. i. verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms aimed at residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability.A facility reported incident, dated 10/3/25 at 10:54 am, by the Director of Nursing (DON), indicated CNA 1 had witnessed CNA 2 verbally and physically abuse Resident 1, and yell at and put a pillow over Resident 2's face on 10/1/25 during the night shift.1. A review of Resident 1's admission record indicated Resident 1 was admitted on [DATE] with diagnoses that included Alzheimer's dementia (a progressive, irreversible brain disorder that causes memory loss, confusion, and a decline in mental ability) and acute back pain. Resident 1 was unable to make her own health care decisions.During a review of Residents 1's Quarterly Minimum Data Set (MDS, a data driven clinical assessment) dated 7/30/25, section C -(Cognitive patterns, the ability to think clearly, reason and remember) indicated a Brief Interview for Mental Status (BIMS, a test for memory and thinking ability with scores from 00 having severe cognitive impairment to a score of 15 memory intact) was conducted, and Resident 1 scored a 4 indicating severe cognitive impairment. Section E- (Behavior assessment) indicated Resident 1 did not exhibit physical or verbal behavioral symptoms (i.e. hitting, pushing, screaming or cursing) directed toward others and did not have episodes of refusing care. Section GG-Functional Abilities indicated Resident 1 was dependent on staff for toileting. Section H -Bowel and Bladder indicated Resident 1 was incontinent (having no control with) bowel and bladder and wore briefs (disposable underwear that collects urine and feces) that required the staff to change.A review of Resident 1's Nursing Narrative Note dated 10/1/25 at 5:00 pm, by Licensed Nurse (LN) D, indicated .a new bruise appeared on her left forearm 9 cm (centimeters, a measurement) x 3 cm.A review of Resident 1's Nursing Narrative Note dated 10/1/25 at 11:50 pm, by LN B, indicated that CNA 1 notified LN B that Resident 1 had received a skin tear to her left forearm measuring 1.5 cm (cm- a measurement of length) x 3 cm skin tear during patient cares on 10/1/25 at 9:30 pm.During a concurrent interview with the DON and email review on 10/3/25 at 2:30 pm, DON stated she had read an email on 10/3/25 in the morning from LN A indicating CNA 2 was abusing residents. The email dated 10/2/25 at 6:58 pm, by LN A indicated: This staff (CNA 1) reported to me that they have witnessed [CNA 2's name] be verbally abusive towards multiple residents and physically abusive to [Resident1's name]. While I was completing wound care on [Resident 1's name] skin tear, this staff member stated to me that they feel like the skin tear was caused by [CNA 2's name] being too rough when completing care. I asked them to elaborate. This staff member stated that [CNA 2's name] often yelled at [Resident 1's name] and other residents when they (CNA 2) got frustrated and was rough when completing care on residents. This staff member also stated that [CNA 2's name] takes [Resident 1's name] hands and often slams them against her chest and slaps her arms and legs around. This staff [CNA 1] member also stated that they [CNA 1] try to complete rounds by themselves, especially [Resident 1's name] so that she isn't yelled at or hit again or any resident. This staff member also stated that other staff has expressed the same concern and witness[witnessed] her yelling and being rough with other residentsDuring a concurrent observation and interview in the DON's office with Resident 1 and the DON on 10/3/25 at 3:20 pm, Resident 1's left forearm was observed in the DON's office to have a bandage wrapped around the left hand and up to half of the left forearm. The DON removed the bandage, and a purple and reddish bruise was noted on the top of her forearm about 3 to 4 inches (approximately 9 cm) long and a skin tear was on the bruised area. The DON said a bruise was discovered on Resident 1's left forearm on the morning of 10/1/25 (before the skin tear happened), but it had never been investigated to find out how it had happened. DON said that it was not normal for Resident 1 to get bruises and should have been investigated. Due to Resident 1's declined cognition level she was unable to identify how she received the bruise or skin tear when asked.During an interview with LN A on 10/3/25 at 3:29 pm, LN A stated that on 10/2/25 in the evening, CNA 1 told him that on 10/1/25 at 9:30 pm, CNA 2 took Resident 1's hands and slapped them on her chest and slapped her arms and caused a skin tear to Resident 1's left wrist because of the rough treatment. LN A said that he sent an email to his DON about the reported abuse.During a phone interview with CNA 2 on 10/6/25 at 11:02 am, CNA 2 stated that when she changed Resident 1's briefs Resident 1 would put her (Resident1's) hands down into her briefs and get them dirty with feces and urine. CNA 2 continued to say that to prevent Resident 1 from getting her hands dirty, CNA 2 would cross Resident 1's arms and put them on her chest and press down on them to keep her from reaching into her soiled brief. CNA 2 said sometimes she swears at me Sometimes I push her arms away and she just keeps trying, we (her and another CNA) have to work kind of fast with her. There might have been a few incidents when I pushed her too hard. CNA 2 said that on 10/1/25 during the changing of the brief of Resident 1, she noticed a skin tear on Resident 1's left hand after she had rolled Resident 1 towards her.During a phone interview with CNA 1 on 10/8/25 at 3:16 pm, CNA 1 stated that during the night shift on 10/1/25, she and CNA 2 worked together, conducting rounds that involved checking and changing residents' briefs. CNA 1 described instances since the beginning of September 2025 where CNA 2 removed blankets abruptly and handled residents roughly. CNA 1 reported that CNA 2 grabbed Resident 1's hands and arms, pushing them against Resident 1's chest hard to keep Resident 1 from reaching into her dirty briefs. CNA 1 stated that Resident 1 would yell and swear at CNA 2 and call her names and say, she is mean. CNA 1 stated that Resident 1 had never called her names or swore at her before but only did this when CNA 2 was in the room with her. CNA 1 said she observed an increase in the assertiveness of CNA 2's behavior during the week of 10/1/25. CNA 1 stated that on 10/1/25 at 9:30 pm, CNA 1 witnessed CNA 2 grab Resident 1's arms and roll her quickly, resulting in a skin tear. CNA 1 stated I was so afraid, and I know I should have said something that night. I knew it was wrong. I went into work early on 10/2/25 at about 3:45 pm and told LN A. I should have known to have reported it (the abuse) right away, but I was scared.During an interview with LN C on 10/8/25 at 4:01 pm, LN C indicated that he worked the night shift and at times would change Resident 1's briefs. LN C stated that Resident 1 had never sworn or yelled at him while he provided care.2. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, chronic (on going) pain, joint pain of the leg, and anxiety disorder. Resident 2 was unable to make her own health care decisions.A review of Resident 2's Quarterly MDS dated [DATE], section C indicated a BIMS was conducted, and Resident 2 scored a 9 indicating moderate cognitive impairment. Section E indicated Resident 2 had daily behaviors that included yelling and screaming and making disruptive sounds. Section GG- indicated that both legs were impaired, Resident 2 was unable to feed herself, required maximal assistance (helper does more than half the effort) with going to the bathroom, upper and lower body dressing, personal hygiene (washing and drying face), and rolling from left to right while in bed. Resident 2 was unable to stand or transfer in and out of bed without total assistance from staff. Section H indicated Resident 2 was incontinent with bowel and bladder and wore briefs that required the staff to change.During an interview with the DON on 10/3/25 at 2:30 pm, the DON indicated that on 10/3/25 at 9:03 am, CNA 1 had notified her by phone that on 10/1/25 Resident 2 was yelling during care, and CNA 2 placed a pillow over Resident 2's face.During an observation and interview with Resident 2 in her room on 10/3/25 at 2:58 pm, Resident 2 was observed in her room lying on her back in her bed and facing the ceiling. Resident 2 had three pillows placed behind and to both sides of her head. The covers were pulled up to her chest. Resident 2 was talking continually and not making any sense. Resident 2 did not answer questions that were asked of her she just continued to say words that did not make sense. During a phone interview with CNA 2 on 10/6/25 at 11:02 am, CNA 2 confirmed that she worked the night of 10/1/25 through morning of 10/2/25. CNA 2 stated that Resident 2 talked a lot and would yell. CNA 2 said that Resident 2's continual talking and yelling was overwhelming for her. CNA 2 said that she got frustrated when Resident 2 yelled. CNA 2 confirmed that at one time a pillow had fallen on Resident 2's face.During a phone interview with CNA 1 on 10/8/25 at 3:16 pm, CNA 1 stated CNA 2 always says shut up, knock it off, and stop screaming to Resident 2. I noticed CNA 2 saying these things to Resident 2 since the beginning of September 2025. On 10/1/25 at 10:30 pm, we were changing Resident 2's brief while she was in bed. Resident 2 was screaming, and CNA 2 intentionally put a pillow over Resident 2's face and said, try screaming, stop screaming [Resident 2's name]! Resident 2 was unable to remove the pillow by herself, so I removed it. CNA 1 continued to say that when they were done changing and positioning Resident 2, CNA 2 threw blankets over Resident 2's face. CNA 1 said I was so afraid, and I know I should have said something that night. I knew it was wrong. I should have reported it right away, but I was scared. CNA 1 said she notified the DON on 10/3/25 at 9:03 am.A review of the facility staffing dated 9/30/25 and 10/1/25, indicated:*CNA 2 worked night shift on 9/30/25 from 4:00 pm to 4:30 am and provided care for Resident 1 and Resident 2.*CNA 1 and CNA 2 worked the night shift together on 10/1/25 from 4:00 pm to 4:30 am and provided care for Resident 1 and Resident 2.

Based on interview and record review the facility failed to ensure one of two residents sampled for dignity (Resident 1), was treated with dignity and respect when Houskeeper (HSK) A made comments to Resident 1 indicating he had sexy legs and a sexy face. This failure caused Resident 1 to feel uncomfortable and unsafe around HSK A. Findings: A review of the facility's policy titled Implementation of Patients' [NAME] of Rights dated 9/22/16, indicated Patient right number 10: to be treated with consideration, respect and full recognition of his/her dignity and individuality. 1. Members of the staff will display respect when speaking with, care for, or talking about patients as constant confirmation of their individuality and dignity as human beings. Staff members will address patients with respect at all times. A review of a Facility Reported Incident (a report written by the facility and sent to the California Department of Public Health (CDPH) dated 7/21/25, indicated On 7/18/25 the Housekeeping Manager (HSKM) notified DON (Director of Nursing) that the LTC (Long Term Care) charge nurse (LN B) had concerns that the housekeeper (HSK A) working in LTC that day was saying inappropriate comments to a male resident (Resident 1). The charge nurse (LN B) stated that he overheard the housekeeper, (Name) HSK A, tell the male resident, (Name) Resident 1, that he had a sexy face. The charge nurse also said that he has witnessed multiple occasions where the housekeeper has referred to (Name) Resident 1, as sexy or make other provocative comments about his body. A review of the facility's final investigation report dated 7/21/25, indicated the DON spoke with (name) Resident 1 in the DON office on 7/18/25 at approximately 1:30 pm. (Name) Resident 1 stated the housekeeper (HSK A), frequently makes inappropriate comments to him. He stated that she often says things like you have sexy legs and other provocative comments about him being sexy. DON asked (name) Resident 1 if these comments made him feel uncomfortable and he shrugged his shoulders and nodded his head. He stated he tries to let these comments roll off his shoulder, but they are occurring more frequently now. A review of Resident 1's face sheet, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis that include unsteady gait, confusion, mild cognitive (the ability to remember and make decisions) impairment, and history of alcohol abuse. A review of Resident 1's Minimum Data Set (MDS, a clinical assessment) dated 7/4/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, a cognitive evaluation ranging from 00- impaired cognition to 15- cognition intact) evaluation performed and scored 15. During an interview on 8/15/25 at 1:17 pm, Resident 1 indicated that HSK A would come into his room and while cleaning his room she would make comments about his legs being sexy. Resident A stated he felt uncomfortable and unsafe around HSK A and would try and avoid her. During an interview on 9/5/25 at 10:18 am, LN B stated he had witnessed HSK A telling Resident 1 that he had sexy legs, a sexy face, and other provocative comments about his body since February 2025. LN B stated he should have reported this sooner but did not think it was an issues because Resident 1 was always laughing and smiling during the interactions. During an interview on 9/5/25 at 11:15 am, DON stated that she was unaware that HSK A was making these comments to Resident 1 since February and it should have been reported to her at that time. DON stated that HSK A was hired on 6/17/24 and discharged from employment to the facility on 7/25/25. DON confirmed that Resident 1 was not treated with dignity and respect and was made to feel uncomfortable when HSK A made these comments.

Based on interview and record review, the facility failed to follow their policies to ensure that Resident 1 was kept safe after he bought two electronic hand warmers to use when we went outside. This resulted in an avoidable accident when Resident one sustained two blisters on his left hand from using the warmers. Findings: In an interview with the DON (Director of Nurses) on 4/28/25 at 10 am, she stated that on 3/27/25, CNA1 (Certified Nursing Assistant) reported that Resident 1 had blisters on his hand that were not being addressed. The DON stated that she was unaware of the blisters and upon assessment of Resident 1's left hand she identified two blisters on his left palm, which measured 2.8 x 1 cm (centimeters) and 2 x 1.4 cm. Resident 1 told the DON that he had purchased lithium battery personal warmers that he attached to his body to keep him warm when he went outside. He stated that he had been using the warmers all winter. He further told the DON that usually there was a layer of clothing between the warmers and the skin, but on one occasion an unidentified staff member placed the warmer directly on his left hand without any protective barrier between the skin and the device. He refused to identify the staff member. The facility policy for Arrival of New Electrical Equipment read, all new electrical equipment will be inspected for electrical safety and physical condition upon arrival at the facility by the Environmental Services department. After this equipment is inspected and approved, maintenance will place a sticker on it with the date of inspection. If the equipment is deemed unsafe and has the potential to cause harm to the resdients or the facility, then the maintenance team will not approve the equipment and it should not be used. In an interview with the Director of Plant Operations (DPO) on 4/28/25 at 11 am, she stated that she remembered two CNA's (she could not remember which two nor could she remember when this occurred) catch me in the hallway one morning as I was heading out the door and they showed me a personal electronic heating device that Resident 1 had bought for himself to keep warm when he goes outside, which is every day. I checked the devices by plugging them in and following the manufacturer's directions. I felt that the devices got too hot for safe use so I told the CNAs not to use the devices for Resident 1. Also, the directions did state that a protective barrier must be used between the skin and the device to prevent burns. I did not write any of this down, nor did I speak with Resident 1 or the DON. I failed to follow our own policy and I take responsibility for that. Resident 1 was discharged on [DATE] and was not available to be interviewed.

Based on observation, interview, and record review, the facility failed to ensure that blood sugar testing equipment was dated when opened and that the glucometers (a machine used to test blood sugar), was calibrated (a control test to ensure the glucometer readings are accurate) when: a. Two vials of glucometer control test vials were not dated when opened, or when the solution was to be discarded. b. Two bottles of glucometer test strips were not dated when opened, or when they were to be discarded. c. Facility failed to perform quality control (QC) calibration checks daily on glucometers. These failures could lead to inaccurate blood sugar test results due to using outdated, inaccurate, and less effective testing equipment and supplies, which could result in negative clinical outcomes for the residents. Findings: A review of the facility's policies and procedures (P&P) titled, Glucose Testing Machine: Care and Use of, dated 6/19/24, indicated, before using the glucometer and testing a resident's blood sugar, facility staff would Verify that QC was performed and within expected limits. A review of the undated document titled, SNF Meeting (notes regarding education reviewed and provided to facility staff during a staff meeting), indicated, facility staff were perform daily glucometer QC checks. The document indicated, The test solution and strips must have an outdate placed on the outside. Expiration date for the control solution is three (3) months from opening, test strips are six (6) months from opening. During a concurrent observation, interview, and record review on 11/6/24 at 2:30 pm, located at the glucometer storage area in the nurse's station, with Licensed Nurse (LN) A, two bottles of glucometer control test vials, two bottles of glucometer test strips, and the Equipment Maintenance Record, dated 6/1/24 through 11/5/24 were reviewed and reflected the following; a. LN A stated, when the control test vials were opened, the expectancy was that LN dated the control test vials with the date it was opened and the date they were to be discarded. LN A confirmed, both control test vials were not dated with the opened or discarded dates and should have been. LN A reviewed the manufacturer's recommendations (MR) titled, Nova StatStrip Glucose Control Solution, dated, 1/1/22, and stated the MR indicated, 'the control test vials were to be discarded three months after opening or the expiration date, which ever date was sooner.' b. LN A stated, when the glucometer control test strips were opened, the expectancy was that LN dated the control test strips with the date they were was opened and the date they were to be discarded. LN A confirmed, both bottles of control test strips were not dated with the opened or discarded dates and should have been. LN A reviewed the MR titled, StatStrip Glucose Hospital Test Strips, dated 1/1/22, and stated, the MR indicated the glucometer test strips were to be discarded six months after opening or the expiration date, which ever date was sooner. c. LN A reviewed the Equipment Maintenance Record, dated 6/1/24 through 11/5/24 and stated the night shift was to perform a QC check on the glucometer every night. LN A confirmed multiple missing entries located on the, Equipment Maintenance Record, eight for the month of June, 12 for the month of July, six for the month of August, three for the month of September, 9 for the month of October, and one in the first 5 days of November. The Equipment Maintenance Record, included instructions to discard control solutions 3 months after opening. On 11/6/24 at 2:45 pm, during an observation and interview, the Chief Nursing Officer (CNO), confirmed two bottles of glucometer control test vials and two bottles of glucometer test strips did not have opened or discarded dates and should have. CNO reviewed the, Equipment Maintenance Record, dated 6/1/24 through 11/5/24, and confirmed there were multiple missing quality calibration checks for the glucometers, and stated the night shift was responsible for performing the glucometer QC test every night.

Based on observation, interview, and record review, the facility failed to observe the meal preferences of one of eight sampled residents when Resident 9 was served brussel sprouts. This failure had the potential to reduce intake of nutrients, weight loss and have negative clinical outcomes. Findings: A review of the facility's undated policy and procedure titled, Skilled Nursing Facility Food Preferences, indicated, the facility would take into consideration resident food preferences. A review of an untitled and undated record indicated, Resident 9 was admitted to the facility on [DATE] with the diagnoses of type 2 diabetes (high blood sugar) and major depressive disorder (a sad mood). A review of the annual (yearly) Minimum Data Set (MDS, an assessment tool), dated 10/8/24, Section C, indicated, Resident 9 had a Brief Interview for Mental Status (an assessment that tested a resident's ability to recall information and memory. The test was scored from 0-15 where 0 meant the resident was not able to remember and 15 meant the resident had intact memory) and scored a 14. During a concurrent observation and interview on 11/4/24 at 12:04 pm, Licensed Nurse (LN) B was observed outside of the resident dining area checking resident lunch trays. LN B stated, when meal trays come out, LNs checked the meal trays to ensure the residents received the correct diet, food preferences, and resident food allergies. During the observation, LN B checked all the lunch trays prior to the residents being served. During a concurrent observation, interview, and record review, on 11/4/24 at 12:09 pm, LN B provided Resident 9 with her lunch tray. When the lid was removed from the lunch plate, Resident 9's smile changed to a frown, she appeared upset, with eyebrows scrunched together. Resident 9 cursed loudly and, having a dislike of brussel sprouts stated, I tell them all the time and I keep getting them. Resident 9's tray card (a card that indicated a resident's diet, allergies, and dislikes) was reviewed and indicated Resident 9 had a dislike of brussel sprouts. LN B apologized to Resident 9 and stated, I forgot to have the brussel sprouts removed. During a concurrent observation, interview, and record review, on 11/6/24 at 11:49 am, the dietary staff was observed plating resident lunches. A document that contained resident food dislikes was observed, taped to a cupboard door near the tray line (where food was placed on plates). The document indicated, Resident 9 did not like brussel sprouts. [NAME] affirmed remaking the resident dislike food list a few days ago and forgetting to add Resident 9's dislike of brussels sprouts to the list. [NAME] stated, the x, indicating a dislike of brussel sprouts was added to the document on 11/4/24 after lunch was served. During a concurrent interview and record review on 11/6/24 at 2:42 pm, Resident 9's Food Preferences, dated 9/28/23, was reviewed with the Registered Dietician (RD). The RD stated, the 'Food Preferences' indicated Resident 9 did not like brussel sprouts and confirmed, Resident 9 was served brussel sprouts at lunch on 11/4/24.

Based on interview and record review, this requirement was not met when the facility failed to obtain the services of a registered nurse for eight consecutive hours, seven days a week. This had the potential to adversely affect residents' care, which could lead to potential negative clinical outcomes. Findings: A review of the facility's Registered Nurse (RN) staffing/schedule documentation from the period of 11/1/24 to 11/30/24 indicated that the RN working as Director of Nursing (DON) was scheduled to work weekdays (Monday through Friday) leaving six weekend days (11/2, 11/3, 11/9, 11/10, 11/23, and 11/30/24) uncovered during this four-week time period. There are two days (11/28, and11/29/24) when the DON had time off. On 11/5/24 at 7 am, during an interview with the facility's Chief Nursing Officer (CNO), the CNO indicated the facility had requested the federal waiver for RN coverage, indicating a reduction in the required registered nurses' hours from 56 hours a week to 40 hours a week to be renewed this year. We have the waiver and will have it renewed again. On 11/6/24 at 9:30 am, during the resident council meeting (a meeting for residents to voice concerns regarding living in a facility), there were no complaints of staffing issues. Four of four confidentially interviewed residents did not have staffing concerns. During an interview and concurrent record review with the Director of Nursing (DON) on 11/06/24 at 10:45 am, the DON confirmed there was no RN coverage on weekends. During review of the staffing schedule the DON stated, I am here weekdays but there isn't an RN on weekend days. An RN is available from the acute hospital, down the connecting hallway, if needed. On 11/6/24 at 2:10 pm, during an interview, Licensed Vocational Nurse A (LN) A stated, On weekends we can call the DON or if really urgent, we can get an RN from either Med/Surg (the medical surgical unit) or the ER. We do that after hours too because there is only an LVN at night for the 12-hour shift. LN A had no concerns regarding the weekend RN staffing. The survey team found no negative outcomes related to continuing this federal waiver for RN coverage, and recommends it be continued.

Based on observation, interview and record review the facility failed to protect twelve (12) of twelve (12) residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) from abuse by a staff member when Licensed Nurse (LN) A, with willful intent, deprived residents of necessary medical care and treatment by withholding Resident one (1) through 12 ' s medications that were ordered by their Medical Doctor (MD). This occurred during the morning (am) shifts of 5/25/24 and 5/26/24. LN A was observed via video from a camera located above the nurse ' s station medication desk throwing medications in the garbage, putting medications in her scrub (uniform) pockets, and leaving some medications in drawers that were subsequently found by LN B. LN A documented that the medications observed being withheld, were administered to residents one through 12. This failure had the potential to cause significant physical harm, pain, and mental anguish by depriving residents of necessary medications that were ordered by their MD, the residents did not receive required medical care and treatment in order to attain or maintain their physical, mental and psychological well-being and resulted in Substandard Quality of Care. Findings: During a review of facility ' s policy and procedure titled, Abuse Prevention, dated 3/5/2019, indicated, Each resident has the right to be free from abuse .by anyone, including but not limited to facility staff .Abuse is the willful infliction of injury .including the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. During a review of facility ' s policy and procedure titled, Medication Administration, dated 5/4/2017, indicated, The purpose of this policy is to ensure proper and safe medication administration practices as best practice .Any medication administered must be charted immediately .If the medication is not administered to the resident after it has been poured and is NOT a controlled substance, the licensed nurse will .Indicate non-administration of medication .note the reason the medication was held .If the medication is not administered to the resident after it has been poured and IS a controlled substance, the licensed nurse will, Indicate non- administration of medication .note the reason the medication was held .Two licensed nurses will verify the medication has been properly disposed of . 1. A review of Resident 1 ' s medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included, Atrial Fibrillation (Afib, irregular often rapid heart rate commonly causing poor blood flow), Heart Failure (heart muscle weakens and stiffens and doesn ' t pump blood effectively), and Hypertension (HTN, High Blood Pressure). The Minimum Data Set (MDS, a tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) dated 4/14/24, indicates Resident 1 rates 14/15, which equates to being cognitively intact. 2. A review of Resident 2 ' s medical record indicated that resident 2 was admitted on [DATE] with diagnoses that included, Psychosis (Mental disorder with disconnection from reality), Failure to Thrive (FTT, General decline in physical and mental health), HTN, and Dementia (Affects brain function such as memory, thinking, and social abilities, and interferes with daily lives). The MDS BIMS dated 5/14/24, indicates Resident 2 rates 3/15, which equates to severe impairment. 3. A review of Resident 3 ' s medical record indicated that resident 3 was admitted on [DATE] with diagnoses that included, Cancer, Chronic Obstructive Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and Depression. The MDS BIMS dated 4/6/24 indicates Resident 3 rates 9/15, which equates to moderate impairment. 4. A review of Resident 4 ' s medical record indicated that resident 4 was admitted on [DATE] with diagnoses that included, Afib, Chronic Kidney Disease (CKD, Gradual loss of kidney function, damage and unable to filter blood adequately), and Dementia (Affects brain function such as memory, thinking, and social abilities, and interferes with daily lives). The MDS BIMS dated 4/10/24 indicates Resident 4 rates 8/15, which equates to moderate impairment. 5. A review of Resident 5 ' s medical record indicated that resident 5 was admitted on [DATE] with diagnoses that included, Quadriplegia (Paralysis of all four limbs), Malnutrition (Not having enough to eat, not eating enough of the right things, or being unable to process or use the food eaten), and Depression. The MDS BIMS dated 3/11/24 indicates Resident 5 rates 15/15, which equates to being cognitively intact. 6. A review of Resident 6 ' s medical record indicated that resident 6 was admitted on [DATE] with diagnoses that included, Cerebrovascular Accident (CVA, Stroke), Coronary Artery Disease (CAD, Damage or disease in the heart ' s major blood vessels), and Heart Failure. The MDS BIMS dated 5/2/24 indicates Resident 6 rates 06/15, which equates to severe impairment. 7. A review of Resident 7 ' s medical record indicated that resident 7 was admitted on [DATE] with diagnoses that included, Heart Failure, HTN, and Chronic Respiratory Failure (Difficulty breathing, lungs cannot get enough oxygen to the blood or too much carbon dioxide exists). The MDS BIMS dated 3/7/24 indicates Resident 7 rates 0/15, which equates to severe impairment. 8. A review of Resident 8 ' s medical record indicated that resident 8 was admitted on [DATE]with diagnoses that included, Afib, HTN, and Osteoporosis (Loss of bone strength and density). The MDS BIMS dated 3/25/24 indicates Resident 8 rates 15/15, which equates to being cognitively intact. 9. A review of Resident 9 ' s medical record indicated that resident 9 was admitted on [DATE] with diagnoses that included, COPD, Dementia, and Respiratory Failure. The MDS BIMS dated 3/7/24 indicates Resident 9 rates 03/15, which equates to severe impairment. 10. A review of Resident 10 ' s medical record indicated that resident 10 was admitted on [DATE] with diagnoses that included, HTN, Alcohol Abuse, Hyponatremia (Low blood sodium), and Hyperkalemia (High blood potassium). The MDS BIMS dated 4/9/24 indicates Resident 10 rates 14/15, which equates to being cognitively intact. 11. A review of Resident 11 ' s medical record indicated that resident 11 was admitted on [DATE] with diagnoses that included, CVA, HTN, and Diabetes Mellitus (DM). The MDS BIMS dated 3/5/24 indicates Resident 11 rates 07/15, which equates to severe impairment. 12. A review of Resident 12 ' s medical record indicated that resident 12 was admitted on [DATE] with diagnoses that included, Afib, Heart Failure, HTN, and CVA. The MDS BIMS dated 4/15/24 indicates Resident 12 rates 8/15, which equates to moderate impairment. 1. During a review of Resident 1's medical records titled, Orders, undated, the medication Orders indicated, Resident 1 was ordered Pantoprazole (treats gastroesophageal reflux disease (GERD), stomach problems) 40 milligrams (mg, measurement unit) 1 tablet (tab) by mouth (PO, per os) every (Q) day. The Pantoprazole was a routine (scheduled medication, assigned a specific time to be administered, not an as needed (prn) medication), medication scheduled to be administered daily at 08:00 am daily. During a review of Resident 1's medical records titled, Cerner Medication Administration Record (MAR) and Pyxis (Automated medication dispensing system), dated 5/25/24 through 5/26/24, indicated, on 5/26/24 at 07:51 am, LN A removed Pantoprazole from the Pyxis, and scanned the Pantoprazole into the MAR as having been administered. On 5/26/24 at 08:06 am LN A was observed via video throwing Resident 1 ' s Pantoprazole in the garbage. A review of Resident 1 ' s medical record indicated that Resident 1 ' s vital signs (VS) were taken on 5/27/24 as follows: blood pressure (BP) 138/77, and heart rate (HR) 78. 2. During a review of Resident 2's medical records titled, Orders, undated, the medication Orders indicated, Resident 2 was ordered Tramadol (pain medication) 50 mg 1 tablet PO Q 6 hours as needed (prn, pro re nata - as the situation demands) for moderate pain, Divalproex Sodium (antiseizure and bipolar treatment) 250 mg 1 tab two times per day (BID), Docusate (constipation treatment) 100 mg 1 tab PO Q day, Magnesium Oxide (mineral) 250 mg 1 tab PO Q day, Metoprolol (high blood pressure treatment) 50 mg 1 tab PO Q day, Calcium Carbonate (mineral) 1000 mg 2 chewable tabs three times per day (TID). Routine medications were scheduled to be administered at 09:00 am daily. During a review of Resident 2's medical records titled Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/26/24 beginning at 08:21 am all the ordered medications were pulled from the Pyxis and scanned into the MAR by LN A. LN A was then observed via video putting Resident 2 ' s Tramadol in a medication cup and then throwing the other medications in the garbage. On 5/26/24 at 08:24 am, LN A was observed via video putting Resident 2 and Resident 11 ' s Tramadol in the same medication cup and left the station for 21 seconds then returned to the station empty handed. A review of Resident 2 ' s medical record indicated that Resident 2 ' s VS were taken on 5/27/24 as follows: blood pressure (BP) 138/75, and heart rate (HR) 78. 3. During a review of Resident 3's medical records titled, Orders, undated, the medication Orders indicated, Resident 3 was ordered Gabapentin (anticonvulsant and nerve pain treatment) 400 mg 1 capsule (cap) PO Q day, Lisinopril (high blood pressure, heart failure treatment) 10 mg 1 tab PO Q day, Sertraline (antidepressant treatment) 50 mg 1 tab PO Q day, Aspirin (Asa, Nonsteroidal anti-inflammatory drug (NSAID) and blood thinner) 81 mg PO Q day, Carvedilol (high blood pressure, heart failure treatment) 3.125 mg 1 tab PO BID, Cholecalciferol (Vitamin D) 1000 International unit (iu, unit of measurement) 1 tab PO Q day, Cyanocobalamin (Vitamin B12) 1000 microgram (mcg, unit of measurement) 1 tab PO Q day, Docusate 250 mg 1 cap PO BID, Loratadine (antihistamine, allergy treatment) 10 mg 1 tab PO Q day, Multivitamin with Minerals 1 tab PO Q day, Omeprazole (Stomach acid treatment) 20 mg 1 cap PO Q day, Vitamin A and D Topical Apply topical ointment BID, Zinc Oxide Topical Apply topical ointment BID, Levothyroxine (Low thyroid treatment) 100 mcg PO Q day. Routine medications were scheduled to be administered to Resident 3 at 09:00 am daily. During a review of Resident 3's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/25/24 beginning at 08:35 am all the ordered medications except for Levothyroxine were pulled from the Pyxis and scanned into the MAR by LN A. On 5/25/24 at 08:43 am, LN A was observed via video throwing Resident 3 ' s medication in the garbage. A review of Resident 3 ' s medical record indicated that Resident 3 ' s VS were taken on 5/27/24 as follows: blood pressure (BP) 199/76, and heart rate (HR) 80. Resident 3 ' s medications were administered, and VS were taken again BP 143/54. 4. During a review of Resident 4's medical records titled, Orders, undated, the medication Orders indicated, Resident 4 was ordered Amlodipine (high blood pressure and chest pain (cp) treatment) 5 mg 1 tab PO Q day, Clonidine (high blood pressure treatment) 0.1 mg 1 tab PO BID, Cyanocobalamin 500 mcg, .5 tab PO Q day, Docusate 100 mg 1 cap PO BID, Hydralazine (high blood pressure treatment) 25 mg 1 tab PO Q 8 hours, Insulin Glargine (high blood sugar treatment) 15 units (u, unit of measurement) 0.15 milliliters (ml, unit of measurement) subcutaneous (SQ) injection (inj) BID, Levothyroxine 50 mcg 1 tab PO Q day, Metoprolol Extended Release (ER) (high blood pressure, chest pain, and heart failure treatment) 100 mg 2 tabs PO Q day, Nystatin topical powder (fungal and yeast infection topical treatment) 1 application topical BID prn rash, and Multivitamin 1 tab PO Q day. Routine medications were scheduled to be administered to Resident 4 at 09:00 am. During a review of Resident 4's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/25/24 beginning at 08:43 am all the ordered medications except Hydralazine, Levothyroxine, and Insulin injection were pulled from the Pyxis and scanned into the MAR by LN A. On 5/25/24 at 08:47 am LN A was observed via video throwing Resident 4 ' s medication in the garbage. On 5/26/24 beginning at 09:20 am, all the ordered medications except Hydralazine, Levothyroxine, and Insulin injection were pulled from the Pyxis and scanned into the MAR by LN A. On 5/26/24 at 09:24 am, LN A was then observed via video throwing Resident 4 ' s medication in the garbage. A review of Resident 4 ' s medical record indicated that Resident 4 ' s vital signs were taken on 5/27/24 as follows: blood pressure (BP) 174/80, and heart rate (HR) 74. 5. During a review of Resident 5's medical records titled, Orders, undated, the medication Orders indicated, Resident 5 was ordered Amlodipine (for high blood pressure) 5 mg 1 tab PO Q day, Ascorbic Acid (vitamin C) 500 mg 1 tab PO Q day, Baclofen (muscle relaxant) 20 mg 1 tab PO four times per day (QID), Dantrolene (muscle relaxant) 25 mg 1 cap PO three times per day (TID), Diclofenac (pain relief, NSAID) topical gel 1 application BID, Docusate 250 mg 1 cap PO Q day, Fluoxetine (antidepressant) 60 mg 3 caps PO Q day, Gabapentin 400 mg 1 cap PO QID, Magnesium Oxide (mineral) 250 mg 1 tab PO Q day, Mirabegron (urinary incontinence treatment) 50 mg 1 tab PO Q day, Multivitamin 1 tab PO Q day, Omeprazole 20 mg 1cap PO Q day, Polyethylene Glycol 3350 (laxative) 17 grams (g, unit of measurement) 1 each PO Q day, Potassium Chloride 10 milliequivalent (mEq, unit of measurement) 1 cap PO BID, Saccharomyces boulardii lyso (probiotic) 250 mg 1 cap BID, Zinc Oxide topical 1 application topical ointment BID, and Methenamine (antibiotic for bladder and kidney infection treatment) 1 gram (g, unit of measurement) 1 tab PO BID. Routine medications were scheduled to be administered to Resident 5 at 09:00 am. During a review of Resident 5's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/26/24 beginning at 09:24 all ordered medication except Omeprazole, Polyethylene Glycol 3350 were documented as pulled from the Pyxis and scanned into the MAR by LN A. On 5/26/24 at 09:24 am, LN A was observed via video pouring five (5) tabs of Methenamine into a cup, Resident 5 only had 1 tab ordered. On 5/26/24 at 09:27 am, LN A was observed via video deliberately not removing several of Resident 5 ' s medications from the cabinet which the medications were located after LN A scanned the medications as being pulled including Ascorbic acid, Docusate, Magnesium Oxide, Multivitamin, and Saccharomyces boulardii lyo. A review of Resident 5 ' s medical record indicated that Resident 5 ' s vital signs were taken on 5/27/24 as follows: blood pressure (BP) 130/72, and heart rate (HR) 54. 6. During a review of Resident 6's medical records titled, Orders, undated, the medication Orders indicated, Resident 6 was ordered Cholecalciferol (vitamin D3), 1000 IU 1 tab PO Q day, Docusate 100 mg 1 tab PO Q day, Duloxetine (antidepressant and nerve pain treatment) 120 mg 2 caps PO Q day, Furosemide (diuretic) 40 mg I tab PO Q day, Gabapentin 300 mg 1 cap PO TID, Levetiracetam (antiseizure treatment) 500 mg 1 tab PO BID, Multivitamins with Minerals 1 tab PO Q day, Pantoprazole 40 mg 1 tab PO Q day, Potassium Bicarbonate (mineral) 10 mEq 1 tab PO Q day, Vitamin A and D 1 application Q day, Zinc Oxide topical 1 application Q day, and Oxycodone Acetaminophen (narcotic pain medication) 5 - 325 mg 1 tab PO Q 6 hours prn pain. Routine medications were scheduled to be administered to Resident 6 at 09:00 am. During a review of Resident 6's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/25/24 beginning at 09:07 am, all ordered medications except Vitamin A and D topical and Zinc Oxide topical were documented as pulled from the Pyxis and scanned into the MAR by LN A. On 5/25/24 at 09:07 am, LN A did not crush the medications (not including the oxycodone) per MD orders. Resident 6 cannot take pills that are not crushed thus, indicating the medications were not administered. The Oxycodone was not removed from its packaging and was kept by LN A at the nurse ' station then was removed from the station when LN A walked towards the break room, as observed on the video. A review of Resident 6 ' s medical record indicated that Resident 6 ' s vital signs were taken on 5/27/24 as follows: blood pressure (BP) 120/55, and heart rate (HR) 56. 7. During a review of Resident 7's medical records titled, Orders, undated, the medication Orders indicated, Resident 7 was ordered Amlodipine (high blood pressure and chest pain treatment) 10 mg 1 tab PO Q day, Apixaban (blood thinner) 5 mg 1 tab PO Q day, Asa 81 mg 1 tab PO Q day, Carvedilol (high blood pressure and heart failure treatment) 12.5 mg a half tab PO BID, Cholecalciferol 2000 iu 2 tabs PO BID, Diclofenac topical 1 application topically QID, Docusate 100 mg 1 cap PO Q day, Duloxetine 60 mg 1 cap PO Q day, Gabapentin 600 mg 2 caps PO BID, Hydralazine 25 mg 1 tab PO TID, Levothyroxine 100 mcg 1 tab PO Q day, Losartan 25 mg 1 tab PO Q day, Multivitamin with minerals 1 tab PO Q day, Oxybutynin (bladder relaxant treatment) 5 mg PO Q day, Vitamin A and D topical 1 application Q day, Zinc Oxide topical 1 application Q day, and Tramadol 50 mg 1 tab PO Q day PRN mild pain. Routine medications were scheduled to be administered to Resident 7 at 09:00 am. During a review of Resident 7's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated on 5/25/24 beginning at 09:26 am all ordered medications except Apixaban and Levothyroxine were documented as pulled from the Pyxis and scanned into the MAR by LN A. On 5/25/24 at 09:26 am, LN A was observed via video deliberately not removing several of Resident 7 ' s medication from the cabinet which they are located after LN A scanned the medications as being pulled. On 5/25/24 at 09:30 am, LN A was then observed via video as finishing scanning medications for Resident 7 and throwing the medications in the garbage. On 5/26/24 at 09:14 am, Tramadol was documented as pulled from the Pyxis and scanned into the MAR by LN A. On 5/26/24 at 09:15 am, LN A was observed via video as putting Resident 7 ' s Tramadol (which was left in the packaging) in a cup and then placed it on the desk. At 09:38 am, LN A walked off the nurse ' station with the Tramadol. A review of Resident 7 ' s medical record indicated that Resident 7 ' s vital signs were taken on 5/27/24 as follows: blood pressure (BP) 135/80, and heart rate (HR) 75. 8. During a review of Resident 8's medical records titled, Orders, undated, the medication Orders indicated, Resident 8 was ordered Diclofenac topical 1 application TID, Docusate 100 mg 1 tab PO Q day, Fluticasone Nasal Spray (for seasonal allergies), 50 mcg 1 spray each nasal BID, Losartan 25 mg 1 tab PO Q day, Multivitamin with minerals 1 tab PO Q day, Polyethylene Glycol 3350 17 gm, 1 each PO Q day. Routine medications were scheduled to be administered to Resident 8 at 09:00 am. During a review of Resident 8's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/25/24 beginning at 09:31 am all ordered medications were documented as pulled from the Pyxis and scanned into the MAR by LN A. On 5/25/24 at 09:33 am, LN A was then observed via video throwing Resident 8 ' s medication in the garbage. A review of Resident 8 ' s medical record indicated that Resident 8 ' s vital signs were taken on 5/27/24 as follows: blood pressure (BP) 115/44, and heart rate (HR) 82. 9. During a review of Resident 9's medical records titled, Orders, undated, the medication Orders indicated, Resident 9 was ordered Docusate 100 mg 1 tab PO Q day, Calcium carbonate (TUMS), 1000 mg 2 chewable tabs Q 4 hours prn dyspepsia (upset stomach), Multivitamin with minerals 1 tab PO Q day, Sertraline (antidepressant) 25 mg 1 tab PO Q day, Fluticasone - Vilanterol (COPD treatment) inhaler 1 puff Q day, Pantoprazole 40 mg 1 tab PO Q day, Albuterol (COPD treatment) inhaler 2 puffs QID, Methylphenidate Hydrochloride (HCL) (stimulant) 5 mg 1 tab PO BID, and Lorazepam 0.5 mg 1 tab PO Q 4 hours prn anxiety. Routine medications were scheduled to be administered to Resident 9 at 09:00 am. During a review of Resident 9's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/25/24 beginning at 09:37 am all medications were documented as pulled from the Pyxis and scanned into the MAR by LN A except Docusate, Fluticasone - Vilanterol, Pantoprazole, Albuterol, Lorazepam and Methylphenidate HCL. On 5/25/24 at 09:36 am, LN A was observed via video throwing Resident 9 ' s medication in the garbage. During a review of Resident 9's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/26/24 beginning 07:49 am, all medications were documented as pulled from the Pyxis and scanned into the MAR by LN A except for Calcium Carbonate, Multivitamin with minerals, and Sertraline. On 5/26/24 at 07:50 am, LN A was observed throwing resident 9 ' s medications in the garbage. A review of Resident 9 ' s medical record indicated that Resident 9 ' s vital signs were taken on 5/27/24 as follows: blood pressure (BP) 102/64. 10. During a review of Resident 10' s medical records titled, Orders, undated, the medication Orders indicated, Resident 10 was ordered Pantoprazole 40 milligrams 1 tab by PO Q day. The Pantoprazole was scheduled to be administered daily at 08:00 am daily. During a review of Resident 10's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/26/24 at 07:52 am, LN A removed Pantoprazole from the Pyxis, and scanned the Pantoprazole into the MAR as administered. On 5/26/24 at 08:06 am LN A, was then observed via video throwing Resident 10 ' s Pantoprazole in the garbage. A review of Resident 10 ' s medical record indicated that Resident 10 ' s vital signs were taken on 5/29/24 as follows: blood pressure (BP) 126/566, and heart rate (HR) 66. 11. During a review of records titled, Orders, undated, the medication Orders indicated, Resident 11 was ordered Amlodipine 5 mg 1 tab PO Q day, Ascorbic Acid 500 mg 1 tab PO Q day, docusate 100 mg 1 cap PO BID, Duloxetine 30 mg 1 cap PO Q day, famotidine (stomach acid treatment) 20 mg 1 tab PO Q day, Haloperidol (antipsychotic) 1 mg 2 tabs PO BID, Multivitamin with minerals 1 tab PO Q day, Oxybutynin 10 mg 1 tab PO Q day, Psyllium (laxative) 3.4 g 1 each, PO Q day, Asa 81 mg 1 tab PO Q day, and Tramadol 50 mg 1 tab PO Q 6 hours PRN pain. Routine medications were scheduled to be administered to Resident 11 at 09:00 am. During a review of Resident 11's medical records titled, Cerner Medication Administration Record (MAR) and Pyxis, dated 5/25/24 and 5/26/24, indicated, on 5/25/26 beginning 9:42 am, all medications were documented as pulled from the Pyxis and scanned into the MAR by LN A except Famotidine, Psyllium, and Tramadol. On 5/25/26 at 09:42 am, LN A was observed via video removing four (4) Haloperidol. Resident 11 only has two (2) Haloperidol ordered. Two (2) Haloperidol were placed in chocolate pieces for Resident 11, as ordered. The other two remained on the desk under papers. On 5/25/24 at 09:48 am, LN A was then observed via video throwing all other Resident 11 ' s medications in the garbage. On 5/26/24 at 08:23 am, Resident 11's Tramadol was documented as pulled from the Pyxis and scanned into the MAR by LN A. On 5/26/24 beginning at 08:23 am, LN A is observed via video pulling Tramadol for Resident 11 and placing it in a cup with Resident 2 ' s Tramadol. LN A left the station for 21 seconds then returned to the station empty handed. A review of Resident 11 ' s medical record indicated that Resident 11 ' s vital signs were taken on 5/27/24 as follows: blood pressure (BP) 131/72, and heart rate (HR) 89. 12. During a review of Resident 12's medical records titled, Orders, undated, the medication Orders indicated, Resident 12 was ordered Apixaban (blood thinner) 2.5 mg 0.5 tab PO BID, Clonidine 0.1 mg (for blood pressure), 1 tab PO Q day, furosemide 40 mg 1 tab PO Q day, Multivitamin 1 tab PO Q day, Potassium Chloride 10 mEq 1 cap PO q day, Sodium Chloride (salt tablet) 1 g, 1 cap PO Q day, Aripiprazole (antipsychotic) 2 mg, 1 tab PO Q day, Bupropion (antidepressant) 300 mg, 1 tab PO Q day, Sotalol (heart rhythm disorder treatment) 80 mg, 1 tab PO Q day. Routine medications were scheduled to be administered to Resident 12 at 09:00 am. During a review of Resident 12's medical records titled, Cerner Medication Administration Record and Pyxis, dated 5/25/24 through 5/26/24, indicated, on 5/26/24 beginning 07:47 am all medications were documented as pulled from the Pyxis and scanned into the MAR by LN A except for Sotalol, Apixaban, and Clonidine. On 5/26/24 at 07:46 am, LN A was observed throwing resident 12 ' s medications in the garbage. A review of Resident 12 ' s medical record indicated that Resident 12 ' s vital signs were taken on 5/29/24 as follows: blood pressure (BP) 134/56, and heart rate (HR) 63. During an interview on 6/4/24 at 12:30 pm, with Chief Nursing Officer (CNO) in the Director of Nursing's (DON ' s) office, CNO confirmed that based on everything in the video, the hospital/facility administrative staff have substantiated the incident as there is no doubt that it happened. During a concurrent observation and interview on 6/4/24 at 2:45 pm, with DON in DON ' s office, video from the camera above the nurse ' station medication desk was viewed. In the video LN A was observed concealing medication in the palm of the hand and slipping the medictions into the pocket of LN A ' s scrub top, blatantly throwing medications that have been scanned to residents and placed in plastic cups, in the garbage and appearing to try to conceal the cups and medications under something in the garbage that is not viewable at the angle of sight, and scanning medications out of the pyxis but not removing them from the cabinet. DON stated all the rest of the video viewed is of the same level of depravation. DON confirms with confidence that the incident affected every one of the facility residents (15 residents), even though not all of the residents have been viewed on video as being affected. The video was not of LN A ' s entire 12-hour shift for either day 5/25/24 or 5/26/24. DON only received a total of six hours of video for both days and in the six hours observed 12 residents who were identified as having been affected. Once all video is retrieved and reviewed every one of the residents will, with certainty, be identified. There was no actual outcome where the residents appeared to have had issues or problems because of the incident. No one had to be transferred to the hospital, we didn ' t have any symptoms that would have inferred problems.

Based on observation, interview, and record review the facility failed to record sanitizing temperatures for the dishwashing machine. This had the potential for staff to not recognize low, non-sanitizing temperatures and spread foodborne illness to residents and cause gastrointestinal (stomach and bowel) illness including nausea, vomiting and diarrhea with the potential for adverse clinical outcomes. Findings: On 12/11/23 at 10:30 AM, a review of the dishwashing temperature logs in the kitchen was conducted with the Certified Dietary Manager (CDM) and the Dishwasher (DW). In October 2023, 9 temperature recordings were missing, in November 2023, 5 temperature recordings were missing, and in December 2023, 2 temperature recordings were missing. The CDM and the DW both confirmed that there were missing temperature recordings on the Dishwasher Temperature Log, and that this could have a negative impact on the health and safety of the residents. On 12/12/23 9:17 AM, during an interview with the CDM she indicated that the dishwashing machine requires heat to sanitize dishes, utensils and various cooking equipment and that it was important for staff to check the temperatures of the dishwater water, and ensure that the dishwasher was running hot enough to sanitize the dishes. The CDM indicated that there was no policy regarding checking the temperatures of the dishwasher.

Based on interview and record review, this requirement was not met when the facility failed to obtain the services of a registered nurse for eight consecutive hours, seven days a week. This had the potential to adversely affect residents' care, which could lead to potential negative clinical outcomes (worsening condition). A review of the facility's Registered Nurse (RN) staffing/schedule documentation from the period of 10/1/23 to 10/31/23 indicated that the RN working as Director of Nursing (DON) was scheduled to work weekdays (Monday through Friday) leaving nine weekend days (10/1, 10/7, 10/8, 10/14, 10/15, 10/21, 10/22, 10/28, and 10/29/23) uncovered during this four-week time period. There were four days (10/26, 10/27, 10/30, and10/31/23) when the DON was on time off. During an interview on 12/12/23 at 3:16 PM, DON confirmed that an RN was not on duty for eight consecutive hours, seven days a week. DON stated, We are a very small town, RNs are difficult to recruit. The position is almost continuously posted, for 5-6 years we have had staffing waivers. DON acknowledged that an RN was available in the acute hospital, through an adjoining hallway, if needed. The facility's Chief Nursing Officer (CNO) requested the federal waiver for RN coverage, indicating a reduction in the required registered nurses' hours from 56 hours a week to 40 hours a week be renewed this year. The facility provided evidence of ongoing advertisements and efforts to fill the open position. The surveyor team found no negative outcomes related to continuing this federal waiver for RN coverage, and recommend that it be continued.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when: Personal staff items were observed in the kitchen area in close proximity to the food preparation area. Food items were not discarded, and labeled properly in the refrigerator and freezers. The ice machine was observed to have a large amount of white substance on the tray below the dispenser. The facility could not provide evidence of when, and how they performed sanitization and descaling of build up visible on the outside of the ice machine. This had the potential for cross contamination and the spread of infection to residents, which could lead to negative clinical outcomes. Findings: During the initial tour of the kitchen, on 10/18/22 at 11:30 am, the following was observed: 1. Staff personal items were observed, in the kitchen by the sink and next to racks of prepared dietary trays for the noon meal. Cook B at this time was observed cooking stew for the noon meal. One purse, backpack and jacket was observed. Also, on a counter next to the stove a personal cell phone, and coffee mug was observed. Dishwasher A acknowledged, that the personal items belonged to staff, and should not be where they were. A review, of the 2017 United States Food and Drug Administration (FDA) Food Code, 3-305.14 under Food Preparation directs that during preparation, unpackaged food shall be protected from all environmental sources of contamination. 2. On 10/18/22 at 11:45 am, the refrigerator was observed with Cook A. A package of brown dried strawberries was observed in the refrigerator with a date of 10/13/22 (five days old), written on the top of the container. On a different shelf in the same refrigerator, an unlabeled cup of fruit salad was observed. Cook A stated at this time that that these items should have been thrown away. The Certified Dietary Manager (CDM) was not available during the initial tour. A review, the facility's policy titled, Dietary Safety Food and Storage, revised 6/29/17, indicated that all left overs are labeled , covered and dated when stored , and are to be used within 72-hours, or discarded. Strawberries are listed good in the refrigerator for three days. Items in the freezer are good for 6 months. On 10/19/22 at 11:25 am, a freezer in the Dry Storage Room was observed with the CDM. The following was observed. An opened box of popsicles, donuts, and ice cream cups. All the items were observed to be without a written date of when they were opened. The ice cream box contained 24 cups, with only eight left in the box. Concurrently, the locked freezer in the hallway by the kitchen was observed with CDM. The following was observed. An opened box of 38 ground beef patties (40 count box). An opened box of 40 count hot dogs, with approximately 20 left in the box. Both boxes failed to have a date of when they were opened. The CDM acknowledged the above findings on 10/19/22 at 11:30 am, stating the items should have been labeled when opened. She stated they usually keep the items in the freezer for 30-days after opening. She stated, that the dietary staff should have noticed the items were not dated when they were used. 3. On 10/19/22 at 11 am, Cook A stated, that the ice machine being used for the residents is now located in the staff break room, as their usual ice machine by the nursing station was removed due to facility repairs. On 10/19/22 at 11:15 am, the ice machine used for the residents in the break room was observed with the CDM. She acknowledged the large amount of white buildup on the outer dispensing tray. The CDM stated, that the Maintenance Department were responsible for cleaning and sanitizing of the machine. A manufacturer's instruction/guideline for the cleaning and sanitization was requested for the Manitowoc ice machine. A review, of the Manitowoc manufacture's instructions showed a handwritten entry indicating that Housekeeping was responsible for cleaning the outer surface of the ice machine in the Break Room daily with disinfectant. On 10/20/22 at 9:15 am, Housekeeper (Hsk) H was interviewed. She stated the outside of the ice machine is cleaned every day with an alcohol CaviWipe. She stated sometimes she will use hot water or a vinegar mixture to clean the mineral build up on the tray under the dispenser. She was unable to tell this surveyor what ratio, or amount of vinegar she used. She stated there was no log to show evidence of routine cleaning to the outside of the ice machine. On 10/20/22 at 10:45 am, the Director of Plant Operations and Safety (DPOS) was interviewed. She acknowledged there was no log for cleaning the outside and descaling the tray of the ice machine. The facility did provide evidence of cleaning and sanitizing the inside of the ice machine per manufacture's recommendations. The inside of the machine was observed at this time with a small amount of white crystal-like builds up on the shoot. DPOS acknowledged descaling should be documented when performed along with daily cleaning/disinfection of the outside of the machine. On 10/20/22 at 11 am, the Housekeeping Supervisor (Hsk Sup) was interviewed. She stated she believed she cleaned the ice machine last week and worked on the buildup on the tray and dispenser. Hsk Sup states she wipes the outer ice machine with a warm wet cloth and a germicidal called Wex-Cide-128. She stated she also uses an unmeasured amount of vinegar to do the descaling, and does not use the manufacturer's descaler. She also stated she does not keep a log of when she cleans/sanitizes or descales the front of the ice machine. On 10/21/22 at 9 am, DPOS confirmed, that the facility failed to have a log for disinfecting the outside of the ice machine daily, and descaling the the tray. She stated it looks bad, but we have hard water up here. A review, of the 2017 FDA Food Code, 1250.28 under Source and Handling of Ice directs that all ice coming in contact with food or drink shall be stored and handled in such a manner as to avoid contamination.

Based on interview, and nursing schedule review, the facility failed to utilize the services of a registered nurse for eight consecutive hours a day, seven days a week. This had the potential to adversely affect resident's care which could lead to potential negative clinical outcomes. Findings: A review, of the facility's Registered Nurse (RN) staffing/schedule documentation from 9/1/22 through 9/30/22, indicated, that the RN working as Director of Nursing (DON), was scheduled to work weekdays leaving 8-weekend days uncovered during this four week time period. During an interview, on 10/19/22 at 10 am, the DON confirmed that an RN was not on duty for eight consecutive hours, seven days a week. The DON was scheduled Monday through Friday, and on the weekend an RN was available in the acute hospital (located in the adjoining hallway) if needed. The facility's Chief Nursing Officer (CNO) requested the federal waiver, indicating a reduction in the required registered nurses hours from 56-hours a week, to 40-hours a week, be renewed this coming year. The facility provided evidence of ongoing advertisements and efforts to fill the open RN position. The surveyor team found no negative outcomes related to continuing this federal flex, and recommended that it be continued.

Based on interview, and record review, the facility failed to prevent abuse for one of three sampled residents (Resident 1) when Resident 1 reported being treated roughly and called names by Certified Nursing Assistant (CNA 1). This failure has the potential for Resident 1 to have increased anxiety and fear, and to lead to negative clinical outcomes. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 received a test of mental status known as a Brief Interview for Mental Status (BIMS) on 3/15/21. Resident 1's score was 8 indicating, she has moderate cognitive impairment. During that interview, Resident 1 was able to recall the correct month, and day of the week, but not the correct year. On 4/7/21 at 4:30 pm, CNA 2 was interviewed regarding the abuse complaint alleged by Resident 1. CNA 2 stated, (Resident 1) complained someone grabbed her arms. I didn't believe so I lifted her sleeves, and asked to see. There were two bruises on each wrist. She wouldn't tell us who did it. CNA 2 reported the suspected abuse to nurses on duty, who then investigated. On 4/7/2021 at 7:45 pm, Licensed Vocational Nurse (LVN) 1 was interviewed, regarding the abuse complaint alleged by Resident 1. LVN 1 related she was told by CNA 2, and went to investigate. LVN 1 stated, .it was like they said. One bruise on each side. The Resident didn't want to talk about it but did say it wasn't anyone here tonight. LVN 1 also stated that after seeing the bruises Resident 1 told her the person, wasn't here tonight but wouldn't say who it was. The only details was that when she said 'ouch' the person said 'don't be such a baby. LVN 1 documented her findings in the resident's records. On 4/7/21 at 8:45 pm, Resident 1 was interviewed in the presence of the Assistant Director of Nursing. Resident 1 was alert, pleasant and willingly discussed the alleged abuse. When questioned Resident 1 replied, Well, she would reach and pull me roughly, and it hurt my arms. I said oww that hurts, and they would tell me that doesn't hurt and don't be such a baby. The resident would not tell the name of the CNA, but did say the person, isn't here any more. On 4/8/21 at 8 am, the Director of Nursing (DON) was interviewed, regarding the alleged abuse of Resident 1. The DON related she investigated and documented statements made by individuals involved. The DON stated, When I got to the name of (CNA 1) she nodded her head, and I asked her if she was sure. She said, 'yes but I didn't say it.' That was how I got her to let me know who it was. The DON reported that CNA 1 was terminated following her investigation into this case.

Based on interview and record review, the facility failed to implement their policy and meet professional standards of practice when nursing staff did not consistently document amounts of intake and output (I&O-what was drank and what body fluids were excreted) for one of three sampled residents (Resident 1), as outlined by the comprehensive plan of care. This failure had the potential to cause Resident 1 to become dehydrated (lacking adequate water in the body) which could have led to other health problems such as weakness or a decrease in blood pressure. Findings: Review of the book titled, Lippincott Manual of Nursing Practice, 11th Edition, dated 2019, indicated Standards of Care Guidelines for Gastrointestinal (digestive tract) Dysfunction (abnormality) in table 18-1. Nurses were to follow these guidelines when caring for residents with any type of gastrointestinal disorder, such as nausea and vomiting. The second of these guidelines directed nurses to monitor (keep track of) food and fluid I & O. Review of the facility policy titled, Fluid Policy for SNF/LT (skilled nursing facility/long-term) Unit, revised 4/30/15, indicated its purpose was to ensure each resident had sufficient fluid intake to prevent dehydration. Residents suspected of insufficient intake would have been placed on I & O and monitored for signs and symptoms of dehydration. Review of Resident 1's clinical record showed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's electronic health record (EHR) showed a nursing note entered on 6/14/19 at 1:47 pm by Licensed Nurse (LN) B indicated Resident 1 had vomited after eating lunch that day. During an interview on 7/11/19 at 1:44 pm, LN B stated that after Resident 1 vomited a second time on 6/14/19, she contacted Registered Nurse (RN) A. Review of the record showed that RN A notified Medical Doctor (M.D.) on 6/14/19 at 5:30 pm via telephone. M.D. ordered medicine to treat nausea to have been given to Resident 1 under the tongue, every six hours as needed. Review of the record showed a nursing note entered on 6/14/19 at 9:25 pm by LN C described how Resident 1 had vomited about 30 cubic centimeters (cc--a unit of measurement for volume), the equivalent of one ounce. Review of the record showed a nursing note entered on 6/15/19 at 5:41 pm by LN D read, Resident had chicken broth for dinner, but no amount was documented. Review of the record showed a nursing note entered on 6/16/19 at 10:25 am by LN E documented Resident 1 was having nausea and vomiting and that clear liquids were encouraged, but no amounts of I & O were noted. During a concurrent interview and record review via secure email on 7/17/19 at 10:04 am, DON confirmed that complete I & O measurements were not recorded for Resident 1 from 6/14/19 to 6/17/19. On 7/24/19 at 8:59 am, the DON confirmed that the facility used Lippincott Manual of Nursing Practice, 11th Edition, as a standard of practice reference.

Based on interview and record review, the facility failed to maintain an atmosphere where residents could openly voice their grievances to the facility, or other agency or entity that hears grievances, without fear of reprisal for two of two sampled residents, Resident 2 and Resident 3. The failure had the potential to result in residents' facility concerns not being heard, going unresolved, and ultimately leading to the creation of an atmosphere which does not seek problem resolution. Findings: The facility policy and procedure, titled, Resident Rights-Exercise of Rights, dated 5/30/19, indicated, The purpose of this policy is to ensure all (facility's name) residents are allowed to exercise their rights without interference, coercion, discrimination or reprisal .The resident has the right to exercise his or her rights as a resident of the facility and as a resident of the United States .The resident has the right to be free of interference .and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. The facility policy and procedure, titled, Resident Right-Resident Contact with External Entities, dated 5/30/19, indicated, A facility will not prohibit or in any way discourage a resident from communicating with federal, state, or local officials, including, but not limited to; federal and state surveyors, other federal or state health department employees . During an confidential facility record review, dated 8/29/19, at 10:25 AM, a Licensed Vocational Nurse (LVN), indicated, This nurse (LVN) went in to a Room to do a dressing . the resident asked me (LVN) to come closely. She told me I am not to tell anyone. I asked her why and she said she cannot say, But I heard that state is coming in for her (Resident 1). I cannot tell you who told me, but you cannot tell anyone . During a concurrent interview with Resident 2 and a Family Member (FM), on 8/29/19, at 10:45 AM, Resident 2 stated that, although she had never officially filed a complaint against the facility, she was concerned about the possibility of retaliation if she were to complain. The FM stated four staff members (FM would not provide their names) approached her to inquire when she was going to file a complaint with the State on their behalf regarding an allegedly disruptive resident since they themselves were concerned about approaching facility management for fear of reprisal. FM also stated she was informed by a staff member (declined to give her name) that a nurse who questioned Resident 1's suitability for being at the facility was shortly thereafter removed from her position. FM stated the nurse who disclosed this information to her was told not discuss what had happened with anyone else. Resident 2's SNF (Skilled Nursing Facility) Progress Note, dated 9/17/19, at 12:56 PM, indicated, I (Physician), suggested to her spouse (FM) . that she (Resident 2) consider noise blocking headphones but (Resident 2) stated she would not wear them. During an interview on 11/25/19, at 11:15 AM, with Resident 3, Resident 3 stated Resident 1's behavior had not changed since this surveyor last visited the facility during August, 2019. She stated Resident 1 still vocalizes loudly, usually on a daily basis, and frequently at night. She stated facility staff transport Resident 1 out to the hallway (by wheelchair) and this tends to calm her. Resident 3 stated Resident 1's behavior upsets her and she opts to stay in her room when Resident 1 is removed out to the hallway since this gives her quiet time and she can watch the news on television. During an interview on 8/29/19, at 2:58 PM, with a Certified Nursing Assistant (CNA), she stated other CNAs have not pushed to have Resident 1 transferred to a different facility since they feel intimidated and are concerned about the potential for facility retaliation. During an interview on 11/25/19, at 1:45 PM, with the AD, AD stated that she and other staff members previously were asked why they had entered unfavorable comments into residents' reports; staff were subsequently asked to remove the negative comments. AD stated she and other staff agreed to remove negative comments from residents' charts over concern for facility reprisal. AD stated that acting as a Social Worker was one of the many roles she performed at the facility. AD stated as a social worker there would be negative commentary in residents' charts and that this was expected.

Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment when a comfortable sound level encouraging resident interaction was not consistently maintained for two of two sampled residents, Resident 2 and Resident 3. This failure resulted in the inability of the facility's residents to shield themselves from unwanted noise and discouraged social interaction amongst residents and between residents and family members. Findings: The facility policy and procedure, titled, Resident Right-Safe, Clean, Comfortable, Homelike Environment, dated 5/30/19, indicated an aspect of this policy includes .the maintenance of comfortable sound levels. The facility policy and procedure, titled, Resident Right-Reasonable Accommodations of Needs and Preferences, dated 5/30/19, indicated, The resident has the right to reside and receive services in the facility with reasonable accommodation of resident .preferences . The facility policy and procedure, titled, Implementation of Patients' Bill of Rights, revised 9/22/16, indicated, Individuals who have a history of .disturbing others will not be admitted to the facility .Individuals who .disturb others while in the facility will not be retained in the facility .All patients (residents) must consider the rights of other patients at all times. It shall be the responsibility of Administration to insure that all patients' rights are protected. During a review of the facility's Record of Admission, (undated), the Record of Admission indicated, Resident 1 was re-admitted to the facility on [DATE]. During a review of the MDS (Minimum Data Set - resident assessment tool used by facilities), dated 5/14/19, the MDS indicated Resident 1 had [DIAGNOSES REDACTED]. Resident 1 was unable to make healthcare decisions for herself. During a clinical record review of Resident 1's Care Area Assessment and Interdisciplinary Team Focus Summary Statements, (CAAIDT- helps to identify critical areas concerning a resident's health which need special attention by a diverse group of health care professionals from various fields), dated 8/6/19-8/12/19, the CAAIDT indicated Resident 1's BIM score was 5 and included Behavioral Symptoms totaling seven crying episodes, four yelling episodes, three agitation episodes, and 6 episodes of talking in the third person during this seven-day period. Resident 1's [MEDICAL CONDITION] (drug that changes brain function and results in alterations in perception, mood, consciousness, cognition, or behavior) medications included [MEDICATION NAME] ([MEDICATION NAME]) 1 mg (milligram) QHS (at bedtime) and 2 mg QD (daily) for [MEDICAL CONDITION]. During a clinical record review of Resident 1's Care Plan (undated), the Care Plan indicated, CP (Care Plan) #2: Cognitive function mildly impaired as evidenced by short term memory loss, a corresponding goal to make her own decisions independently and establish her own goals, and an approach which allowed Resident 1 to make her own decisions about (her) treatment regime in order to provide a sense of control. During a review of Resident 1's Interdisciplinary Care Conference (ICC) record, dated 8/14/19, there was no indication Resident 1's CP #2, which focused on Resident 1's cognitive decline followed by corresponding nursing interventions, had been addressed. During a clinical record review of Resident 1's Patient Progress Notes (PPN), dated 8/2019, the PPNs indicated the following: 8/13/19, at 1:20 PM, under Social Services Notes, indicated, During look back period (the time period over which a resident's condition or status is viewed, usually seven days) resident (Resident 1) has 7 episodes of crying, 4 episodes of yelling, talking loudly X8 (8 times), agitated X3. Resident striked at another resident X1. 8/13/19, at 3:07 PM, under C.N.[NAME] (Certified Nursing Assistant) Notes, indicated, Resident is yelling out in 3rd person, staff is taking turns trying to come (calm) her down. 8/18/19, at 8:55 AM, under Activity Coordinator Notes (ACN), indicated, .resident started talking in third person. Activities talked with resident and offered music .Activities offered coloring supplies to resident. Resident colored for about 5 minutes crying and talking to herself. 8/18/19, at 9:45 AM, under ACN, indicated, Resident was getting very loud in dining room. 8/18/19, at 1:02 PM, under Nursing Notes (NN), indicated, Resident is crying out after lunch. She stated she wanted to take a nap but continues to cry out in gerichair (large, comfortable reclining chair) get me out of here. 8/19/19, at 1:31 PM, under ACN, indicated, Note; offered resident book on tape. Resident got very upset once they started reading. She stated, turn it off, I don't want to hear this over and over. 8/20/19, at 6:47 PM, under NN, indicated, Resident (Resident 1) napped until around 1630 (4:30 PM). Once awake she almost immediately started crying out and needed one on one redirection .I got her sat comfortably but she keeps crying out (Resident 1) what do you want? and spelling out words. Redirection only works with one on one so we (staff) will take turns redirecting. 8/20/19, at 10:47 PM, under NN, indicated, (Resident 1) Was sitting in recliner in hall at shift change calling out to herself and spelling words loudly. Other res (residents) were getting upset. During a concurrent interview on 8/29/19, at 10:45 AM, with Resident 2 and Family Member (FM), who stated the previous (facility) manager said Resident 1 needed a higher level of care. FM stated she has observed Resident 1 speaking loudly to herself for upwards of an hour and a half so that other facility residents can hear her and goes on and on. Resident 2 stated she closes her room door since Resident 1's loud voice is disruptive. FM stated CNAs spent upwards of one-and-a-half hours calming Resident 1 and this affected the quality of care given to other residents. FM and Resident 2 stated that facility staff members have even approached them regarding their time spent with Resident 1. FM stated four staff members had approached her and asked when she was going to issue a noise-related complaint with the State over Resident 1's disruptive behavior since they themselves were concerned the facility would retaliate if they spoke openly. During an interview, on 8/29/19, at 12:10 PM, with Resident 3, Resident 3 was awake and alert, sitting upright in her bed, eating her lunch. Resident 3 stated, reluctantly and hesitatingly, that Resident 1 is troubled, although she has never been aggressive towards her. Resident 3 stated that approximately two weeks ago she was visiting with Resident 2 in Resident 1 and Resident 3's room. Unprovoked, Resident 1 told Resident 2 to Get out of my room, for no apparent reason. During an observation on 8/29/19, at 12:15 PM, in the dining area, Resident 1 was well-groomed, dressed, sitting in a wheelchair, and feeding herself without issue. Resident 1 did not acknowledge this surveyor's presence despite standing right next to her. During a concurrent observation and interview with Resident 1 in her room, on 8/29/19, at 12:30 PM, Resident 1 was awake and alert, seated in a wheelchair situated next to her bed. Resident 1 stated she had lived at the facility for approximately [AGE] years. Resident 2's SNF Progress Note, dated 8/29/19, at 2:30 PM, indicated, (Resident 2) has been unhappy with a fell ow resident (Resident 1) who talks to herself constantly .She (Resident 2) may need to wear noise canceling headphones. During an interview with a Certified Nursing Assistant (CNA), on 8/29/19, at 2:58 PM, CNA stated that attending to Resident 1 requires significant one to one time which made it hard for her to focus on her other residents. CNA confirmed Resident 1 was, at times, loud and disruptive at night. She stated Resident 1 is a sweetheart, although she screams, hollers, and disrupts other residents and so therefore is probably not a good fit at the facility. CNA 1 stated she and other staff members agreed Resident 1 should probably not have been there (at the facility). Resident 2's SNF (Skilled Nursing Facility) Progress Note, dated 9/17/19, at 12:56 PM, indicated, I (Physician), suggested to her spouse (FM) . that she (Resident 2) consider noise blocking headphones but (Resident 2) stated she would not wear them. During an interview on 11/25/19, at 11:15 AM, with Resident 3, Resident 3 stated Resident 1's behavior had not changed since this surveyor last visited the facility during August, 2019. She stated Resident 1 still vocalizes loudly, usually on a daily basis, and frequently at night. She stated facility staff transport Resident 1 out to the hallway (by wheelchair) and this tends to calm her. Resident 3 stated Resident 1's behavior upsets her and she opts to stay in her room when Resident 1 is removed out to the hallway since this gives her quiet time and she can watch the news on television. During an interview on 11/25/19, at 12:23 PM, with the Activities Director (AD), AD stated Resident 1 required a lot of one-to-one attention. AD stated she had utilized the Trauma-Informed Care (TIC- involves treating the whole person, taking into account past trauma and the resulting coping mechanisms when attempting to understand behaviors and treat the patient) treatment model and other approaches when working with Resident 1, although was mostly unsuccessful, lamenting that really no approach had worked. During an interview on 11/25/19, at 1:45 PM, with the AD, AD stated Resident 1 had auditory hallucinations and so it was hard to implement workable interventions. AD stated, It is hard to bring her (Resident 1) back to reality. During an interview on 11/25/19, at 1:45 PM, with the AD, AD stated different interventions to quiet Resident 1 were not successful. She stated putting Resident 1 in a geri-chair sometimes worked, although this intervention was hit and miss .(and) you never know what's going to work. AD stated she was told by the current Director of Nursing (DON) that if visitors to Resident 1 and Resident 3's room were disrupted by Resident 1, then the visitor or Resident 3 should seek out a different facility.