Every finding on record at Sequoias San Francisco Convalescent Hospital

Based on observation, interview, and facility document review, the facility failed to ensure food contact surfaces of equipment were clean and/or in good repair including:Cutting boards;Muffin pans;Bulk-food bins;Industrial can opener;Ice machines; andItems such as cooking utensils/equipment stored in the dish room (room where equipment/utensils are washed and sanitized and stored before use) when pests were present.The failure to maintain food-contact equipment clean and/or in good repair, had the potential to result in contamination of food leading to food borne illness for 39 residents who received food from the kitchen out of a census of 39. Findings:According to the 2022 Federal Food Code standards of practice, multi-use food-contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Food-contact surfaces of equipment and utensils shall be clean to sight and touch. Food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Cutting surfaces such as cutting boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized or discarded if they are not capable of being resurfaced. Food shall only contact surfaces of equipment and utensils that are cleaned and sanitized. Equipment food-contact surfaces and utensils shall be cleaned at any time during the operation when contamination may have occurred.An observation and interview in the kitchen and interview on 2/9/26 at 10:32 a.m., showed 21 cutting boards stored on a metal rack used for cleaned pots, pans, and other cleaned equipment and utensils located in the dishmachine room. Each of the cutting boards were significantly scored (scratched/notched), with imbedded black and/or yellow residue imbedded in in the cutting board surfaces, and with pieces of surface coating flaking off. When asked at what point the cutting boards are replaced, V1DD stated the cutting boards had to be replaced at some point. An observation and interview in the kitchen on 2/10/26 at 3:55 p.m., showed one long, white cutting board attached to the top of a sandwich refrigerator, and another long white cutting board on top of a metal cart, both located in a food preparation/tray-line food service area. Both cutting boards were significantly scored and had black residue embedded in the surface. V1EC confirmed the cutting boards were scored and discolored and were not clean to sight.2. An observation and interview on 2/9/26 at 10:40 a.m., showed three metal muffin pans stored on a metal rack used for cleaned pots, pans, and other cleaned equipment and utensils located in the dishmachine room. Each of the muffin pans had yellow and dark brown, dried residue that resembled food residue build-up on the top surface of the pans. V1DD confirmed there was residue build-up on the cleaned pans.3. An observation and interview in the kitchen on 2/10/26 at 2:34 p.m., showed bulk-food bins stored under a food preparation table. Three of the bins which held, food thickener, flour, and brown rice had brown, yellow, and orange spots of residue on the inside surface. When the residue inside the binds was wiped with a damp towel, the residue transferred to the towel. V1RDNW stated the bins should be cleaned before they were filled and if they became soiled after they were filled, any food contents should be discarded and the binds cleaned before refilling again.4. An observation and interview in the kitchen on 2/10/26 at 3:50 p.m., showed an industrial can opener held in a base plate attached to a food preparation table. There was rough, light gray matter on the surface of the can opener blade. In addition, there was dried, brown residue on the surface of the base plate and imbedded in the seam where the plate came into contact with the table. V1EC confirmed the can opener blade was not clean and the can opener was to be cleaned after each use. V1EC also confirmed there was residue on the base plate.5. During an observation and interview in the kitchen on 2/11/26 at 3:16 p.m., the top of the ice machine, was opened. The cover over the evaporator plate (a metal grid where water pours over and freezes to make ice cubes) had pink and yellow residue on the surface that faced the evaporator plate. In addition, there was pink residue on the plastic frame above the evaporator plate. There were also two patches of a sticky, rough residue on the plastic surface just above the ice bin (where the ice cubes are stored). V1DD and V1EC confirmed the residue inside the ice machine and stated ice machine cleaning was performed quarterly by an outside vendor and the last cleaning was in December 2025. V1EC stated there was no monitoring for cleanliness between services. An observation on 2/11/26 at 3:56 p.m., showed an ice machine in the facility nourishment next to the activity room. There was yellow residue on the inside surface along the top frame of the evaporator plate, and inside the plastic trough tray below the evaporator plate. V1 Director of Dining Services Support (DDS) from another affiliated facility confirmed there was yellow residue inside the ice machine. V1DDS stated he did not think the parts could be removed for cleaning. Review of the ice machine manufacturer's manual for the ice machine located in the facility nourishment room titled [Manufacturer name] UnderCounter Ice Machines QM30 Models Installation, Operation and Maintenance manual dated 2014, showed directions for cleaning the ice machine. The directions showed how to clean and sanitize the ice machine and how to remove lime scale (a hard, off-white/yellow deposit that builds up on fixtures and appliances due to hard water) build-up. The steps showed how to remove the water trough tray for cleaning and how to clean the evaporator plastic parts.6. During an interview in the kitchen on 2/9/26 at 12:21 PM., V1DD stated he could not say all utensils and equipment stored on dish room racks were clean because of the presence of cockroaches (Cross-reference F925). During a concurrent observation and interview on 2/9/26 at 12:36 PM with Vendor 1 Sous Chef (V1SC) in the kitchen, V1SC was observed taking a black skillet pan from the kitchen dish room and went to lite stovetop and poured a white liquid into pan. V1SC stated he was cooking an item for a resident and reported dishware (pots, pans, equipment) in dish room were considered already clean. No additional cleaning or sanitization was observed prior to use of pan, despite several cockroaches being observed in the dish room area.

Based on observation and interview, the facility failed to ensureUsed fat/oil drained from cooking equipment was covered and was discarded to prevent attraction of pests (Cross reference F925). the lids to outside compost and recycle dumpsters were closed.This failure had the potential to attract pests resulting in contamination of food and/or utensils used for eating for 39 residents who received food from the kitchen out of a census of 39. Findings:According to the 2022 Federal Food Code, the standard of practice is receptacles used for refuse inside the food establishment shall be covered when containing food residue and are not in continuous use. Refuse shall be removed from the premises at a frequency to minimize conditions that attract or harbor insects and rodents. Proper storage and disposal of refuse are necessary to prevent waste from becoming an attractant and harborage or breeding place for insects and rodents. Improperly handled refuse creates nuisance conditions such as making housekeeping difficult. Observations, interviews, and document review confirmed German Cockroach and rodent activity in the kitchen during the survey from 2/9/26-2/13/26 (Cross-reference F925).During a concurrent observation in the kitchen and interview on 2/9/26 at 10:33 AM with V1DD, showed an uncovered, large pot, 50% filled with black liquid with particles floating stored on floor under 3-compartment sink. There was brown, greasy in appearance, liquid drips down the outside surface of the pot. V1DD verified contents in the pot were used grease/oil from cooking and the contents was dumped daily.During an interview on 2/10/26 at 4:06 p.m., V1DD stated the pot of cooking grease under the 3-compartment sink, was not dumped at the end of the night (on 2/8/26) so the pot filled with grease was out overnight. V1DD stated the pot of grease should be discarded after each meal service.According to the 2022 Federal Food Code, the standard of practice is to keep outside receptacles and waste handling units for refuse, recyclables, and returnables, covered with tight fitting lids. An observation on 2/13/26 at 4:52 p.m., showed two dumpsters with lids open located at the loading dock area. The compost dumpster was filled with bags of food waste, and the recycle dumpster was filled with recyclables including opened food cans with food residue inside the cans. In a concurrent interview on 2/13/26 at 4:52 p.m., Vendor 1 Executive Chef (V1EC) stated the dumpster lids should be closed because there was the risk of attracting pests. V1EC explained different departments used the dumpsters, but if kitchen staff noticed the lids open, they should close the lids. During a phone interview on 2/17/26 at 12:23 p.m., Vendor 2 Pest Control Market Manager (V2PCMM) stated if pests entered the building, they would find hiding places and eventually find their way to food sources. V2PCMM confirmed there were recent pest sightings in the building and kitchen (Cross-reference F925)

Based on interview and document review, the facility failed to ensure there was an effective, comprehensive, data-driven quality assurance and performance improvement (QAPI) program that included the Food and Nutrition Services (FANS) Department. This failure had the potential to result in not identifying issues and making system improvements in the FANS department eventually leading to contamination of food, food borne illness, and/or decreased quality of food for 39 residents who received food from the kitchen out of a census of 39.Review of the policy and procedure titled Leadership - Interrelationships of Qualified Dietitian and Directo of Dining date of revision 1/2026, showed the Qualified Dietitian meets on a regular basis with the Food and Nutrition department, at a monthly minimum. The Qualified Dietitian reviews all aspects of the operation and service components to include but not limited to food safety and sanitation, QAPI program and survey readiness. The Qualified Dietitian maintains a written record of the above activities. Review of the Policy and Procedure (P&P) titled Quality Assurance and Performance Improvement Plan reviewed 1/2022, showed the Sequia Living approach to quality improvement starts with identifying areas of performance that are most essential to effective and efficient service delivery. Then, valid quality indicators are selected, evidence based practices are applied to achieve goals, and data are accurately collected. Once the data are appropriately analyzed, decision makers have the information they need to accurately paint a picture of achieved progress, and to make adjustments if needed. For each quality measure selected, measurable performance targets are established; employees are instructed how to reliably, accurately, and completely collect data. The P&P showed the QAPI committee included Food Services. Each department reports at least quarterly. Based on evidence presented, the QAPI committee recommends new quality improvement initiatives. A performance tracking tool will be provided to reflect the QAPI plan. The tracking tool will be submitted monthly. During the recertification survey from 2/9/26 to 2/17/26, the facility identified multiple issues in the kitchen concerning pests (cross-reference F925), cleanliness and sanitation (cross-reference F812, F921), and maintenance of equipment (cross-reference F908). During an interview on 2/9/26 at 9:48 a.m., Vendor 1 Registered Dietitian (V1RD) stated she was the full-time RD, and her main focus was the skilled nursing facility (SNF). V1RD stated she was responsible for completing audits in the kitchen and also watched trayline food service. During an interview on 2/12/26 at 1:17 p.m., V1DD stated a Dining Safety Assessment, which he said was a sanitation audit, was completed once a month, but not necessarily in the kitchen each month. V1DD stated the audit was completed in the kitchen at least quarterly and when the kitchen was audited, all areas in the kitchen were observed, including behind equipment and counters. V1DD explained the last audit for the kitchen was conducted on 1/30/26 and said he did not check all areas thoroughly or in depth. During an interview on 2/13/26 at 10:02 a.m., V1RD stated food safety and sanitation audits for the kitchen were done quarterly and she also did monthly trayline audits. During an interview on 2/13/26 at 11:50 a.m., V1RD stated she completed quarterly sanitation audits in the kitchen. V1RD stated she looked for anything that needed to be fixed in the kitchen as well as cleanliness and sanitation. V1RD stated she thought the audits should be done more frequently, at least once a month, and stated she needed to be more thorough including observing under and behind equipment. V1RD stated she had a kitchen safety and sanitation QAPI project ongoing for the past three years. When V1RD was asked for documentation for the QAPI project including data, V1RD stated there was not a strategy developed for improving any identified issues and there was no data to track improvement. V1RD stated the kitchen safety and sanitation QAPI project was not quantifiable. Then V1RD explained for quarterly QAPI meetings she provided her audits as well as the audits V1DD completed.

Based on observation, interview, and facility document review, the facility failed to ensure sanitary environmental conditions in the kitchen and nourishment room when:Walk-in cooler floors, kitchen tile floor, baseboards were not in good repair and were not clean;Ceiling was not in good repair and not clean;Walls were not in good repair and/or not clean;Vents and fans were not clean;Metal storage racks were not clean;A metal rolling cart was not clean;Caulking (a flexible sealant used to fill gaps) for the 3-comapartment sink (used for cleaning pots and pans) and a walk-in freezer door was not in good repair and/or not clean, and the door gasket for a walk-in refrigerator door was not in good repair;The outer surface of a drainpipe under the 3-compartment sink was not clean;Equipment wheels were not clean;Conduit, electrical boxes were not clean;Sprinkler head in the walk-in refrigerator was not clean;There were rodent droppings in a nourishment room and throughout the kitchen food preparation and food storage areas (Cross-reference F925); andThe dish room floor was very wet throughout the day when cockroaches were present (Cross-reference F908 and F925); andThese failures had the potential to provide harborage for pests and/or contaminate equipment and/or food containers leading to contamination of food and/or utensils used for eating for a 39 residents out of a census of 39.Findings:According to the 2022 Federal Food Code standards of practice, physical facilities are to be cleaned as often as necessary to keep them clean. Floor, wall, and ceiling surfaces under conditions of normal use are to be smooth, durable, and easily cleanable. In kitchen areas that are cleaned by methods other than water flushing, floor and wall junctures are to be coved (concave or arched transition between call and floor, designed for ease of cleaning) and closed no larger than 1 millimeter (mm). Intake and exhaust air ducts are to be cleaned so they are not a source of contamination by dust, dirt, and other materials. Plumbing fixtures are to be cleaned as often as necessary to keep them clean. Non-food contact surfaces are to be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. In addition, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. Non-food surfaces of equipment are to be kept free from an accumulation of dust, dirt, food residue, and other debris, and are to be cleaned at a frequency necessary to preclude accumulation of soil residues. Equipment shall be maintained in a state of repair. Review of the policy and procedure titled Leadership - Interrelationships of Qualified Dietitian and Directo of Dining date of revision 1/2026, showed the Qualified Dietitian meets on a regular basis with the Food and Nutrition department, at a monthly minimum. The Qualified Dietitian reviews all aspects of the operation and service components to include but not limited to food safety and sanitation. The Qualified Dietitian maintains a written record of the above activities. Review of the job description titled Director of Dining Services signed by Vendor 1 Director of Dining Services (V1DD) on 1/2/25, showed the Director of Dining Services was responsible for the day-to-day foodservice operations. Key responsibilities included but were not limited to directing and conducting safety, sanitation and maintenance programs.Review of the policy and procedure titled Safety and Equipment Maintenance date revised 1/2026, showed proper maintenance of the physical plant and all equipment in the Department is the responsibility of the Director in cooperation with the Maintenance Department.During an interview on 2/17/26 at 10:35 a.m., the Administrator (Admin) stated Vendor 1(V1), a contracted service, ran the kitchen operation. Admin stated it was the facility's responsibility to ensure kitchen tasks regarding safety and sanitation, were being done. Admin explained Vendor 1 Registered Dietitian (V1RD) and Vendor 1 Director of Dining Services (V1DD) were the experts for monitoring safety and sanitation in the kitchen, however, audits conducted for kitchen safety and sanitation were not submitted to him.During an interview on 2/12/26 at 1:17 p.m., V1DD stated a Dining Safety Assessment, which he said was a sanitation audit, was completed once a month, but not necessarily in the kitchen each month. V1DD stated the audit was completed in the kitchen at least quarterly and when the kitchen was audited, all areas in the kitchen were observed, including behind equipment and counters. V1DD explained the last audit for the kitchen was conducted on 1/30/26 and said he did not check all areas thoroughly or in depth. V1DD explained he did not document the condition of the ceilings, dusty fans or vents. V1DD stated there was also a daily audit completed and it was not an in depth audit. V1DD explained that there are contracted vendors who clean the kitchen, there are contractors hired by V2 and contractors hired by the building administration. V1DD stated he was responsible for monitoring the work of all the contractors for the kitchen. V1DD explained if something needed maintenance, he reported it to the building Maintenance Manager (MM).During an interview on 2/13/26 at 11:50 a.m., V1RD stated she completed quarterly sanitation audits in the kitchen. V1RD stated she looked for anything that needed to be fixed in the kitchen as well as cleanliness and sanitation. V1RD stated she thought the audits should be done more frequently, at least once a month, and stated she needed to be more thorough including observing under and behind equipment. V1RD showed she documented spots and splatter on ceiling on 5/7/25 but did not document the condition of the ceiling on 11/4/25. V1DM showed on her 11/4/25 audit, debris on the refrigerator floor and racks was documented, but she did not document things such as gaps in the freezer floor. During an interview on 2/13/26 at 2:06 p.m., MM stated he only went into the kitchen upon request from V2 staff. Observations and interviews in the kitchen on 2/10/26 starting at 3:15 p.m., showed two walk-in refrigerators and one walk-in freezer along one wall. In walk-in refrigerator 1 there was dark brown and yellow residue build-up along edges of the metal floor. The metal floor did not reach the baseboard at one side of the refrigerator with up to a one inch gap between the floor and the baseboard. There was small debris build-up in the floor gap. The metal floor was raised in some areas, creating gaps along the floor surface. The metal baseboard was pulled away from the wall in some areas creating gaps between the wall and the baseboard. The V1 Regional Director of Nutrition and Wellness (RDNW) and Vendor 1 Executive Chef (V1EC) confirmed there were gaps in the floor with residue and small debris build-up. Observations and interviews in the kitchen on 2/10/26 starting at 3:32 p.m., showed metal floor panels in walk-in refrigerator 2 were not flush with the floor and there were gaps between the floor and the metal floor panels. There was brown residue on the floor, mainly along the walls and also on the metal baseboard. V1EC confirmed all residue inside refrigerator number 2. Observations and interviews in the kitchen on 2/10/26 starting at 3:44 p.m., showed dried, expanded foam along the floor surface in walk-in freezer number 3. Like refrigerator number 1 and 2, the floor was uneven with gaps between the metal floor panels and the floor. V1RDNW confirmed the floor in the freezer was uneven.Observations and interviews in the kitchen on 2/10/26 at 3:46 p.m., showed the floor just outside freezer 2, had broken tiles and missing grout along where the kitchen floor tile met the metal flooring of the freezer. There was small particle build-up in the gap between the freezer metal floor and the kitchen tile floor. Along the tile floor just to the side of the freezer was a metal baseboard. There was white, jagged caulking along the seam where the baseboard met the tile floor. What appeared to be older caulking under the newer white caulking, was visible and had black residue imbedded into the surface. Pieces of caulking were broken off and scattered around the floor. V1RDNW confirmed there was missing grout between the freezer and kitchen tile floor with particle build-up in the flooring gap. V1EC confirmed there missing caulking, cracked tiles, and jagged caulking on the floor outside of the freezer.An observation in the kitchen and concurrent interview on 2/13/26 at 4:35 p.m., showed the surface of the baseboard between the floor and the wall adjacent to the service elevator, was cracked, and significantly chipped, with jagged edges. The baseboard also had dark brown residue along the surface. V1DD stated the baseboard needed to be repaired but was not reported to maintenance.2. During the initial tour of the kitchen, observations and concurrent interviews on 2/9/26 at 10:19 a.m., showed the ceiling throughout the kitchen was covered with two by four foot ceiling panels connected with a grid framework. Panels, especially closer to, and inside the dish room (the room where items such as utensils, dishes, pots, and pans were cleaned using equipment such as the dishmachine machine, the three-compartment sink, and/or the pot/pan sanitizer machine; and where the cleaned items were dried on racks and/or stored on racks until use) were discolored and had brown, spattered residue, and/or black fuzzy residue on the surface. In addition, the grid framework was bent in areas throughout the kitchen, which made gaps in the ceiling. V1 Registered Dietitian (RD) stated she was aware of the condition of the ceiling and it's been noted before to the responsible parties. It takes quite a long time to get them fixed. When V1RD was asked if the condition of the ceiling was reported in Sanitation audits, V1RD stated she did not remember when she last documented ceiling on her quarterly food safety audit. V1RD said it was likely within 12 months, but she was unsure she documented the condition of the ceiling on each audit. 3. During an observation and interview on 2/10/26 at 3:47 p.m., there was a missing tile behind a food storage rack and a visible hole in the wall at least a half-inch wide. V1DD and V1EC confirmed the hole in the wall. V1DD stated the hole in the wall could be an entry point for pests.4. During the initial tour of the kitchen, observations and concurrent interviews on 2/9/26 at 10:19 a.m., showed black residue on the surface surrounding ceiling vents located throughout the kitchen. V1DD stated the vents were dusty. As the initial tour continued and observations and interviews were conducted on 2/9/26 at 10:43 a.m., there was dark, fuzzy matter on the surface of the fan guard of a fan in operation, attached to the wall above the clean side of the dish machine. In addition, there was a wall vent above the clean side of the dishmachine with a dark, fuzzy substance across the surface. V1DD stated the fan and the vent were dusty. An observation and concurrent interview in the kitchen on 2/10/26 at 2:58 p.m., showed a vent located in the dry food storeroom above a rack that stored cans of food. The vent had black residue in between the vent slats. Black chunks of residue, as well as orange residue were on the surface of the food rack, just under the vent. V1DD confirmed there was black and orange residue on the food rack and stated it was likely from the vent above. The vent was wiped with a paper towel, and chunks of black residue fell out.5. An observation and interview in the kitchen on 2/10/26 at 3:39 p.m., showed a metal storage rack against the wall between walk-in refrigerator 1 and 2. The rack held items such as shelf stable food. There was brown, sticky residue and a gray fuzzy matter throughout the rack surface. V1EC confirmed residue on the rack surface. An observation and interview in the kitchen on 2/10/26 at 3:44 p.m., showed Another tall, metal storage rack was located against the adjacent wall right next to walk-in freezer 3. The rack surface was covered with white, and brown rough residue. V1EC confirmed the residue on rack and stated it needed to be cleaned. 6. During the initial tour of the kitchen, an observation and interview on 2/9/26 at 10:41 a.m., a metal cart stored next to the 3-comp sink had dark brown and beige residue build-up throughout the surface of the cart. V1DD stated the cart did not look like it was cleaned recently. 7. During the initial tour of the kitchen, an observation and interview on 2/9/26 at 10:29 a.m., showed a three-compartment (3-comp) sink with caulking between the sink and the backsplash. The edges of the caulking were peeled away from the surface and had jagged, rough edges. The caulking also had black residue along the surface. V1DD stated the caulking between the 3-comp sink and the backsplash was not good. An observation and interview in the kitchen on 2/10/26 at 3:37 p.m., showed the door of the refrigerator had silver caulking, that was jagged and partially detached from the door. The rubber door gasket (a seal strip designed to seal the door when closed to keep cold air in and warm air out) was detached from the door at one top corner. There was also dark, brown residue on the refrigerator door frame. V1EC confirmed the residue on the door of refrigerator. V1EC also stated he did not see the purpose of the silver caulking on the door, and it should be removed. 8. An observation and interview on 2/9/26 at 12:21 p.m., showed thick, dark brown, residue on the surfaces of drainpipes under the 3-comp sink. V1EC confirmed residue build-up on the drainpipes. 9. An observation and interview in the kitchen on 2/10/26 at 3:59 p.m., showed two deep fryers with yellow and black residue build-up on the wheels and wheel fixtures. V1EC stated the wheels did not look they had been cleaned and needed to be cleaned. An observation and interview in the kitchen on 2/10/26 at 3:20 p.m., showed the wheels and wheel fixtures on rolling food carts located in walk-in refrigerator 1, had brown grime build-up on the surfaces. V1EC stated the food cart wheels and fixtures needed to be cleaned due to residue build-up. 10. An observation and interview in the kitchen on 2/10/26 at 2:42 p.m., showed an area behind a large mixer with a gray fuzzy substance on conduit, a large plug plugged into an outlet with a significant amount of gray substance on the surface, and an outlet box with brown residue build-up, and particles resembling food crumbs on the surface. V1EC stated the area behind the mixer was not clean.11. An observation and interview in the kitchen on 2/10/26 at 3:35 p.m., showed black, fuzzy matter on a ceiling sprinkler fixture and on the ceiling around the fixture. V1EC confirmed there was residue build-up on and around the sprinkler fixture.12. Observations and concurrent interviews from 2/9/26 to 2/13/26 showed black pellets with tapered ends, the size of grains of rice which V1EC confirmed as rodent droppings on 2/9/26 at 12:08 p.m., on surfaces in the kitchen and nourishment room. The observations and interviews were as follows: on 2/9/26 at 12:08 p.m., in the dry food storeroom, confirmed be V1EC; 2/9/26 at 12:18 p.m., in a food preparation area, confirmed by V1EC; 2/9/26 at 1:31 p.m., behind a reach-in refrigerator in a nourishment room, confirmed by Utility Maintenance Staff 1(UM1); 2/10/26 at 2:36 p.m., behind reach-in refrigerator number 5, confirmed by V1EC; 2/10/26 at 3:14 p.m., under a metal, food storage rack next to walk in refrigerator number 1, confirmed by V1EC; on 2/10/26 at 3:47 p.m., under a food storage rack next to walk-in freezer number 3, confirmed by V1DD and V1EC, on 2/13/26 at 4:24 p.m., on top of a box of food stored on a rack in the dry food storage room, confirmed by V1DD; and on 2/13/26 at 5:07 p.m., on top of standing refrigerator number 6 showed rodent droppings in kitchen areas, confirmed by V1DD. (Cross-reference F925).13. An observation in the kitchen on 2/9/26 at 10:45 a.m., cockroaches in the dish room on the floor, walls, dishmachine, and dishmachine racks (Cross-reference F925). The floor surface throughout the dish room was very wet.An observation and interview in the kitchen on 2/9/26 at 12:21 p.m., showed areas around the dishmachine leaked while the dishmachine was in use. The leaks were confirmed by V1EC (Cross-reference F908).During an interview on 2/13/26 at 11:50 a.m., VIRD stated she saw a lot of water on the floor in the dish room but stated she just saw a lot of water on the floor and did not know the dishmachine leaked. During an interview on 2/13/26 at 5:07 p.m., V1 Director of Dining Services (DD) stated the dishmachine was leaking for a long time.During an interview on 2/17/2026 at 12:22 PM, Vendor 2 Pest Control Market Manager (V2PCMM) stated V2PCMM kitchen staff were not keeping the kitchen dry for V2's pest control standards.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program free of cockroaches and rodents: Multiple German cockroaches of varying sizes were found in the kitchen dish room. Rodent activity was found including a live mouse inside the kitchen, one live mouse in the atrium dining area, and rodent droppings throughout the kitchen. Rodent droppings were observed in the Health Center's (Skilled Nursing Facility) nourishment room (space designed for storing, preparing, and serving snacks, beverages, or light meals). Entry points/structural issues for rodents were not addressed. The facility did not address pest activity in a timely manner, and did not review all pest reports, including recommendations, provided by the pest control company. These failures led to 39 medically compromised residents who received food from the kitchen, out of a census of 39, being exposed to potential food contaminants that could cause food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), infection, or death. On 2/9/26 at 5:01 PM an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has cause, or it is likely to cause, serious injury, harm, impairment, or death to a resident) under Federal tag F925 was declared with the Administrator, Vendor 1 Director of Dining Services, Vendor 1 Registered Dietitian, and MDS Coordinator regarding the following identified concerns: Multiple cockroaches of varying sizes were found in the dish room. Additionally, rodent droppings were observed in several locations throughout the kitchen, and one mouse was found in dry storage area. The presence of pests had the potential to spread infection and food borne illnesses to 39 residents out of a census of 39 residents. Definitions: Harborage: Any place, condition, or structure that provides shelter, protection, food, or water, allowing insects, rodents, or other pests to live, hide, and breed. Entry points: Any gaps, cracks, or openings in a building's exterior-foundation, walls, roof, doors, or windows-that allow insects and rodents to enter. German Cockroach: Small (1/2 to 5/8 inch), light brown to tan insects with two distinct dark, longitudinal stripes behind their head. Atrium dining area: Dining area available to all community residents. Separate from the Health Center dining room. Health Center: Skilled Nursing Facility Dish room: A room in the kitchen where equipment, utensils, and dishes used for storing, preparing, and serving food are cleaned and sanitized and stored until used. Door sweep: a device that seals a gap under doors.A review of the Center for Disease Control (CDC) guidelines for Environmental Infection Control in Health-Care Facilities updated 2019, showed anthropods (insects with segmented bodies and jointed legs/antennae/mouth parts) including cockroaches can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (an organism such as an insect that transmits a pathogen, i.e. bacteria or virus, from one organism or source to another). Insect habitats are characterized by warmth, moisture, and availability of food. Insects forage in and feed on substrates (a surface material from which an organism lives, grows, or obtains food), including but not limited to food scraps from kitchens/cafeteria, foods in vending machines, and routine solid waste. From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities. Modern approaches to institutional pest management usually focus on a. eliminating food sources, indoor habitats, and other conditions that attract pests b. excluding pests from the indoor environments; and c. applying pesticides as needed (Accessible https://www.cdc.gov/infection-control/hcp/environmental-control/index.html Guidelines for Environmental Infection Control in Health-Care Facilities Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) Atlanta, GA 30329 2003 Updated: July 2019) Review of the 2022 Federal Drug Administration Food Code, Insects and rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. (FDA 2022 Annex 3 - Public Health Reasons/Administrative Guidelines, 6-202.15 Outer Openings, Protected.) During a review of the facility's policy and procedure titled Chapter 9 Pest Control dated October 2012, indicated, .Maintenance Staff's Role and Responsibilities:.Ensure that all holes are repaired, caulked and sealed.Install barriers to pest entry and movement.Monitor for pests and report problems.Housing staff will closely monitor that Pest Control Company is rotating product quarterly so flavors and scents are always changing in order for treatments to be effective.Maintenance has crucial role in maintaining a healthy building. Maintenance staff need to work closely with the pest control professional to respond to maintenance problems documented in the log. They also need to get to the root of the pest problems such as water and holes.Janitorial Staff Roles and Responsibilities.Keep common areas clean and sanitary (especially trash chutes and dumpsters).Roaches.b) Prevention: Good sanitation and habitat reduction, along with vacuuming, surveillance, a baiting program, and some sealing of cracks.Mice.b) Prevention: To keep mice and other rodents out, make sure all holes of larger diameter than a pencil are sealed.Seal any cracks and voids.Rats.b) Prevention: Remove debris piles. Seal any holes larger than 1/4 inch. Remove moisture and harborage sources. On 2/9/26 at 5:01 PM, in the presence of the Administrator (Admin), Vendor 1 Director of Dining (V1DD), Vendor 1 Registered Dietitian (V1RD), and the MDS (Minimum Data Set) Coordinator (MDSC) an Immediate Jeopardy under Federal tag F925 was declared for the facility did not maintain an effective pest control program when the facility was not free of pests. A record review showed the facility's Plan of Action to maintain an effective pest control program included: a kitchen-wide inspection by a licensed pest control vendor (Vendor 2) on 2/9/26; treatment for cockroaches and mice by Vendor 2 started evening of 2/10/26 including fumigation; daily pest service until pests eradicated; monitoring of pest activity; door sweeps ordered to seal rodent entry points at main level dining, kitchen, and Health Center (to arrive on 2/11/26); cleaning and sanitizing areas in the kitchen by staff started on 2/9/26; cleaning of Health Center by housekeeping staff initiated 2/10/26; deep cleaning by 2 outside vendors scheduled 2/10/26 and 2/11/26; dish machine put out of order to address leaks and moisture in the dish room; plumbing service to addressed 1 leak (target fix date 2/12/26); procedures initiated to minimize moisture in the dish room; dining and Health Center staff in-serviced for identifying and reporting pest activity starting 2/10/26; training of cleaning and sanitation practices for dining staff beginning 2/10/26. During an interview, in the presence of Admin, MDSC, V1DD, the Executive Director (ED), the Director of Nursing (DON), and Vendor 1 Regional Director of Nutrition and Wellness (V1RDNW), the Immediate Jeopardy was removed on 2/13/26 at 7:21 PM when additional pest services were started to eradicate cockroaches and rodents, pest activity significantly decreased, the kitchen and nourishment room were deep cleaned, structural issues for rodent entry points were addressed, the dish machine leaks and moisture in dish room addressed, and pertinent staff were trained regarding cleaning and monitoring for pests. During an interview on 2/17/26 at 12 PM, the MDS (Minimum Data Set) Coordinator confirmed all 39 residents ate meals prepared in the kitchen. During a concurrent observation and interview in the kitchen on 2/9/26 at 10:33 AM with V1DD, large amounts scattered black residue noted on pipes under the 3-compartment sink, there was dark brown residue along the wall under the 3-compartment sink, splattered residue on the upper outside surface of the pot sanitizer machine, dark brown and beige residue build-up throughout the surface of the cart metal cart stored next to the 3-compartment sink. and a large pot, 50% filled with black liquid with particles floating on the top was found sitting on floor under 3-compartment sink. The Vendor 1 Dining Room Director (V1DD) verified contents in the pot were used grease/oil from cooking. Also, observations of residue build-up on and around the equipment were confirmed by V1DD. During a concurrent observation and interview on 2/9/26 at 10:45 AM with V1DD and Vendor 1 Registered Dietitian (V1RD) in the kitchen dish room, the dish room floor was very wet and multiple brown 4-legged insects of varied sizes with antennas crawled on dish racks, the dish machine, the floor, and walls. V1DD stated the insects were cockroaches and cockroach sightings began the week prior, and the facility had a pest service for cockroaches on 2/6/26. An observation and interview in the kitchen on 2/9/26 at 12:21 PM., showed the areas connected to the dishmachine were leaking (drainpipes, and above from the counter). Also, water dripped from the counter attached to the clean side of the dishmachine. Vendor 1 (V1) Executive Chef (EC) confirmed the leaks around the dishmachine. V1DD stated the pot of cooking grease under the 3-compartment sink was not discarded after meal service the night before, so the oil was sitting out overnight. V1DD stated used oil and food debris can contribute to pest harborage and potential food sources. Cockroaches were observed on the floor, walls, and on the dish machine. V1DD stated he could not say all utensils and equipment stored on dish room racks were clean because of the presence of cockroaches. During a concurrent observation and interview on 2/9/26 at 12:36 PM with Vendor 1 Sous Chef (V1SC) in the kitchen, V1SC was observed taking a black skillet pan from the kitchen dish room and went to lite stovetop and poured a white liquid into pan. V1SC stated he was cooking an item for a resident and reported dishware (pots, pans, equipment) in dish room were considered already clean. No additional cleaning or sanitization was observed prior to use of pan, despite several cockroaches being observed in the dish room area. During an interview on 2/12/26 at 1:13 PM with V1DD, V1DD stated he contacted Vendor 2 via text message on 2/5/26 reporting his staff witnessed increased pest activity. V1DD stated he tried to contact the building Maintenance Manager (MM) prior due to reports by staff of pests including mice and cockroaches. V1DD stated it was difficult to get a response from MM, who was responsible for contacting V2 for extra services. V1DD reported he was aware of rodent/insect activity since November 2025. During a review of a Customer Service Report dated 1/8/26 from Vendor 2, the report showed cockroaches were noted in the kitchen dish room. Review of an email correspondence from Vendor 2 Pest Control Market Manager (V2PCMM) to Vendor 1 Regional Director of Operations (V1ROM), dated 2/11/16, showed V2 was contacted for German Cockroach activity in the kitchen dish room, and rodent activity in the kitchen, dining areas, 1st floor common areas, and the 2nd floor (Health Center) break area (nourishment room). During an interview on 2/13/26 at 5:07 p.m., V1DD stated the dishmachine was leaking for a long time, but he did not report it. During an interview on 2/17/2026 at 12:22 PM, Vendor 2 Pest Control Market Manager (V2PCMM) stated there were sightings of an infestation (the presence of an unusually large number of insects or animals in a place) of German cockroaches inside kitchen and a pocket of insects in the dish room. V2PCMM confirmed kitchen staff was not keeping the kitchen dry for V2's pest control standards. V2PCMM stated the pipe flush service conducted on 2/10/26 was always general recommendation to be completed monthly, even when it was not in the V2 pest reports. V2PCMM stated it was a while since a flush was done in this kitchen. During a concurrent observation and interview on 2/9/26 at 10:11 AM with V1RD, multiple gaps in ceiling panels, several brown discolorations, residue, and particle buildup were noted throughout kitchen ceiling. During a concurrent observation and interview on 2/9/26 at 12:08 PM with Vendor 1 Director of Dining Services (V1DD) and Vendor 1 Executive Chef (V1EC) in the kitchen dry storage room, small black, tapered pellets the size of rice grains were observed along wall and under food racks. V1EC verified the pellets were rodent droppings. One grey mouse was observed exiting dry storage room and followed wall to posterior corner of kitchen under vertical racks and equipment. V1EC confirmed the mouse sighting. An observation in the kitchen and concurrent interview on 2/9/26 at 12:18 PM, showed rodent droppings were observed along the wall in a food preparation area where a rolling food rack was stored. V1EC confirmed there were more rodent droppings. During a concurrent observation and interview on 2/9/26 at 12:47 PM with V1DD and V1EC in the Atrium dining area, under a winged backed chair, a snap trap with mouse caught in trap was observed. The rodent appeared dead and slightly dried up. The findings were verified by were confirmed by V1DD and V1EC. During a concurrent observation and interview on 2/10/26 at 2:36 PM with V1EC and in the Administrator (Admin), in the kitchen, multiple black rodent droppings were observed behind standing refrigerator #5. V1EC verified findings and stated cleanliness in all areas in the kitchen should be maintained. During a concurrent observation and interview on 2/10/26 at 3:14 PM with V1EC and V1RDNW in the kitchen, multiple black rodent droppings were found on the kitchen floor in the corner under Vertical rack (on wheels) with food items stored on shelving units next to walk-in refrigerator #1. V1EC and V1RDNW verified findings as more mouse droppings. Observations and interviews in the kitchen on 2/10/26 starting at 3:47 PM, showed a metal storage rack against the wall to one side of walk-in refrigerator 1. There were rodent droppings around the legs of the rack. There was also a metal storage rack against the wall between walk-in refrigerator 1 and 2. The rack held items such as shelf stable food stored on the rack. There was brown, sticky residue and a gray fuzzy matter throughout the rack surface. Another tall, metal storage rack was located against the adjacent wall right next to walk-in freezer 3. The rack surface was covered with white, and brown rough residue. There was a missing tile on the wall behind the rack and a visible hole in the wall at least a half-inch wide. There was thick, dark brown reside in the corner on the floor under the rack. V1DD and V1EC confirmed the rodent droppings, residue on racks and the floor, and the hole in the wall. VIEC stated the areas and racks needed to be cleaned. V1DD stated the hole in the wall could be an entry point for pests. During an observation and interview on 2/11/26 at 4:44PM in the Atrium dining area, one brown haired mouse was observed walking down wall the dining room coming from a hole in the ceiling/concrete facade and witnessed going into a hole under the glass dining room door in between the concrete wall facade on the floor. V1DD and V1ROM were notified of the sighting and the hole.During an interview on 2/13/26 at 10:33 AM, V2FM stated rodent sightings and droppings were observed at the building for the longest time, since last January. V2 stated mass trapping (a high density of traps set in the evening after closing of the kitchen and picked up early in the morning before opening of the kitchen) and fixing structural issues, such as door sweeps were recommended by V2 in the past.During a concurrent observation and interview on 2/13/26 at 4:24 PM with V1DD and V1EC, in the kitchen, rodent droppings were found on top of a white box labeled Noodle- [NAME] Stick Dry, labeled as received on 1/15/26, in the dry food storage room. V1DD stated he completed a cleaning and sanitary inspection the morning of 2/13/26, however he did not inspect on top of the boxes. During a concurrent observation and interview on 2/13/26 at 4:56 PM with V1EC, in the loading dock with direct access to kitchen through service elevator, three large commercial garbage bins (two blue, one green) inspected and all three trash can lids were open. V1EC stated all garbage bins should be always closed due to attracting pests and also increases the potential of pest harborage sites. An observation and concurrent interview in the kitchen on 2/13/26 at 5:07 PM, showed what appeared to be mouse droppings on top of reach-in refrigerator number 6. V1DD confirmed there were mouse droppings on top of the refrigerator. During an interview on 2/17/26 at 10:04 AM with the ED, ED stated a main concern currently identified was the loading dock area and the exterior/perimeter of the facility. Adding, because that is where the bugs, mice and other pests are coming in. During an interview on 2/17/2026 at 12:22 PM with Vendor 2 Pest Control Market Manager (V2PCMM), V2PCMM stated there was a current infestation of mice, and when rodents enter the building rodents will find hiding places and make their way to food. They can hide in holes and the ceiling if there are gaps. During a review of a Customer Service Report dated 12/8/25 from Vendor 2, the report indicated mice were noted during dining service (in the Atrium dining area). Mass trapping and equipment placed. Also, mice were noted during kitchen service. There were new mouse droppings and mice in traps. Additional traps placed. Hole/gap in dining area, will need to repair/seal to prevent pest harborage. The report also showed to place a door sweep on the door to the interior kitchen production point. In an interview on 2/17/26 at 11:07 AM, V1DD and V1ROM confirmed, although there was a recommendation for door sweeps on door to the interior kitchen production point, the double automatic door to the kitchen was propped open during meal service hours: 7:30-9 AM, 12-2 PM, and 5-7 PM. During a review of a Customer Service Report dated 1/21/26 from Vendor 2, the report indicated in the kitchen area rodent droppings needed to be removed from corner underneath a table that was holding mini soda cans, and to please clean. During a review of a Pest Elimination Report dated 2/6/26 from Vendor 2, the report showed mice were noted in the kitchen during service. Two mice were observed and a lot of droppings that need to be cleaned. A lot of holes were found. Can start fixing. During a concurrent observation and interview on 2/9/26 at 1:31PM in the Health Center Noursihment room, multiple black pellets, resembling the rodent droppings observed in the kitchen, were found behind the full-size refrigerator. A Utility Maintenance staff (UM1) verified refrigerator was in use with multiple dated nourishments found inside. UMI also verified there was black pellets behind the refrigerator. During an interview on 2/13/26 at 2:50 PM HS stated housekeeping staff never reported pest sightings or droppings. HS also reported housekeeping staff daily duties include but were not limited to vacuuming all areas of the building (except for exterior and kitchen). Housekeeping staff vacuumed the dining room and atrium area daily in the morning, after breakfast, after lunch. HS reported there was no recent change to the cleaning schedule in the Health Center, Dining or Atrium area due to reported pest activity. HS reports no additional training or rodent prevention practices have been provided to her regarding pest control eradication measures. During a subsequent interview on 2/13/26 at 3:21 PM with HS, HS stated, she managed all housekeeping staff that services the entire building, which included all levels of care (Independent Living, Assisted Living, Memory Care, and the Health Cener). HS reported she provides all training for housekeeping staff. HS reported she was not currently aware of what rodent droppings looked like and was not provided training regarding monitoring for rodent findings or pest activity throughout the building. When asked what measures were taken by the housekeeping staff if infection control issues were identified, HS reported she would do More training with staff. When asked if any pest control customer service reports from Vendor 2 were reviewed with her, HS stated findings were not reviewed with her and added We don't do anything special based on the (Vendor 2) reports, just the same cleaning. During an interview on 2/13/26 at 3:32 PM with a Health Center Housekeeper (HCH), HCH reported she was unaware of rodent droppings and could not identify if seen throughout facility. During a concurrent observation and interview on 2/13/26 at 3:47 PM with MM, Perimeter/exterior facility door noted in atrium dining area noted with no door sweep at bottom of door. Gap measured to approximately 0.25in (w) x 0.75in (h) identified. MM confirmed prior door sweeps were removed about a month ago because the doors did not close properly. MM stated it was possible for a rodent to access the facility from the identified door gap while awaiting new door sweeps delivery. An additional hole was noted in Atrium dining area ceiling (concrete facade), where the mouse was observed on 12/11/26 at 4:44 PM. MM stated he was unaware of the hole. During an interview on 2/17/26 at 10:04 AM with the Executive Director (ED), the ED explained there should be no thresholds for pests within the facility, adding that his role was to adequately monitor services provided regarding pest control. ED stated he was aware that only 3/4 recommendations for exterior door sweeps were installed despite Vendor 2's recommendations. During an interview on 2/17/26 at 12:22 PM with V2PCMM, V2PCMM stated the building management was aware of possible entry points into the dining room area and they removed door sweeps and weather stripping that was previously installed by Vendor 2 due to doors not closing properly. V2PCMM explained the door sweeps were intended to eliminate pest entry points from the exterior doors. When the walk through was conducted on 2/11/26, eight exterior doors were inspected and all eight doors did not have door sweeps and/or weather stripping, to keep pests from entering, including the Atrium doors. V2PCMM stated the lack of door sweeps increased the likelihood of rodents entering the building and particularly the kitchen attempting to find food. When asked how likely it was for a rodent to access the kitchen from an entry point identified in the dining room, V2PCMM stated, Very likely that the rodent would be able to access the kitchen, find hiding spots, and eventually make way to food source. (Rodents) going to be drawn to food. During an interview on 2/12/26 at 1:17 p.m., V1DD stated. at times, it was difficult to reach MM, so if additional pest service was needed due to pest activity, getting pest service could be delayed. When more signs of pests were reported to MM at the beginning of last week, MM suggested a meeting to discuss pests for middle of the next week. V1DD stated he did not want to wait to have a meeting, so he called V2 himself. V1DD stated he should have taken initiative and requested a more robust pest service when increased pest activity was observed. During a review of several email communications from V1DD to MM dated 12/19/25 at 9:45 AM and 1/26/26 at 9:08 AM, the emails indicated increased pest activity was witnessed in the kitchen and dining areas by multiple staff members and Vendor 2's continued efforts to coordinate with MM and Housekeeping Supervisor (HS) to provide proactive measures to eliminate the increase in pests throughout the facility. Emails were as follows: During a review of an email communication from V1DD to MM dated 12/19/25 at 9:45 AM, the email stated, .I had a conversation with (Vendor 2) regarding pest sighting in the dining room. (Vendor 2) will be reaching out to both of you [ MM and Housekeeping Supervisor (HS)] regarding proactive measures they would like to confirmation before doing the work. During a review of an email communication from V1DD to MM dated 1/26/26 at 9:08 AM, the email stated, My morning team had communicated to me today that as they come in, in the morning, the pest activities is starting to increase in the kitchen.We need to start getting (Vendor 2) involved in this situation and I have started the communication with them.but they have told me that the final confirmation needs to come from you.The last communication I had with them was on January 4th letting me know they will contact you regarding some proactive work dealing with the situation. During a review of an email communication from the Executive Director (ED) to MM dated 1/26/26 at 9:44 AM, the email stated, .I increased our pest control budget to be more aggressive as there has been activity in the Atrium level.let's do a more thorough walkthrough to see if we can find any penetrations we are not aware of, like the [NAME] doors on A level that have small holes. During an interview on 2/13/26 at 2:07 PM with MM, MM stated pest control reports were designated into two types of services. One service report was generated for the kitchen and dining room, and another report was generated for the perimeter pest control measures (which include all structural concerns identified). MM stated V1DD and V1EC had access to pest control company service reports for the kitchen and dining room area. MM stated V1DD and V1EC reviewed reports and all recommendations noted. was to contact him (MM) for additional services (treatments, fumigations) if pests were sighted but could be requested by V1DD and V1EC in his absence. MM reported in the absence of the EVS Director, pest control service reports were provided to HS, and she reviewed recommendations and findings with HS for housekeeping staff for extra cleaning needed. During an interview on 2/13/26 at 2:50 PM with HS, HS stated Vendor 2 services the building for pests two times a week and as needed. Housekeeping staff daily duties included but were not limited to vacuuming all areas of the building (except for exterior and kitchen) daily in the morning, after breakfast, and after lunch. When asked if any pest control customer service reports from Vendor 2 were reviewed with her, HS stated pest reports went to the Environmental Services Director Administrative Assistant (EVSAA), and findings were not reviewed with her and added We don't do anything special based on the (Vendor 2) reports, just the same cleaning. HS reported no change to cleaning schedule or additional training for rodent prevention practices have been provided to her regarding pest control eradication measures in the Health Center, dining or atrium area. HS stated she never saw rodent droppings in the building and did not know what rodent droppings looked like.During an interview on 2/17/26 at 11:50 AM with EVSAA stated she received Vendor 2 Invoice/Customer service reports with pest control recommendations and filed them upon receiving them. EVSAA was not aware of discussing report findings/recommendations with any facility staff and/or directors. During an interview on 2/17/26 at 10:04 AM, ED reported he was responsible for reviewing and ensuring all recommendations from Vendor 2's pest reports were implemented, ED stated he reviewed V2's reports but did not look at the second page which showed structural recommendations.

Based on observation, interview, and document review, the facility failed to maintain kitchen electrical and mechanical equipment in safe operating condition when:Parts associated with the dishmachine were leaking; andLight covering under a vent hood was missing.The failure to maintain kitchen mechanical and electrical equipment had the potential to result in food contamination from pests attracted to a wet environment, as well as fragments falling into food from an unprotected light bulb for 39 residents who received food from the kitchen out of a census of 39.Findings:Review of the policy and procedure titled Repairs date revised 1/2026, showed the Food and Nutrition Services Department requests equipment repairs in work orders from the Maintenance Department according to established procedures. Repairs of essential equipment are initiated by the Maintenance Department within 24-hours, which may consist of a call to service company by the Maintenance Department.Review of the policy and procedure titled Safety and Equipment Maintenance date revised 1/2026, showed proper maintenance of the physical plant and all equipment in the Department is the responsibility of the Director in cooperation with the Maintenance Department.According to the 2022 Federal Food Code, standards of practice include equipment is to be maintained in a state of repair.An observation in the kitchen on 2/9/26 at 10:45 a.m., showed the dishmachine was in use in the dish room (the room where items such as utensils, dishes, pots, and pans were cleaned using equipment such as the dishmachine, the three-compartment sink, and/or the pot/pan sanitizer machine; and where the cleaned items were dried on racks and/or stored on racks until use), and the floor was very wet.An observation and interview in the kitchen on 2/9/26 at 12:21 p.m., showed the dishmachine was in use and a pipe under the dishmachine was leaking. Also, water dripped from the counter attached to the clean side of the dishmachine. Vendor 1 (V1) Executive Chef (EC) confirmed the dishmachine drainpipe was leaking and thought there was a crack in the counter at the clean side of the dishmachine where water was getting through. During an interview on 2/13/26 at 5:07 p.m., V1 Director of Dining Services (DD) stated the dishmachine was leaking for a long time, but he did not report it.2. An observation in the kitchen on 2/10/26 at 4:01 p.m., showed multiple lights under a vent hood which covered multiple pieces of cooking equipment. One of the light covers was missing, so the light bulb was exposed. In a concurrent interview on 2/10/26 at 4:01 p.m., V1DD stated maintenance was informed of the missing light cover under the hood but not the refrigerator light cover. In an interview and concurrent document review with V1RD on 2/13/26 at 11:50 a.m., V1RD stated she reported the missing hood light on audits dated 8/28/25 and 11/4/25. Review of the audit document titled CCL-FS&S Quick Pulse - Completed dated 8/28/25 and 11/4/25 showed open panel in hood, no cover for light fixture in good area, and hood light has no cover. During an interview on 2/13/26 at 2:06 p.m., the Maintenance Manager (MM) stated he was responsible for maintenance of equipment in the kitchen. MM stated he only went into the kitchen upon request, when he was informed of a maintenance issue. MM stated he was aware of the hood light missing a cover and was looking for a cover.

Based on observation, interview and record review, the facility failed to complete medication self-administration assessment for one resident out of four residents (Resident 15) observed during medication administration of inhaler and nasal spray, when no documentation that Resident 15 can self-administer medication. This failure resulted in Resident 15 given the wrong dose of nasal spray. FINDINGS: During the medication administration observation on 11/19/24 at 9:20 a.m.,, for Resident 15, Licensed Nurse (LVN) 2 was observed preparing and administering (6) oral medications. LVN 2 pulled out Fluticasone propionate 50 mcg/ actuation nasal spray 1 spray both nares twice a day for postnasal drip, Trelegy Ellipta 100 mcg-62.5 mcg-25 powder for inhalation I puff inhalation once a day for Emphysema. LVN 2 handed Fluticasone bottle to resident, per LVN 2, resident does it herself. Resident shook the bottle and sprayed 2 sprays on the right nose and 2 sprays on the left nose. LVN 2 came out of the washroom and asked resident, how many sprays did you do Resident stated, 2 they don't work anyway. LVN 2 handed the inhaler to resident, reminded to take deep breath, resident pushed the inhaler button once, handed the inhaler back to LVN 2. Resident rinsed her mouth with water provided by LVN 2. A review of Resident 15's clinical record indicated, admitted on [DATE] with diagnoses including: Emphysema(a lung disease that makes it difficult to breathe), Atrial Fibrillation(irregular heartbeats). During an interview on 11/19/24 at 10: 30 a.m., with Resident 15, per Resident 14, I give it to myself, I gave 2 sprays they don't even work, maybe I don't need it. Resident stated she used to give this spray to herself. During an interview on 11/19/24 at 11 a.m.,, with LVN 2, per LVN 2, resident has been giving herself the inhaler and nasal spray since she has been admitted to the SNF. She came from the Independent Living floor. Don't remember completing the self-administration assessment form. During a concurrent interview and record review with on 11/20/24 at 10:15 AM, NM, per NM, there is a process for self- administration of medication. Resident request to self administer and IDT will meet and document result from the assessment form, if the resident is capable of doing her own medication. MD will have to be involved and IDT will need to care plan. needs pharmacy approval. Per NM, there is no documentation in the record about self -administration, no care plan and no MD order. Review of BIMS (Brief Interview for Mental Status) score is 10, mild cognitive impairment. A review of facility Policy and Procedure, Medication: Self Administration dated 4/24, indicated: Policy: An individual resident may self-administer medications if the interdisciplinary team (IDT) had determined that this practice is safe, and the physician writes an order for self -administration of the specific medications. 2. If a resident wants to self-administer medications, the IDT shall assess the resident's cognitive, physical, and visual ability to carry out this responsibility. 3. A licensed nurse will perform an assessment of the resident's ability to self-administer medications and submit the results to the IDT .5. Residents requesting to self-administer handheld nebulizers shall be required to demonstrate the capability of safely and effectively using the hand-held nebulizers without assistance or oversight of a licensed nurse. 6. The self-administration assessment and any other information will be presented to the physician and the IDT for final determination of the resident's ability to self-administer medications. The assessment shall be documented in the resident's chart. 7. The resident may not begin self-administration prior to approval by the IDT and the resident's physician .

Based on observation, interviews and record review, the facility had a medication error rate of 7.41 % when two medication errors occurred out of 27 opportunities during the medication administration for two of four (Resident 8) and (Resident 19). The failure resulted in the nursing staff not following the facility's policy and procedures (P&P) and had the potential for the resident not receiving full therapeutic effects or causing side effects for the residents. FINDINGS: 1.During the medication administration observation on 11/19/24 at 8:03 AM, for Resident 19, Licensed Vocational Nurse (LVN) 1 was observed preparing and administering (5) oral medications and Thera Tears eyedrop eye 0.25% droperette, 1 drop both eyes, 4x a day for dry eyes. Resident pulled right lower eyelid down, LVN instilled one drop, Resident pulled the left lower eyelid down, LVN instilled one drop. Resident closed eyes and LVN handed a tissue, resident wiped her eyes. 2. During the medication administration observation on 11/19/24 at 8:59 AM for Resident 8, LVN 1 was observed preparing and administering six oral medications and one eyedrop, Timolol ophthalmic 0.5% one drop both eyes once a day. Resident pulled down lower lid of right eye, LVN instilled one drop and did the same for the left eye. Resident closed eyes and wiped her eyes right after. A review of Resident 19's clinical record indicated, admitted on [DATE] with diagnoses including: Anxiety Disorder( condition causing excessive fear feeling of fear that affects daily life),History of Falling. A review of Physician Order, indicated TheraTears 0.25% eye drops one drop both eyes 4times a day for dry eyes. A review of Resident 8's clinical record indicated admitted on [DATE] with diagnoses including Acute Kidney Failure(condition when kidney is not working properly),Type 2 Diabetes Mellitus (condition with high blood sugar). Review of Physician's Order, indicated, an order for Timolol maleate 0.5% eye drops-0.5% both eyes once daily for Glaucoma, (eye disease that can lead to blindness). During an interview on 11/19/24 at 10AM, with LVN1, per LVN1, how to give eyedrops, ask the permission of the resident, follow five R's of medication administration, read orders, wash hands before and after, tissue to wipe, let resident close eyes and hold it, some residents do what they want. LVN or resident did not hold the eyes. During an interview on 11/19/24 at 10:15AM, with Nurse Manager, per NM, there is a process we follow when administering eye drops. Handwashing for infection control. Follow the policy and procedure. Looking at the P&P, per NM, the LVN did not press thumb over inner canthus to prevent systemic absorption. Per NM, inservices are given by DSD (director of Staff Development) on medication administration yearly. Per NM, will check with Pharmacist for inservices on medication administration. A review of facility Policy and Procedure, Medication Administration through Certain Routes of Administration, dated 4/1/22, indicated, Opthalmic Drops: Eye drops, ointments are applied to the eye for diagnostic and therapeutic purposes .Procedure: Eyedrops: 13. Gently press thumb over inner canthus for 1 to 2 minutes after instilling Drops while resident closes eyes gently to prevent systemic absorption and allow medicine to distribute over surface of eye. Wipe off excess solution with tissue.

Based on observation, interview and record review, the facility failed to ensure food sanitation when: 1. Two expired 1.86 liters of chocolate caramel were found on the shelf of the canned food storage area, 2. A kitchen equipment and stove/warmer were found unclean in the plating area of the kitchen. These failures have the potential to place the residents at risk for food borne illness. Findings: 1. During the initial tour of the facility's kitchen on [DATE] at 9:20 am, it was observed that two 1.86 liters can of Chocolate Caramel were stored on the front of the second layer of the canned food storage shelf. During a concurrent interview with the Executive Chef (EC), Director of Dining Services and Registered Dietitian (RD), they stated that it was a mistake and an omission. They said that the cans of chocolate caramel were not supposed to be on that shelf and these were supposed to be discarded. The facility's undated policy and procedure titled the Food and Supply on page 1, indicated, Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. 2. During observation on [DATE] at 9:21 am, the oven/warmer in the kitchen area was found to be dirty. When asked, the EC stated that they must order supplies to clean the equipment while the RD said they have to contact the company that made the equipment to come and loosen the parts so they can clean it. During observation on [DATE] at 11:00 am, the oven warmer was still not cleaned up. In a concurrent interview, the EC and RD stated that they called the company to come loosen the stove before they can clean it. The EC and RD could not say when is the appointment date/time. During a review of Area and Equipment Cleaning Policy on [DATE] at 2:00 pm, it indicated in the procedure: Director develops a reference manual on cleaning areas and equipments in the Food and Nutrition Services/Dinning Services, Assigns daily cleaning responsibilities in each position workflow .Management and Supervisory Personnel. Assigns weekly and special cleaning to be completed

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment when: 1. Residents 13 and 23's handheld nebulizer masks were unlabeled and uncovered while not in use. 2. Residents 23 and 42's oxygen tubing were unlabeled. 3. Resident 42's humidifier was unlabeled. These deficient practices could potentially result in the transmission and spread of infection causing harm to the residents. Findings: 1a. Resident 13 was admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD- A group of lung diseases that block airflow and make it difficult to breathe). During an observation on 5/10/23 at 12:59 PM, Resident 13 was in bed, asleep. There was a nebulizer with an attached handheld mask that was uncovered and unlabeled on the bedside table. During an interview on 5/10/23 at 1:11 PM, Registered Nurse (RN) 1 acknowledged that the nebulizer mask was unlabeled and uncovered. RN 1 stated, The mask should be covered when not in use, so bacteria won't get in. For infection control. 1b. Resident 23 was admitted on [DATE] with diagnosis that included COPD. During the initial tour observation on 5/8/23 at 9:39 AM, Resident 23 was sitting on her wheelchair while watching television. There was a nebulizer with an attached handheld mask that was uncovered and unlabeled on the bedside table During an interview on 5/8/23 at 12:41 PM, the Licensed Vocational Nurse (LVN) 1 acknowledged that the nebulizer mask was unlabeled and uncovered. LVN 1 stated, When not in use, we have to cover so dust won't contaminate it. During an interview on 5/9/23 at 4:05 PM, the Infection Preventionist (IP) said, the nebulizer should be covered when not in use and should have the resident's name on it. Review of facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection revised in November 2011, indicated, .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol .7. Store the circuit in designated bag, marked with date and resident's name, between uses .9. Discard the administration set-up every seven (7) days . 2a. During the dining observation on 5/8/23 at 12:30 PM, Resident 23 was sitting on her wheelchair, watching television while eating her lunch. Resident 23 was on oxygen via nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) attached to a small oxygen cylinder tank. The nasal cannula was unlabeled. During an interview on 5/8/23 at 12:36 PM, the Certified Nursing Assistant (CNA) 1 stated, She's (Resident 23) always on oxygen, 24/7. During an interview on 5/8/23 at 12:41 PM, the Licensed Vocational Nurse (LVN) 1 said, Resident 23 is on oxygen at 1 liter/minute when out of bed. LVN 1 acknowledged that the oxygen tubing was not dated, and stated, Not labeled. During an interview on 5/9/23 at 4:05 PM, the Infection Preventionist (IP) said, the nasal cannula should be dated and changed weekly. Review of facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection revised in November 2011, indicated, .Infection Control Considerations Related to Oxygen Administration .6. Change the oxygen cannulae and tubing every seven (7) days, or as needed . 44478 2b. Resident 42 was admitted on [DATE] with diagnoses including multiple fracture (breaking) of ribs, pleural effusion (water on the lungs). During the initial tour observation on 5/8/23, at 10:35 AM, Resident 42 was in her room sitting up on her wheelchair with oxygen concentrator (a medical device) on at one liter per minute via nasal cannula. The nasal cannula was not labeled. During a concurrent observation and interview on 5/8/23, at 10:38 AM, RN 1 checked the oxygen concentrator and the nasal cannula tubing, stated, I don't see any label. Further stated, There should be a label and change tubing every 72 hours. During an interview on 5/8/23, at 10:40 AM, DON acknowledged by stating, Yeah, we are supposed to label tubing when we put it together. During an interview on 5/9/23, at 4:05 PM, the IP stated, . the nasal cannula tubing should be dated and changed weekly. 3. Resident 42 was admitted on [DATE] with diagnoses including multiple fracture (breaking) of ribs, pleural effusion (water on the lungs). During the initial tour observation on 5/8/23, at 10:35 AM, Resident 42 was in her room sitting up on her wheelchair with oxygen concentrator on at one liter per minute via nasal cannula. The humidifier (a medical device used to humidify supplemental oxygen) attached to the oxygen concentrator was not labeled. During a concurrent observation and interview on 5/8/23, at 10:38 AM, RN 1 checked the oxygen concentrator and the humidifier, stated, I don't see any label. Further stated, There should be a label and change the humidifier when it's empty. During an interview on 5/8/23, at 10:40 AM, DON acknowledged by stating, Yeah, we are supposed to label when we put it together . looking at how often we have to change it. During an interview on 5/9/23, at 4:05 PM, the IP stated, humidifier should be dated and changed daily. Review of Physician's Orders (PO) for 5/11/23 on 5/11/23, at 3:00 PM, PO indicated, .Date and change humidifier bottle - every week or when water level is low. Review of facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection revised in November 2011, indicated, .Infection Control Considerations Related to Oxygen Administration . 3. [NAME] bottle with date and initials upon opening and discard after twenty-four (24) hours. 6. Change the oxygen cannula and tubing every seven (7) days, or as needed .

Based on observation, interview, and record review, the facility failed to ensure medications and/or medical supplies were properly labeled and stored. There were four expired nasal swabs, two packets of expired supplement powder, six packets of expired food thickener in Atrium medication cart. Also, there were boxes of expired insulin syringes, 18 expired electrocardiogram (ECG/EKG - records the electrical signal from the heart to check for different heart conditions) electrodes (sticky patches placed on the chest to record the heart's electrical signals), one canister of expired Sani-Cloth Purple Wipes, six expired intravenous (IV) catheters (a flexible tube inserted to a vein to administer fluids or medications), two expired IV start kit, two expired CADD (Continuous Ambulatory Delivery Device -a small, battery-operated pump that can be used to send fluids, medication, and chemotherapy as an intravenous infusion) administration sets, five dressing change trays, five expired foam dressings, 21 expired syringe tip caps, 12 expired needleless connectors (device that allow quick access to the infusion line, ensuring a secure connection), 41 expired female luer lock caps (connect to all syringe tips in place of a dispensing tip), 18 expired duoderm dressings (indicated for the management of lightly exuding wounds), one expired IV connecting tubing, two expired hypodermic safety needles (medical tool which enters the skin, a very thin, hollow tube with one sharp tip), two expired angiocaths (thin hollow tubes that allow the introduction of contrast [NAME] into various areas of the body for diagnostic purposes) and an expired vacutainer safety lok blood collection set (a sterile closed system for drawing blood from difficult veins) found in the medication storage room. This deficient practice had the potential to cause unsafe and/or inappropriate storage and administration of medications to residents. Findings: 1. During an observation on [DATE] at 10:35 AM, with Registered Nurse (RN) 3, there were four nasal swabs in the third drawer from the top, on the left side of the Atrium Medication Cart. The swabs indicated an expiration date of [DATE]. During a concurrent interview, RN 3 said, the swabs were used for respiratory pathogen panel (checks for virus, bacteria, or other organism that causes an illness in the respiratory tract). RN 3 stated, It should not be there, should be discarded. During an observation on [DATE] at 10:35 AM, with RN3, there were two JUVEN (brand name) supplement powder with an expiration of [DATE] and six packets of SIMPLY THICK (brand name) food thickener with an expiration of [DATE], in the fourth drawer from the top, on the left side of the Atrium Medication Cart. During a concurrent interview, RN 3 said, the food thickener is used to thicken thin liquids for residents on nectar thick diet. RN 3 stated, It should not be in the cart. 2. During an observation of the Medication Storage Room on [DATE] at 10:52 AM, with RN 3, the following were found: A box of insulin syringes (110 pieces) with an expiration date of [DATE]; 18 ECG/EKG electrodes with an expiration date of [DATE]; A canister of Sani-Cloth purple wipes with an expiration date of [DATE]; IV catheters with different expiration dates: one on [DATE], four on 2022, and one on [DATE]; Two IV start kit with an expiration date of 2022 Two CADD administration sets with an expiration date of 2022 Dressing change trays with different expiration dates: two on 2022, and three on [DATE]; Five Allevyn (brand name) dressing with an expiration date of [DATE]; Syringe tip caps with different expiration dates: 14 on ,d+[DATE] and 7 on ,d+[DATE]; 12 Needleless connectors with different expiration dates: ,d+[DATE], ,d+[DATE], and ,d+[DATE]; Female Luer Lock caps with different expiration dates: three on 2020, 19 on ,d+[DATE], and 19 on ,d+[DATE]; Duoderm dressings with different expiration dates: three on ,d+[DATE], seven on ,d+[DATE], and eight on ,d+[DATE]; One IV connecting tubing with an expiration date of ,d+[DATE]; Two hypodermic safety needles with an expiration date of ,d+[DATE]; Two angiocaths with an expiration date of ,d+[DATE]; and A vacutainer safety lok with an expiration date of [DATE]. During a concurrent interview, RN 3 acknowledged the above findings. During an interview on [DATE] at 1:03 PM, with RN 2 and the Director of Nursing (DON), RN 2 confirmed the above findings. The DON said, the expired supplies should not be in the medication storage room and should be discarded. Review of facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles last revised on [DATE], indicated, .3. General Storage Procedures .3.4 Facility should ensure that infusion therapy products and supplies are stored .according to the manufacturer's or supplier's recommendations .3.7 Facility should ensure that .disinfectants and other household substances are stored separately from medications .19. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis .

Based on observation, interview, and record review, the facility failed to ensure one of four residents (Resident 23) reviewed were free from unnecessary psychotropic medication (drugs that affect brain activities associated with mental processes and behavior) when: 1. Resident 23 received Seroquel (Quetiapine [generic] - an antipsychotic medication to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) without appropriate indication, patient centered non-pharmacological approaches, and adequate behavior monitoring; 2. There was no evidence Gradual Dose Reduction (GDR - a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Seroquel use was attempted; 3. Care plan did not reflect specific target behavior to be monitored for the use of Seroquel; 4. There was no rationale indicated when Lorazepam (medication used to treat anxiety) PRN was used for more than 14 days, and there was no duration of therapy indicated in the physician's order. These deficient practices had the potential to result Resident 23 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis. For short-term adjunctive use while addressing underlying cause(s) of severe symptoms. In patients without a clinically significant response after an adequate trial (e.g., up to 4 weeks), taper and withdraw therapy. Only continue in patients with demonstrated benefit; attempt to taper and withdraw at regular intervals (e.g., within 4 months of initiation). [https://online.[NAME].com/lco/action/doc/retrieve/docid/patch_f/7598 accessed on 5/22/23]. According to the American Geriatrics Society (AGS) based on the Beers Criteria(R) (AGS Beers Criteria - Guidelines for Healthcare Professionals to help improve the safety of prescribing medications for older adult) for Potentially Inappropriate Medication (PIM) Use in Older Adults 2023, .Quetiapine .Increased risk of stroke and greater rate of cognitive decline and mortality in persons with dementia. Avoid antipsychotics for behavioral problems of dementia or delirium unless documented nonpharmacologic options (e.g., behavioral interventions) have failed and/or the patient is threatening substantial harm to self or others. If used, periodic deprescribing attempts should be considered to assess ongoing need and/or the lowest effective dose. The recommendation is to strongly avoid the use of this medication . Findings: Resident 23 was admitted on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, Alzheimer's disease (a progressive disease beginning with mild memory loss), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels of the brain) with agitation. Review of Resident 23's Minimum Data Set (MDS- a care area assessment and screening tool), dated 4/13/23, indicated, Resident 23's cognition was moderately impaired. 1. During an observation and concurrent interview on 5/8/23 at 9:39 AM, Resident 23 was in her wheelchair watching television, smiling and in good spirits. Resident 23 said she loved staying in the facility, it felt like being home. Resident 23 was also observed on multiple occasions: on 5/8/23 at 12:30 PM, and on 5/9/23 at 10:22 AM, during which she did not exhibit any types of behaviors. During an interview on 5/8/23 at 12:36 PM, Certified Nursing Assistant (CNA) 1 said, Resident 23 was combative but usually nice, when asked what behavioral disturbance Resident 23 manifested. During an interview on 5/11/23 at 2:17 PM, CNA 2 said, at times Resident 23 would say, My mom was here earlier. CNA 2 stated, I think that's her hallucination. During an interview on 5/11/23 at 2:29 PM, Registered Nurse (RN) 1 said, behaviors manifested by Resident 23 were: sometimes she's in the hallway and wants to go out or would say that she doesn't want the medications. RN 1 further said, hallucinations as manifestation of behavioral disturbance was generalized because different people have different manifestations of hallucination (auditory or visual). RN 1 stated, Monitoring of hallucination should be specific to see if medication is effective. Review of current physician's orders included: Seroquel 25 milligram (mg) by mouth twice daily (BID) with a start date of 1/8/23, and Quetiapine 50 mg daily at 2:00 PM with a start date of 4/9/23, both for vascular dementia with behavioral disturbance manifested by (m/b) agitation, paranoia, and hallucinations. The orders did not indicate what specific target behaviors were to be monitored. 2. Review of Resident 23's medication administration record (MAR) indicated: - Seroquel 25 mg three times a day was administered from 1/1/23 to 1/7/23 - Seroquel 25 mg BID was administered from 1/8/23 to 5/11/23 - Quetiapine 50 mg daily was administered from 1/8/23 to 5/10/23 During a concurrent interview and record review on 5/12/23 at 9:54 AM, with the Director of Nursing (DON), the Pharmacy Services Report April 2023 with an attachment titled Note to Attending Physician/Prescriber printed 4/1/23 was reviewed. The Note to Attending Physician/Prescriber indicated, .If appropriate, please consider a GDR at this time. If not appropriate, please document rationale for contraindication . The DON said, there was no documentation the physician acted upon the pharmacist's recommendation for GDR and stated, We don't have it. During an interview on 5/12/23 at 10:46 AM, the Consultant Pharmacist (CP) said, MRR is done monthly and a formal note to the physician is written for recommendations that are appropriate at the time of review. CP stated, Yes, it is expected the physician needs to see it (MRR) and elect what to do. Review of Resident 23's physician notes dated 4/11/23 and 5/5/23, did not indicate pharmacist's recommendation for GDR, identified in the MRR printed 4/1/23, has been reviewed and what action has been taken to address it. 3. During a concurrent interview and record review on 5/11/23 at 10:54 AM, with RN 2, Resident 23's care plan for psychotropic drugs was reviewed. The care plan did not indicate behaviors to be monitored for the use of Seroquel. RN 2 said, the care plan should reflect the overall care provided to the resident. RN 2 stated, Resident 23's care plan was not individualized, there was no behavior monitoring indicated, only observe for side effects for the use of Seroquel. 4. During a review of Resident 23's clinical record, the following were found: - The Physician Orders for 5/11/23 indicated, .Lorazepam 0.5 mg (milligram) 1 tab (tablet) by mouth every 8 hours as needed (PRN) for anxiety . with a start date of 10/4/22 and no stop date indicated. - The MAR for 1/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on January 3 and 15, 2023. - The MAR for 2/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on February 22, 2023. - The MAR for 3/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on March 22, 2023. - The MAR for 4/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on April 16 and 19, 2023. - The MAR for 5/2023 indicated, .Lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed for anxiety . and was administered on May 3 and 8, 2023. During an interview on 5/12/23 at 10:46 AM, CP said, for PRN psychotropic medications, he goes through the resident's medications twice or three times to evaluate, and for the medication to not stay on the resident's profile, only 10-14 days. The CP then writes a formal note to the physician for recommendations that are appropriate at the time of review. Review of facility policy titled, Psychotherapeutic Medication Management Program last revised on 6/21, indicated, .A. Physician Responsibilities .2. The psychotherapeutic medication order shall include the following information: Manifestations of the disorder and/or specific behavioral targets treated i.e., auditory hallucinations, hitting others, refusing to eat, etc. 4. The physician shall review the monthly psychotherapeutic summary and determine if the resident should remain on the same dose, or an adjustment should be made .G. Interdisciplinary Team .1. The resident's interdisciplinary care plan shall include the reason for the drug and describe the behaviors the drug was prescribed to treat .

Based on interview and record review, the facility failed to ensure that irregularities in the Pharmacy Medication Regimen Review (MRR-a systematic evaluation of medication therapy) for one of three sampled residents (Resident 23) were acted upon when there was no evidence the attending physician reviewed and documented if actions had been taken to address the identified irregularities (includes use of medications without adequate monitoring, in excessive doses, and/or in presence of adverse consequences) for MRR dated April 2023 in response to the pharmacist's recommendations. This deficient practice had the potential risk for harm by causing adverse consequences related to medication therapy. Findings: Resident 23 was admitted on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, Alzheimer's disease (a progressive disease beginning with mild memory loss), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Review of Resident 23's Minimum Data Set (MDS- an assessment tool) dated 4/13/23 indicated, Resident 23's cognition is moderately impaired. Review of Resident 23's Physician Orders for 5/11/23 indicated, Resident 23 was on Mirtazapine (antidepressant) 15 milligram (mg) at bedtime for depression manifested by (m/b) inability to sleep/insomnia, Lorazepam (medication used to treat anxiety) 0.5 mg every 8 hours as needed for anxiety m/b agitation and/or verbalization of belief that staff may be taking things from her room, Seroquel 25 mg twice daily and Quetiapine [generic] 50 mg daily at 2:00 PM (an antipsychotic medication that treats several kinds of mental health conditions) for vascular dementia with behavioral disturbance m/b agitation, paranoia and hallucinations. Review of MRR dated 4/1/23 indicated, no response from the physician. In a concurrent interview on 5/11/23 at 10:54 AM, Registered Nurse (RN) 2 said, the pharmacist comes to do the medication review, and has a binder of the monthly individualized report. RN 2 stated, If the physician responds, he makes a note and signs it. During an interview on 5/12/23 at 9:54 AM, the Director of Nursing stated, We don't have it, when asked for the physician's response to the pharmacist-reported irregularities on Resident 23's MRR dated 4/1/23. During an interview on 5/12/23 at 10:46 AM, the Consultant Pharmacist (CP) said, MRR is done monthly and a formal note to the physician is written for recommendations that are appropriate at the time of review. The CP stated, Yes, it is expected the physician needs to see it (MRR) and elect what to do. Review of Resident 23's physician notes dated 4/11/23 and 5/5/23, did not indicate identified irregularities in the MRR dated 4/1/23 has been reviewed and what action has been taken to address it. Review of facility policy titled, Medication Regimen Review with effective date of 11/28/16, indicated, .7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it .

Based on observation, interview, and record review, the facility had a 7.69% error rate when two medication errors out of 29 opportunities were observed during a medication pass when: 1. Resident 10 received Symbicort (medication used to treat asthma and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) was not in accordance with the manufacturer's instructions for use. 2. Resident 42 received Metoprolol (medication used to treat high blood pressure, chest pain, and heart failure) not in accordance with the physician's order. These failures resulted in medications given not in accordance with the physician's order and manufacturer's instructions for use that may affect the residents' clinical conditions. Findings: 1. During a medication pass observation on 5/9/23 at 9:28 AM, Registered Nurse (RN) 1 prepared Resident 10's Symbicort 160 microgram (mcg)-4.5 mcg/actuation HFA aerosol inhaler. RN 1 did not shake the inhaler prior to administering two puffs by mouth. During an interview on 5/9/23 at 9:31 AM, RN 1 acknowledged that he did not shake the inhaler before administering the medication, and stated, Yeah, I should shake before giving. Review of Symbicort instructions for use indicated, .Shake your Symbicort inhaler well for 5 seconds right before each use . 2. During a medication pass observation on 5/9/23 at 9:41 AM, RN 1 was observed preparing eight medications for Resident 42. Included in the medications was Metoprolol Succinate ER (Extended Release) 25 milligram (mg). RN 1 checked Resident 42's vital signs (clinical measurements, specifically heart rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and had a heart rate of 59 beats per minute. Then, RN 1 proceeded to give the eight medications to Resident 42. During an interview on 5/9/23 at 9:46 AM, RN 1 read Resident 42's heart rate on the monitor as 59 and acknowledged that the resident took all medications. RN 1 stated, Yes, all eight. During a concurrent interview and record review on 5/10/23 at 12:35 PM, with RN 1, Resident 42's electronic medication administration record (eMAR) dated 5/9/23 was reviewed. The eMAR indicated, a physician's order for Metoprolol Succinate ER 25 mg tablet once daily for hypertension, hold for SBP (systolic blood pressure - measures the pressure in the arteries when the heart beats) less than 100 or HR (heart rate) less than 60. RN 1 read the physician's established parameters and acknowledged that the medication was administered on 5/9/23 with Resident 42's HR at 59. RN 1 stated, I should have held the medication. RN 1 said, Resident 42's heart rate might go down and can cause loss of consciousness. Review of facility policy titled, Medication Administration revised on 2/18, indicated, .B. Holding Medications .2. The following criterion must be met in order to hold ordered medications .For cardiovascular drugs, BP or pulse outside MD established parameters .

Based on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standards of quality for Resident 13 when the licensed nurse failed to sign the medication as given on the electronic Medication Administration Record (eMAR - a tool used by nurses to keep track of the medications given to patients) as ordered by the physician (person qualified to practice medicine). This deficient practice could potentially compromise the health and safety of the resident. Findings: Resident 13 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). During a medication administration observation on 5/9/23 at 10:08 AM, Registered Nurse (RN) 1 administered Albuterol sulfate 2.5 milligram (mg)/3 milliliter (ml) via nebulizer to Resident 13. Review of Resident 13's Physician's Orders for 5/11/2023 indicated, Resident 13 had an order for Albuterol sulfate 2.5 mg/3 ml (0.083%) solution for nebulization - 1 vial inhalation via nebulizer every 4 hours as needed for COPD/SOB (shortness of breath). During a concurrent interview and record review, on 5/10/23 at 12:42 PM, with RN 1, Resident 13's eMAR dated May 2023 was reviewed. The eMAR indicated, on 5/9/23, for the 10:08 AM administration time, there was no licensed staff initials in the box for Resident 13's Albuterol sulfate (medication used to prevent and treat difficulty breathing, shortness of breath) 2.5 mg/3 ml, to demonstrate the medication was administered. RN 1 acknowledged that there was no documentation on the eMAR dated May 2023 that indicated Resident 13 received the Albuterol sulfate 2.5 mg/3 ml on 5/9/23 at 10:08 AM. RN 1 stated, It should have been signed. If not signed, it will show as not given. Review of facility policy titled, Medication Administration last revision date of 2/18, indicated, .Administration of Medications .5. The licensed nurse shall chart the date and time of each administered medication by putting his/her initial in the corresponding box for that date and time on the eMAR .If the medication is given on a per need (PRN) basis, the time shall be noted on the eMAR .

Based on observation, interview and record review, the facility failed to ensure manufacturers guidelines for safety and maintenance were implemented for bed rails (adjustable metal or rigid bars that attach to the bed and come in a variety of types, shapes and sizes. Examples of bed rails include grab bars and assist bars) when: 1) 35 out of 35 beds did not have routine scheduled maintenance in place for the use of bed rails, 2) 15 out of 35 residents (Residents 1, 2, 3, 4, 10, 12, 13, 16, 18, 19, 21, 23, 24, 25, 28) did not have reassessments for the use of bed rails, and 3) 28 out of 35 residents (Residents 1, 3, 4, 5, 6, 7, 8, 10, 11, 12, 20, 13, 14, 15, 16, 17, 18, 19, 21, 23, 24, 25, 27, 139, 138, 140, 141 and 142) did not have bed rail care plans implemented. A substandard quality of care deficiency was identified regarding the use of bed rails. Failure to implement a comprehensive approach for the use of bed rails had the potential to place residents at risk for entrapment or physical injury. Findings: 1) During observation on 8/26/19 at 9:45 AM, 16 resident occupied beds in the following rooms had bed rails in their up position: Rooms 201, 202, 204, 205, 206, 207, 208, 209, 211, 213, 224, 226, 230, 233, 234, 237. During observation on 8/29/19 at 11:23 AM, 25 resident occupied beds in the following rooms had bed rails in their up position: Rooms 202,206, 208, 210, 212, 214, 217, 219, 221, 223, 220, 225, 222, 224, 226A, 226B, 227, 229, 235, 237, 238, 234, 228, 230, 233. During an interview on 8/27/19 at 3:46 PM, Resident 28 stated she was concerned about the grab bars (bed rails) because the bed control attached to it keeps sliding down to the mattress and is very difficult to get to. Resident 28 stated this has been brought up to staff several times during the resident council meetings but nothing has been done about it so she sticks a pillow between the bars under the bed control to try and keep it from slipping down. During record review of Resident Council minutes dated 6/20/19 indicated, Another difficulty with the new rails (bed rails) is that the call light and the bed raising buttons keep falling to the floor. Clips will be attached to these (the call lights) and clipped to the bed clothes to keep them within reach. There was no documentation of the facilities response to the concern regarding the bed raising buttons. During record review of the Resident Council minutes dated 7/18/19 indicated the clips for the bed controls were discussed. There was no documentation of the facilities response to the sliding bed raising button control bar concern. During record review of the Resident Council minutes dated 8/15/19 indicated no documentation for follow-up from the facility to residents regarding concerns about the sliding bed raising button control bars on beds. During an interview on 8/27/19 at 3:40 PM in hallway after the Resident Council meeting, the Director of Nursing (DON) stated they had not completed any work regarding the issue with the bed raising control bars sliding down and would put in a request order that day. During review of a Work Order 7 dated 8/27/19 at 4:38 PM, indicated initiation of work to secure the remote control holders to the assist bars for all rooms. During record review on 8/30/19 at 10:51 AM, the Administrator provided a copy of a maintenance log titled, Completed Work Order 7 for HC (Health Center) quarterly beds inspection dated 8/2/19 indicating, Ensure all the BC beds are safe and working in good conditions, report all the issues to supervisor. Preventative maintenance is a schedule of planned maintenance actions including equipment inspection, lubrication, calibration, etc. aimed at the prevention of breakdowns and failures before they occur. Ensure the thickness is at (left blank). Ensure no cracks, holes, slits, openings, stains etc. - need to replace mattress. The administrator also provided a copy of section 8 of the bed rails Transfer Assist User Manual, undated, which indicated a Mechanical Inspection and Maintenance Checklist that should include: Inspect rail latches; Ensure that all rails engage and lock as specified; Lubricate rail pivot points and all mechanical hinge points, bushings, and surface contact points as needed with white [MEDICATION NAME] grease; Inspect bed, rails, assist rails, or assist bars for the presence of tubing end caps and replace as required; Inspect all bed components (i.e. rails, clevis pins, hitch pins, etc .) for damage or excessive wear and replaced as necessary; Visually examine all welds for cracks; Inspect the head and foot sections for bending, warping or damage; Inspect all bolts and rivets to ensure that they are securely tightened and functioning properly. Check sleep surfaces to ensure all slats are intact; Check casters to ensure they lock if applicable and roll properly. In a concurrent interview, after reviewing the work order and user manual checklist, the Administrator stated, I do not have anything to support specific notes for routine maintenance of the assist bars. This work order does not specify the checklist was completed and should be more detailed. 2) During a tour of the facility on 8/26/19 at 10:47 AM, the beds in rooms 215, 219 and 221 were observed to have bed rails in an up locked position regardless of whether or not a resident was in the bed. During a concurrent interview, Registered Nurse (RN) 2 stated, It is our normal practice to have bedrails up at all times and to have an assessment and consent on file. During an interview on 8/26/19 at 11:10 AM, the Director of Nursing (DON) stated, We got rid of all bed rails and switched to transfer assist bars due to changes in the regulation so we wouldn't have to do assessments and consents. During an interview on 8/26/19 at 3:40 PM, the DON stated, Grab bars are an opt out system. They are placed on almost all beds except one or two that said they didn't want them. During an interview on 8/27/19 at 12:14 PM, Resident 3 stated, Side bars were put on bed a few months ago. I was told the government wanted them there. They never asked me if I wanted them. During an interview on 8/29/19 at 11 AM, Registered Nurse (RN) 1 stated, no, we didn't perform resident assessments on use of the bed transfer assist bars. They are not restraints. During review of the clinical records on 8/30/19, there was no documented evidence to support quarterly reassessment of bed rails for 15 of 35 residents (Residents 1, 2, 3, 4, 10,12, 13, 16, 18, 19, 21, 23, 24, 25 and 28). During an interview on 8/30/19 at 11:22 AM, the DON stated, The current assist bars were installed the end of (MONTH) 2019. Quarterly care conferences are held to determine updated consent status. The DON further stated, There is a lapse of timely assist bar consent reassessments for Residents 5, 7 and 11. 3. During review of the clinical records on 8/30/19, there was no documented evidence to support implementation of bed rail care plans for 28 of 35 residents (Residents 1, 3, 4, 5, 6, 7, 8, 10, 11, 12, 20, 13, 14, 15, 16, 17, 18, 19, 21, 23, 24, 25, 27, 139, 138, 140, 141 and 142). During review of the facility's user manual for the Assist Bar, undated, it indicated under section 2 Safety, 2.1 General Guidelines .Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment .To avoid injury . always maintain and inspect equipment per the instructions in this manual. Under section 2.2 Intended use, it indicated, The purpose of the Assist Bar is to provide the resident a grab bar in which they can use to assist themselves from a sitting position to standing while exiting a long-term care bed. Clinical staff must decide whether a resident would benefit from the use of this aid. Under section 5 Usage, indicated, To avoid patient entrapment from use of assist bar .only use the assist (up) position while attending to the resident. Return the assist bar to the storage (down) position when unattended. Under section 7 Maintenance, it indicated, 7.1 Cleaning and Care .maintenance and cleaning procedures should be conducted initially, between users, on a regular schedule and as needed. During review of the Policy and Procedure titled, Side Rails/Assist Bars dated 06/19 indicated, Procedure .3. Nursing staff .shall assess the need for assist bar upon admission, quarterly and when indicated . An assessment form and informed consent will be completed by nursing staff. 4. Nursing staff shall document initial assessment in the medical record and develop a care plan

Based on observation, interview and record review, facility failed to maintain an account of all controlled drugs when the facility was not able to provide evidence of documentation of accounting of receipt and disposition of discontinued controlled substance (is generally a drug or chemical whose manufacture, possession, or use is regulated by a government; a prescription from a licensed physician (medical doctor) is needed to acquire these medications). This deficient practice had the potential for drug diversion. Findings: During medication room observation and concurrent interview with the Nurse Manager 1 (NM 1) on [DATE] at 1:40 PM, the storage for discontinued controlled substance medications contained the following: 14 [MEDICATION NAME] capsules - medication to treat sleep problem; 17 [MEDICATION NAME] tablets - medication to treat anxiety (excessive fear and worrying); eight [MEDICATION NAME] tablets - medication to treat sleep problem; nine Zoldipem tablets - medication to treat sleep problem. NM 1 stated, when the controlled substance medications are discontinued the nurses give them to me. We do not have any kind of form to log the controlled substance medication that was given to me. During an interview with the Director of Nursing (DON) on [DATE] at 1:30 PM, the DON stated, No, I don't deal with that (discontinued controlled substance medications), you have to talk to the Nurse Manager (NM 1). During a review of the facility policy and procedure titled, Disposal/Destruction of Expired or Discontinued Medications, Effective Date [DATE], indicated, Disposal of Controlled Substance Medications, 13. The facility should record destruction of controlled substances on: 13.1 Medication Disposition/Destruction Form; . 13.3 Medication Destruction Log Book.

Based on observation, interview and record review, the facility failed to ensure medications were properly labeled and stored when: 1. 75 suppositories used to treat nausea (feeling of an urge to vomit) and vomiting were found without labeling. 2. The temperature of the refrigerator containing vaccines was not monitored. This failure had the potential to dispense medication without a physician order and decrease the effectiveness of the vaccines. Findings: 1. During the medication room observation and concurrent interview with Nurse Manager 1 (NM 1) on 8/26/19, at 2:10 PM, 48 unlabeled [MEDICATION NAME] suppositories, and 27 unlabeled [MEDICATION NAME] suppositories were found in one of one medication refrigerator in one of one medication room. NM 1 acknowledged the suppositories were not labeled and stated, Those are house supplies, we don't label them. During an interview with the Director of Nursing (DON) on 8/28/19 at 2:10 PM, DON stated, we do not have a specific policy for labeling. That's all we have, 2. During the medication room observation and concurrent interview with NM 1 on 8/27/19 at 2:15 PM, the temperature of the refrigerator containing 12 Prevnar 13 vaccine (used for prevention of pneumonia (a potentially serious lung disease)) and two Purified Protein Derivative (PPD, used for skin testing to determine if a person has [MEDICAL CONDITION] (TB)) was not monitored. NM 1 acknowledged the finding and stated, I didn't know the temperature of the refrigerator containing vaccines has to be monitored twice a day. Review of the facility policy and procedure titled, Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, dated 10/2016, indicated, .Facility should ensure that medications and biological's were stored at their appropriate temperature according to the United States Pharmacopeia guidelines for temperature ranges. Facility staff should monitor of vaccines twice a day .

Based on observation, interview and record review, the facility failed to ensure controlled drugs (medications regulated by the government due to high risk for potential abuse and dependence) were accurately reconciled and accounted for two random residents (random resident 12 (R 12) and random resident 6 (R 6) when: The controlled drug records for R 12 and R 6 did not match the medication administration records. This failure had the potential for the pharmaceutical needs of R 12 and R 6 not being met. This failure had the potential to result in loss or diversion of controlled medications. Findings: During a controlled drug inspection of the medication cart assigned in the Tower Wing, on 8/29/18, beginning at 2:17 PM, with Licensed Vocation Nurse 1 (LVN 1), the controlled drug record did not match the eMAR (electronic medication administration record) for R 12. In a concurrent interview and record review, LVN 1 confirmed she could not find documentation in the eMAR that [MEDICATION NAME] 5mg-325 mg tablet ([MEDICATION NAME]-[MEDICATION NAME]) (a controlled drug that treats pain) . was administered to R 12 on 7/22/18. Review of the clinical record for R 12, the Controlled Drug Record indicated the following: [MEDICATION NAME]-Acet 5MG-325MG TABLET .DATE, 7/22/18; TIME, 8:25 PM; AMOUNT USED, 1; AMOUNT REMAINING, 47 . Review of the clinical record for R 12, the Medication Record for 07/2018, indicated there was no documentation that [MEDICATION NAME] 5mg-325 mg tablet ([MEDICATION NAME]-[MEDICATION NAME]) . was administered on 7/22/18. During a controlled drug inspection of the medication cart assigned in the Tower Wing, on 8/29/18, beginning at 2:17 PM, with LVN 1, the controlled drug record did not match the eMAR for R 6. In a concurrent interview and record review, LVN 1 confirmed she could not find documentation in the eMAR that the evening dose of [MEDICATION NAME] 5 mg-325 mg tablet ([MEDICATION NAME]-[MEDICATION NAME]) was given to R 6 on 7/25/18. Review of the clinical record for R 6, the Controlled Drug Record indicated .: [MEDICATION NAME] (one)-Acetamin (ophen) 5MG-325MG TABLET .DATE, 7/25; TIME, 11:10 P (M); AMOUNT USED, 2; AMOUNT REMAINING, 5 . Review of R the clinical record for R 6, the Medication Record for 07/2018 indicated there was no entry on 7/25/18 for the evening dose of 2 [MEDICATION NAME] 5 mg-325 mg ([MEDICATION NAME]-[MEDICATION NAME]) tablets. In an interview and record review with the Director of Nursing (DON) on 8/30/18 at 8:35 AM, in the activity room, the DON acknowledged the discrepancies on R 12's Controlled Drug Record and Medication Record. The DON stated I cannot say what happened without talking to staff .common practice (to) always document you gave the medication to resident, either given to resident or wasted . The DON stated that the Pharmacist (PharmD) did the audits comparing the Controlled Drug Record and the Medication Record. During a concurrent interview and record review with the Director of Nursing (DON) on 8/30/18 at 8:35 AM, in the activity room, the DON also acknowledged the discrepancy on R 6's Controlled Drug Record and Medication Record for the evening dose on 7/25/18, and said, not sure what happened, same assumption . gave meds to resident but failed to write it in . should've marked it was given. Review of facility document, titled, Documentation of Medication Regimen Review For Sequioas, dated, 07/12/18 signed by the PharmD, indicated, .PSDA Monitoring: Comparison of Controlled Substances Doses Signed Out On Count Sheet With Doses Charted In Computer: From 7/4 Thru 7/11 One Resident's [MEDICATION NAME] (a controlled drug that treats pain) was signed out for 2 doses on 7/6, but only 1 dose charted. Then on 7/9 one dose was signed out but not charted. From 7/2 thru 7/9 one resident's [MEDICATION NAME] had 8 doses signed out, but only 6 doses charted. These apparent discrepancies need further investigation. In an interview with the PharmD on 8/30/18, at 11:24 AM, in the medical record room by the nursing station, PharmD stated the previous DON investigated the incident in the audit report dated 7/12/18. When PharmD was asked about the discrepancies found on R 12 and R 6's Controlled Drug Records and Medication Records, the PharmD stated, We don't know, looks like diversion. When asked about the frequency of discrepancies PharmD stated, it happens . main issue . chart when you pour, supposed to chart . The PharmD added, the Quality Assurance Committee was aware of the issue .they wanted me to do it (medication pass observation with every nurse) every year. During a follow up interview with the DON on 8/30/18 at 1:28 PM, in the DON's office, the DON acknowledged she was aware of the controlled substance audit report dated 7/12/18, and stated a plan was in place to prevent future occurrences. Review of facility policy, titled, 5.4 Inventory Control of Controlled Substances, latest revision 01/01/13, indicated, . Procedure .1.2.3 The facility should routinely reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Count Sheet, to the Medication Administration Record [REDACTED]. Facility should ensure that staff immediately reports suspected theft or loss of controlled substances .Facility should also conduct an investigation to determine: 4.2.1 Whether a dose was in fact administered and, if so, the reason the administration was not charted; and, 4.2.2 Whether a dose was refused. 5. A facility representative should regularly check the inventory records to reconcile inventory. Facility should regularly reconcile .Current inventory to the controlled medication declining inventory record and to the resident's MAR . Review of facility policy, titled, 10.4 Loss or Theft of Medications, dated 12/01/07, indicated, .Procedure: 1. Where facility staff suspect theft or loss of medications, facility staff should take such actions as required by applicable law .1.1 Immediately reporting suspected theft or loss of drugs to a supervisor/manager or the Director of Nursing for appropriate investigation and follow-up; 1.2 Investigating and reconciling discrepancies; and, 1.3 Notifying the appropriate facility administrator of controlled substance discrepancies, and if such discrepancies are not reconciled, notifying the appropriate law enforcement agencies according to applicable law .

Based on observation, interview and record review, the facility failed to complete accurate assessments for two of 13 sampled residents, Resident 23 and 15; when coding on Section P of the Minimum Data Set (a resident assessment tool) did not reflect the use of side rails on an ongoing basis. Failure to complete accurate assessments may harm residents by not providing needed care and services to maintain their highest level of functioning. Findings: Resident 23 was admitted on [DATE] with [DIAGNOSES REDACTED]. (A progressive disease that destroys memory and other important mental functions). Review of the admission and most recent quarterly Minimum Data Set (MDS, a resident assessment tool) dated 4/47/18 and 7/18/18 respectively, indicated Resident 23 had cognitive impairment and required extensive staff assistance for some activities of daily living like bed mobility, transferring from and to bed, dressing, toileting and personal hygiene. She was not steady on her feet and required staff supervision. During an observation on 8/27/18 9:20 AM, Resident 23 was lying in bed with two half side rails in the up position, in the middle (between the head and foot) of the bed. During an observation 8/27/18 9:48 AM, Resident 23 was dressed, sitting in a wheelchair next to her bed. The two side at the head end of the bed were in the up position. Resident 23 smiled when greeted but appeared to not be able to engage verbally. Record review of the 4/17/18 admission MDS, and the 7/18/18 most recent quarterly MDS for Resident 23; regarding side rails use, indicated on Section P0100 a code of 0, for Not used. During an observation 8/28/18 8:35 AM, Resident 23 was asleep in bed with two half side rails in the up position, in the middle (between the head and foot) of the bed. During an interview with the Registered Nurse MDS Coordinator (RNC), on 8/28/18 at 8:20 AM, she stated We always code Section P as 0, because we do not do restraints in this facility. We use side rails for repositioning . When asked if half side rails in the up position on both sides of the bed would impede free movement and residents would not be able to undo or put down the side rails, RNC acknowledged and stated, Yes, I understand, but we are not using the side rails as restraints . Resident 15 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of two quarterly MDS dated [DATE] and 4/8/18, as well as the most recent 7/7/18 annual assessment, indicated Resident 15 was severely cognitively impaired and required extensive staff assistance or was totally dependent on staff for activities of daily living, such as, eating, dressing, toileting, personal hygiene and transferring from and to bed. During multiple observations on 8/27/18 at 8 AM and 10:45 AM, 8/28/18 at 9 AM and 8/29/18 at 8:30 AM; Resident 15 was asleep in bed with two half side rails in the up position, in the middle (between the head and foot) of the bed. During an observation of Resident 15, on 8/29/18 at 9:01 AM, both half side rails were in the up position, the bed was in the low position with a rubber pad next to bed. Resident 15 was asleep. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 8/29/18 at 9:10 AM, she stated, Resident 15 has side rails because of a request of her responsible party being afraid of a fall from the bed . the resident moves in bed when she is soiled or wet . When asked if the side rails were in use as a fall prevention intervention, LVN 2 stated, Yes, mainly ., and when asked how often Resident 15 was monitored, LVN 2 added, We have hourly rounds the CNAs are aware of that . During an interview with RNC on 8/29/18 at 9:35 AM, after RNC observed the two half side rails in use on Resident 15's bed, RNC stated, I see your point, she cannot undo that and yes, she has no free movement We don't use the side rails as restraints RNC acknowledged section P in the MDS does not reflect the actual use of side rails for several residents in the facility, we always code section P0100 as 0 . During an interview with the Administrator on 8/29/18 at 2:15 PM, she acknowledged use of 0 for coding of side rails, and stated, Yes, I see how that does not document the use of side rails with multiple residents currently in the facility . Record review of a facility policy titled Side Rails indicated under Purpose .To determine the use of a bed side rail as an assistive device to enhance resident mobility while in bed and/or while transferring that does not limit freedom of movement and complies with anti entrapment legislation .

Based on observation, interview and record review, the facility failed to prevent accidents when one resident (Resident 1) had 3 fall incidents in his room while unsupervised. The facility failed to remove accident hazards when breakable plates were used on his meal tray until [DATE] despite the fact that the resident was a high risk for fall. The Resident was able to remove his tab alarm. The care plan was not revised or updated to address the ineffective use of the tab alarm as an assistive device to alert the staff to prevent falls. The first fall incident was on [DATE], Resident 1 sustained multiple lacerations in his body that required surgical treatment, blood transfusion and hospitalization when he fell on broken glass from his meal tray. The second fall incident was on [DATE] with no injuries. The licensed staff failed to provide adequate monitoring to Resident 1 who was very restless and agitated and was left unsupervised at 4 AM on [DATE]. Resident 1 fell , hit his head and developed a subdural hematoma. He was transferred to the hospital and died on [DATE]. Findings: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to Resident 1's Minimum Data Set (MDS- an assessment tool) dated [DATE], Resident 1 had clear speech, adequate vision, minimal hearing difficulty. The total score for his Brief Interview for Mental Status was 13. (A score of ,[DATE] indicated that the resident was cognitively intact.). He required one person physical assistance to perform activities of daily living including transfers to or from bed, chair, wheelchair, walk in corridor, locomotion on or off the unit, dressing, eating, toilet use and personal hygiene. The Resident was not steady, and only able to stabilize with human assistance when moving from seated to standing position, when walking with an assistive device, moving on and off the toilet, and during surface to surface transfer between bed and chair or wheelchair. He had impairment on one side of his upper extremity. The same MDS dated [DATE] also identified several active [DIAGNOSES REDACTED]. Review of the monthly Medication Administration Record for [DATE] indicated Resident 1 was receiving several routine medications ordered on [DATE] including the following medications: [REDACTED] 1. Lisinopril 40 mg. 1 tablet everyday -for hypertension. Hold for SBP (systolic blood pressure) less than 100. 2. Coreg 25 mg. one tablet twice a day for CHF (congestive heart failure) 3. Furosemide 40 mg one tablet everyday for CHF 4. Amlodipine 10 mg 1 tablet everyday -for hypertension hold for SBP less than 100. According to Geriatric Dosage Handbook 12th Edition, the possible adverse reaction from furosemide and lisinopril is orthostatic hypotension; amlodipine and Coreg can cause dizziness and hypotension. Review of Nurses Notes dated [DATE] at 7:45 AM indicated, " Resident was eating breakfast at the edge of the bed, at 7:20 AM, CNA (Certified Nursing Assistant) heard a loud sound, when check pt. (patient) found on the floor on R (right) side lying position, trays pushed away, foods scattered on the floor, glasses everywhere and urinal on his R (right) arm. Noted some bleeding on R (right) temporal area and R (right) forearm bleeding with broken glasses stuck on his arm ...called Paramedics and arrived in 30 minutes ... " Review of the Emergency Department record notes by Physician 3 dated [DATE] indicated, " ...he (Resident 1) had a mechanical fall, tripped and face planted into a glass bowl which quickly fell apart, suffering lacerations and abrasions to the anterior aspect of his body, including his face, right forearm, both hands and knee ... " Review of the Operative Record notes by Physician 2 dated [DATE] indicated, " Apparently during breakfast, he lost consciousness fell with his face striking the table and culinary dishes present ...He sustained a deep laceration over the right forearm into the muscle with significant hemorrhage at the site and also in the emergency room ... " Review of the Discharge Summary from Hospital X by Physician 1 dated [DATE] indicated, " The patient required two units of packed red blood cells on the day following admission ... " Review of the Fall, Physical Restraint, & Safety assessment Form dated [DATE] indicated Resident 1's Fall Risk Evaluation score was 38. A total score of ,[DATE] indicated a low risk for falls, ,[DATE] score indicated a moderate risk for falls, a total score of 16 or more indicated the resident was high risk for falls. Review of the Short Term Care Plan dated [DATE] indicated that Resident 1 was at high risk for falls caused by unsteady gait; medication; recent surgery/ hospitalization ; poor compliance with instructions/precautions; lost balance; transfer unassisted. The care plan also checked the resident as Moderate Risk: memory deficits; unsteady gait; history of falls; and presence of pain. The box for high risk was not checked despite a fall risk score of 38. Postural hypotension and dizziness were not specified as a potential factor that can cause falls secondary to the medications Coreg, amlodipine, lisinopril and furosemide that he was taking at that time before the fall on [DATE]. The Goal was that the Resident will be free of injury from falls; Risk factors will be evaluated and addressed. Interventions listed included: Assess contributing problems; b. PT/OT screen eval(evaluation); c. Need to be in bed for breakfast with HOB (Head of the Bed) up (not sitting @ edge of the bed); d. Call bell in reach in bed; d. Call bell in reach in chair; e. PT program for gait retraining; f. Side rails up times 2. g. Notify MD/family; h. Instruct to call for assistance with transfers/ambulation. There were no interventions listed in the above Short Term Care Plan dated [DATE] to address the problem of poor compliance with instructions/precautions. There were no interventions to address potential orthostatic hypotension and dizziness. The resident had an unwitnessed fall and could have a potential head injury but neuro check was not included in the interventions. There was no indication that breakable glassware and plates will not be used on meal trays to prevent potential injury from broken glass in the event that the resident accidentally drops the glass on the floor. Review of the facility policy and procedure titled, Fall Prevention Program-SNF dated ,[DATE], indicated, " Purpose: To prevent accidents and injuries by providing an environment that is free from hazards over which the facility has control. Policy: All residents' environment shall remain as free of accident hazard as is possible, and all residents shall receive adequate supervision and assistive devices to prevent accidents. " Review of facility's Fall Prevention Program dated ,[DATE] indicated Post Fall Procedures as follows: a. Following a resident 's fall, the licensed nurse shall assess the resident for injuries and necessary treatment. b. The licensed nurse shall immediately assess the following: Determine consciousness ... Complete neuro checks for all unwitnessed falls, falls where possible head trauma could have occurred, or known head injury, including blood pressure, hand grip, dizziness, unsteady balance, pupils reaction to light. If no apparent injury, assist off floor. Once up, do a lying and standing or sitting blood pressure (orthostatic B.P.). Protocol for Documentation: ...4. Fill out the Fall Assessment Form and place in back of the care plan section of the chart. Include Orthostatic B.P. 5. The IDT (Inter-Disciplinary Team) reviews the fall assessment and signs the form. 6. Document all information in Nurses Notes. " Review of the Discharge Summary Preliminary Report from Hospital X dated [DATE] indicated the discharge [DIAGNOSES REDACTED]. Review of the Nurses Notes dated [DATE] at 3:35 PM indicated that Resident 1 returned to the facility via ambulance following hospitalization for treatment of [REDACTED]. Review of Nurses Notes dated [DATE] at 6:45 am indicated the following, "...0600 (6AM) c (with) episode of angry outbursts for not getting the kind of food he ' s ordering from his menu. States of feeling hungry (sic) offered sandwich but he refused. Keeps on yelling, told resident to inform dietitian about his complaints. Refused morning meds ... At 0625 (6:25AM) found resident by the CNA sitting on the floor near his table. No injury noted. No evidence of hitting his head. Assist resident to get up c (with) two person assist. Resident upset, agitated, uncooperative, won ' t explain how the incident happened ...V/S (Vital Signs) T (Temp)-98 degrees, P (pulse) 68, R(respiration) 24, BP-,[DATE]." Review of facility 's Physician Orders showed a telephone order dated [DATE] at 3:50PM that stated, "Get orthostatic BP x1 then call back Physician 1". Further review of Nurses Notes dated [DATE] indicated, "...At 4:30 PM, notified Physician 1 about the orthostatic BP of the pt ..." Review of physician's orders dated [DATE] showed an order for [REDACTED]. Record review showed a Short Term Care Plan (Fall Care Plan) was developed on [DATE]. It documented the following: a. Resident is at risk for falls (Score 35) (A score of 35 indicated high risk for fall). At Risk/Causative Factors: Unsteady gait, sensory impairments, medication ..., recent surgery/hospitalization , poor compliance with instructions/precautions, lost balance, transfer unassisted. The care plan was marked for moderate risk: memory deficits, unsteady gait, history of falls, and presence of pain. The box for high risk was not marked. b. The Goals: Resident will be free of injury from falls; Risk factors will be evaluated and addressed. c. Approaches: a. Assess contributing problems; b. PT/OT screen eval (evaluation); Have MD review psych meds/dose; d. Try using plastic instead of glass on meal trays; e. Call bell in reach in bed; f. Call bell in reach in chair; g. PT program for gait retraining; h. Side rails up times 2. i. Notify MD/family; j. Instruct to call for assistance with transfers/ambulation. There was no intervention listed in this care plan to address the problem of poor compliance with instructions/precautions. There was no written plan to increase monitoring due to history of multiple falls. The box for neuro checks was not checked. The care plan was not updated to reflect the physician's order on [DATE] to apply tab alarm on the resident. Review of the Nurses Notes dated [DATE] at 3 PM indicated, "... After lunch, (Resident 1) became irritated and combative with CNA while assisting ADLs. Transfers with assist wheelchair. BP ,[DATE], (pulse) 73, FS (finger stick blood sugar) 171 at 11:30 AM. Express anger toward nurse f. After calming down, sitting in chair, BP ,[DATE]. Safety precautions. Refused tab alarm for chair ... " The Nurses Notes dated [DATE] at 6:30 AM documented the following: "Awake all night. Restless, agitated, refused CPAP machine. Tylenol given at 0110 (1:10 AM) for general discomfort with less efficacy. Verbalizes wants to go to the hospital in the 6 floor and would jump out of the building. Keeps on asking 'Why you keep me holding on? ' Attempts to get out of bed, placed resident in a wc (wheelchair) in front of nurses ' station ... Monitored through the night ... " Review of IDT Conference Summary notes dates [DATE] at 2PM showed the reason for assessment : Significant Change and Deterioration. It was documented that Resident 1 was at risk for accidents, had 2 fall incidents (on [DATE] and [DATE]) since last MDS assessment. He sustained multiple lacerations and bruises status [REDACTED]. Record review of the Nurses Notes dated [DATE] at 6:30 AM indicated the following: "At 0130 (1:30 AM) resident restless, agitated, took off his CPAP (Continuous Positive Air Pressure) machine, keeps on removing his tab alarm. Several attempts to get out of bed. At 0400 (4 AM) resident was being attended by the CNA. Resident was found lying on the floor near the foot part of his bed at 0405. Took off his tab alarm, can 't tell how the incident happened. Assessment done- found head laceration 2 x .5 cm (centimeters) oozing with blood. There was no documented evidence that the physician was notified on [DATE] and [DATE] to report the significant change and deterioration of Resident 1 ' s behavior demonstrated by increased agitation and restlessness before he fell on [DATE] at 4 am. The Physician 's Orders dated [DATE] at 4:15 am indicated "OK to transfer to ER for head laceration. " Review of the Consultation notes dated [DATE] dictated by Physician 4 indicated, "...The patient was reported to have fallen at his nursing facility at approximately 4:00 am, this morning. He was then transferred to Hospital X Emergency Department where he was noted to have a left parietal scalp laceration that was stapled closed. A head CT then demonstrated an acute left sided subdural hematoma and neurosurgical consultation was requested. Patient is DNR. (Do not Resuscitate)... I contacted the patient ' s son ... and discussed the radiographic and clinical findings with him in detail. At this point, given the patient ' s advanced age, multiple medical issues and the large subdural hematoma which would necessitate a craniotomy for evacuation, with the need for intubation and general anesthesia, the son does not wish to pursue surgical intervention. We did discuss that without surgical intervention he could progress to death or to persistent vegetative state. The son expressed understanding of this situation and did not wish to proceed with any invasive procedure at this time. " Review of the Medical Examiner 's Report on Resident 1 showed the following information: date of death : [DATE] Manner of Death: Accident Method:Fall Cause of Death: Complications of blunt trauma of head with subdural hemorrhage Other conditions: Dementia Review of the Night Shift Staffing Record (11:00 PM to 7:30 AM) provided by the facility indicated that on [DATE], the total number of staff was 5 (2 Licensed and 3 CNAs). CNA 1 who was assigned to Resident 1 had a total of 13 residents assigned to her. On [DATE] at 11:40 AM, a site visit was conducted at the facility. The DON accompanied the surveyor to the room that Resident 1 used to occupy. The room had a low bed, two upper side rails were up, the tab alarms were operable and laying near the head of the bed, call light was on the bed. The DON stated, "We left the room as it was." When asked about the tab alarm on the bed, the DON stated, " He (Resident 1) removed his tab alarm before and a mattress alarm annoyed the resident because they go off frequently. " During an interview with CNA 2 on [DATE] at 1:40 PM, she was asked to describe the fall incident on [DATE]. She said, " Resident 1 was on the floor, tray on the floor, food on the floor, urinal on the floor. He was conscious. He kept saying, ' I wanted to get up.' He had lost a lot of blood. " During an interview with CNA 1 on [DATE] at 3:55 PM, she was asked to describe Resident 1 's fall incident on [DATE]. She stated, " I'm working the night shift. I don't remember the date. To my shift, he (Resident 1) fell around 3:,[DATE]:30 AM. I stay with him by the door. He tried to get up. I called my charge nurse. She helped me and he sit by the bed. He said, 'I want to lay down.' He closed his eyes. I went to answer the call light. I did not tell to my charge nurse because I saw him sleeping. When I came back, I saw he fell . I told my charge nurse. I called her. He is alert. There is blood in the head. " During an interview with Charge Nurse 1 (CN 1) on [DATE] at 9 AM regarding the fall incident on [DATE], she stated that, "I saw CNA1 going from Resident 1's room. I was giving meds. My med cart was just 3 rooms away. I asked CNA 1 where Resident 1 was. She said, 'He's asleep '." During interview with the Director of Nursing (DON) on [DATE] at 4:30 PM, she agreed that that there were no interventions listed in the Short Term Care Plan dated [DATE] to address the problem of poor compliance with instructions/precautions. There was no indication that breakable glass will not be used on meal trays to prevent potential injury from broken glass in the event that the resident accidentally drops the glass on the floor. During interview with the DON on [DATE] at 4:45 PM, she confirmed that Resident 1 had another unwitnessed fall on [DATE]. She acknowledged that there was no documented evidence that the licensed staff that did the post fall assessment of Resident 1 on [DATE] did neuro checks that included checking hand grip, dizziness, unsteady balance, and pupils reaction to light. There was no evidence that a lying and standing or sitting blood pressure (orthostatic B.P.) was checked along with the vital signs after the resident was assisted off the floor after the fall at 6 AM on [DATE]. The resident ' s orthostatic BP was checked 10 hours later at 4:30 PM following a physician 's order. During interview with the DON on [DATE] at 4:55PM, the DON acknowledged that there was no evidence that the physician was notified or was there a treatment order to address Resident 1's change in behavior exhibited by increased restlessness and agitation on [DATE] and [DATE]. During interview with the DON on [DATE] at 5PM, she acknowledged that there was no evidence that on [DATE], the charge nurse requested for additional staffing to provide continuous monitoring for Resident 1 who has history of multiple falls who was restless and agitated, who knew how to remove his tab alarm and made several attempt to get out of bed. The facility failed to prevent accidents when one resident (Resident 1) had 3 fall incidents in his room while unsupervised. The facility used breakable glassware and plates on his meal tray until [DATE] despite the fact that the resident had a recent history of serious injury after falling on broken glass on [DATE]. The Resident was able to remove his tab alarm. The care plan was not revised or updated to address the ineffective use of the tab alarm as an assistive device to alert the staff to prevent falls. The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result, or a substantial probability the death or serious physical harm would result.