Every finding on record at Sherwood Healthcare Center

Based on observation, interview and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Employees were unable to demonstrate the correct concentration for sanitation solution, 2. Several pots, pans, bowls, and trays were found stacked wet (in ready to use areas), 3. Two frying pans were found darkened, stained, and scratched, 4. Three ladles, two saucepans, and a colander were found stored with a white film covering the food contact surfaces, 5. Two sandwiches stored in the refrigerator had missing information on label, and an opened gelatin container lacked any labeling, 6. Broken, chipped tiles and missing paint found on floor of kitchen and storeroom, 7. Frozen sausage patties were left open to the environment in freezer and a bag of penne pasta was not properly secured in the dry storage, 8. An in-use fan in the kitchen was covered in whitish, gray particles, directed into the food preparation area, and 9. A cell phone was found lying on the food preparation counter. These failures had the potential to lead to cross contamination and food borne illness for the 51 residents eating facility prepared meals. Findings: 1. During the initial kitchen tour on [DATE] at 8:26 a.m. Dietary Aide 1 (DA 1) demonstrated how to check the sanitation concentration in the red bucket used to sanitize fixed equipment and kitchen work surfaces. DA 1 took a test strip and placed it into solution for approximately 5 seconds, stating that the goal for the strip was to change to the color that indicated the solution was at 200 parts per million (ppm). When removed, the test strip did not change to the desired color and a second strip was used with the same outcome. Dietary [NAME] (DC) replaced the solution with fresh solution and tried testing with a second package of test strips. Again, the test strip did not change to the color of the strip indicating the correct concentration. Reading of the test strip bottle directions for the first strip showed the strip needed 90 seconds in solution, while the second strip required 10 seconds. DC tried both types of strips again, following the directions, but neither showed the correct concentration. Review of expiration date on the bottle of the first strips indicated that they had expired as of ,d+[DATE] ([DATE]), while the second bottle did not have an expiration date. During a review of the concentration log filled in for the Month of May, it indicated that the test earlier that morning had reached 200 ppm, as well as all previous readings for the month of May. During a return visit to the kitchen on [DATE] at 1:52 p.m. DA 2 stated that the red sanitation bucket was changed at the beginning of the shift by refilling buckets and changing out the cleaning rags. DA 2 demonstrated checking the concentration, stating the goal was to be at 200 ppm. DA 2 held the test strip in the sanitation solution for approximately 8 seconds. The removed test strip did not show the color change, indicating the proper concentration. After reading the bottle instructions, DA 2 stated it needed to be in the solution for 90 seconds. During an interview on [DATE] at 11:40 a.m. with the Registered Dietitian (RD), the RD stated that not having the correct sanitizer concentration leads to uncertainty in the ability to sanitize surfaces. The RD further stated that the concentration could be too high which could be a danger to the residents, we want it to be the right concentration. During an interview on [DATE] at 3:20 p.m. with the DS, the DS stated that The surface needs to be sanitized properly. We need the bacteria to be killed. Review of facility provided policy titled Sanitation (2001 Med-Pass, Inc.) indicated The food service area is maintained in a clean and sanitary manner. It further indicated in bullet 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using . chemical sanitizing solutions. 5. b. (3) The chemical solution is maintained at the correct concentration, based on periodic testing . 8. When cleaning fixed equipment (e.g., mixers, slicers, and other equipment that cannot readily be immersed in water), the removable parts are a. washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution (at the effective concentration) . 2. During the initial kitchen tour on [DATE] at 8:46 a.m., Two out of Four large pots noted on a shelf of the steam table, were stored upright with water collected at the bottom of the pot. During an interview on [DATE] at 9:48 a.m. the DS stated that the pans should be turned upside down on drying rack to air dry completely, as pooling water can lead to bacterial growth. During the initial kitchen tour on [DATE] at 8:57 a.m., a stored sheet pan had collected water in corner and a colander was stored with water still on the surface. During an interview on [DATE] at 9:48 a.m., the DS stated that the pots and pans needed to be air dry before storing. During an interview on [DATE] at 11:42 a.m. with the RD, the RD stated My expectation would be the utensils, pots and pans should be stored once completely dry. We don't want an environment for bacteria to grow. Review of facility provided policy titled Sanitation (2001 Med-Pass, Inc.) indicated in bullet 7. Food preparation equipment and utensils that are . washed are allowed to air dry . 3. During the initial kitchen tour on [DATE] at 9:05 a.m., 2 out of 3 fry pans were found with dark brown staining, and scratches over the cooking surface. During an interview on [DATE] at 9:48 a.m. with the DS, the DS stated these pans should not be used as they could no longer be cleaned and sanitized properly. Review of facility provided policy titled Sanitation (2001 Med-Pass, Inc.) indicated in bullet 12. Damaged or broken equipment that cannot be repaired is discarded. Review of the US Food and Drug Administrations 2022 Food code section ,d+[DATE].12 on Cooking and Baking Equipment indicated Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. 4. During the initial kitchen tour on [DATE] at 9:12 a.m., three sheets of pans were stored in the ready-to-use area but covered with a white coating on the surface. Two large mixing bowls had white discoloration, and a colander also had a white film. Two black handle ladles and one with a white handle were noted with white staining on the surface. During an interview on [DATE] at 9:48 a.m., the DS stated they all needed to be rewashed. During an interview on [DATE] at 11:42 a.m., the RD stated the kitchen utensils with the white residue were likely covered with soap residue from the dishwasher. The RD further stated I don't want white residue on food service utensils. I expect those items to be clean. Review of facility provided policy titled Sanitation (2001 Med-Pass, Inc.) indicated in bullet 6. b. Rinse with hot water to remove soap residue . 5. During the initial kitchen tour on [DATE] at 9:26 a.m., two sandwiches (a peanut butter and jelly as well as a ham) were in the reach-in refrigerator with a date of ,d+[DATE]. During the initial kitchen tour on [DATE] at 9:38 a.m. in the dry storage, an opened bag of gelatin was found without an open date or use by date. Review of storage guidelines on the wall indicated that the gelatin was good for 3 months after opening. During an interview on [DATE] at 9:48 a.m., the DS stated that labeling should include the year. The DS further stated that since the gelatin lacked any dating, it would not be possible to determine if it was still safe. During an interview on [DATE] at 11:42 a.m., the RD stated that food labels should include the date received, date opened, and the used-by date. It should have the full date including the year as You don't know if it was there for the whole year. They [staff] might use the [unsafe] food and could get the residents sick. Review of facility provided policy titled Food Receiving and Storage (2001 Med-Pass, Inc.) indicated Foods shall be received and stored in a manner that complies with safe food handling practices. It further indicated in bullet 4 in the section on Dry Food Storage that . foods . stored . labeled and dated (use by date). Such foods are rotated using a 'first in-first out' system. In the section on Refrigerated/Frozen Storage bullet 7. Refrigerated foods are labeled, dated and monitored so they are used by their 'use-by' date, frozen, or discarded. 6. During the initial kitchen tour on [DATE] at 9:25 a.m. broken, chipped tiles were noted in the dry storage, and paint was chipped from on the floor of kitchen on either side of the stove. During an interview on [DATE] at 9:48 a.m. the DS concurred that the floors on either side of oven had peeling paint which compromised the ability to clean and sanitize it. Review of the US FDA 2022 Food Code section ,d+[DATE].11 on Repairing indicated that Physical Facilities shall be maintained in good repair. It further indicated that Poor repair and maintenance compromises the functionality of the physical facilities. Review of the US FDA 2022 Food Code section ,d+[DATE].11 on Surface Characteristics indicated . (B) . materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: (1) smooth, durable, and easily cleanable for areas where food establishment operations are conducted; . Review of the US FDA 2022 Food Code section ,d+[DATE].12 on Cleaning, Frequency and Restrictions indicated that Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. 7. During the initial kitchen tour on [DATE] at 9:32 a.m. in the reach-in freezer a box of sausage patties was left open to the environment when the inner bag was not closed. In the dry storage, an opened bag of penne pasta that had been twisted but not secured. During an interview on [DATE] at 9:48 a.m. the DS stated that he expected opened food products to be closed tightly to keep food safe from cross contamination. The DS further stated the penne pasta should have been placed in a plastic, zip lock bag. Review of facility provided policy titled Food Receiving and Storage (2001 Med-Pass, Inc.) indicated Foods shall be received and stored in a manner that complies with safe food handling practices. In the section on Dry Food Storage it indicated in bullet 3. Dry foods . are . stored in a manner that maintains the integrity of the packaging until they are ready to use. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ('use by' date). 8. During the initial kitchen tour on [DATE] at 8:36 a.m. a large fan was noted to be covered in white and gray particles, in use, and blowing onto the food preparation area during the lunch preparation. During an interview on [DATE] at 9:48 a.m. the DS stated the fan appeared dusty and needed cleaning. During a review of the US FDA 2022 Food Code section ,d+[DATE].11 on Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated in (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The objective of cleaning focuses on the need . to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 9. During the initial kitchen tour on [DATE] at at 9:45 a.m. a cellphone was stored on the food preparation counter. During an interview on [DATE] at 3:20 p.m., the DS stated that cellphones were not to be in the kitchen due to the potential of cross contamination. Review of the US FDA Food Code section ,d+[DATE].11 on Equipment Food-Contact Surfaces and Utensils indicated (A) Equipment food-contact surfaces and utensils shall be cleaned: . (5) At any time during the operation when contamination may have occurred. 52669

Based on observation, interview, and record review, the alternative food options provided to residents who choose the peanut butter and jelly (PB&J), or grilled cheese sandwiches were not of similar nutritive value to the main entree. This failure had the possibility of leading to malnutrition and weight loss. Findings: During a visit to the kitchen during lunch meal plating on 5/8/25 at 11:25 a.m., a grilled cheese sandwich was prepared and left on the grill. Dietary [NAME] (DC) stated it was for a resident who had ordered the sandwich for lunch instead of the main meal. During the lunch meal plating, Resident 162 had a standing order for a half of a PB&J sandwich and a cup of soup instead of the main meal. During an interview with the Registered Dietitian on 5/08/25 at 11:42 a.m., the RD stated grilled cheese & PB& J sandwiches need to have an additional protein source added to the meal such as cottage cheese or yogurt. Without an additional protein source, the meal would not be equivalent to the main meal. Review of facility provided recipe Grilled Two-Cheese Sandwich (Healthcare Menus Direct, LLC.) indicated that each sandwich contained 2 slices of bread, 2 teaspoons of margarine and 2 ounces of cheese. This would provide approximately 414 calories and 18 grams of protein. Review of facility provided recipe Peanut Butter and Jelly Sandwich (Healthcare Menus Direct, LLC.) indicated that each sandwich contained 2 slices of bread, 2 tablespoons of peanut butter, and 1-2 tablespoons of jelly. This would provide approximately 588 calories and 20 grams of protein. Note 4 ounces of chicken from the lunch meal would provide 32 grams of protein and the meal would provide over 700 calories. 52669

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 54 when: 1. Dust particles were observed on the vents above the clean linen area and the fan blades had accumulated blackish particles; 2. The log for lint cleaning was incomplete and clean items were stored in the soiled linen area; 3. The utility room was used to store medical supplies and containers used for soiled linens/trash; and, 4. A container of opened and unlabeled distilled water (a purified water that's been boiled to remove impurities and minerals) was observed on the floor for Resident 53. These failures increased the risk for cross contamination (movement or transfer of harmful bacteria from one person, object, or place to another). Findings: 1. A concurrent observation and interview was conducted on 5/8/25 starting at 7:36 a.m., with Laundry Staff 1 (LS 1) and the Housekeeping and Laundry Supervisor (HLS) in the clean linen area. The fan located on top of the table in the folding area had accumulated blackish particles on the fan blades and the 2 vents above the clean linen area had dust particles. The HLS confirmed the findings and stated the fan was dirty and it should be cleaned. 2. A concurrent observation and interview was conducted on 5/8/25 at 7:42 a.m., in the soiled linen area with the HLS. The daily lint cleaning log for 5/7/25 was incomplete and there were stack of pillows and mop heads in the room. The HLS confirmed the daily lint cleaning log was not signed on 5/7/25 from 4:30 p.m. to 10:30 p.m. The HLS stated there was laundry done on those times. The HLS further stated her expectation was for laundry staff to clean the lint and document in the log every 2 hours as scheduled. The HLS stated the pillows and mop heads were clean. In a follow up interview on 5/8/25 at 7:57 a.m., the HLS stated if the particles from the fan blades and the vent goes to the clean linens, the clothes or linens become unclean. The HLS further stated all laundry and housekeeping staff are responsible in keeping the laundry area clean, the vents are cleaned every month and as needed. 3. A concurrent observation and interview was conducted with the Infection Preventionist (IP) on 5/8/25 at 4:04 p.m. inside utility room [ROOM NUMBER]. The IP confirmed the soiled linen and trash containers were stored in the same room where medical supplies, oxygen concentrators and personal hygiene supplies were stored. One container was overflowing, the lid was open and there was a clear plastic bag containing soiled linen. The IP confirmed the findings and the IP stated there was a potential for cross contamination. In an interview on 5/9/25 at 11:15 a.m., the Director of Nursing (DON) agreed the containers for the soiled linen/trash should not be in the same room with the medical supplies. The DON further agreed the pillows and mop heads should not be in the dirty linen room. The DON stated there is a potential for cross contamination. A review of the facility's policy revised December 2009 and titled, Storage Areas, Environmental Services indicated, Housekeeping and laundry department storage areas shall be maintained in a clean and safe manner .All housekeeping and laundry storage areas shall be kept free from accumulation of trash, rubbish, oily .etc., at all times. A review of an undated facility policy and titled, Lint Removal Policy indicated, .All lint traps in facility dryers shall be cleaned each day to reduce fire hazards and maintain efficiency .All staff operating laundry machines must clean lint traps regularly .Staff will log each lint trap cleaning in the laundry maintenance logbook, including date and initials. A review of the facility's policy revised January 2014 and titled, Departmental (Environmental Services) - Laundry and Linen indicated, .Consider all soiled linen to be potentially infectious and handle with standard precautions .All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture .Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination . 48445 4. During a review of Resident 53's admission records, the records indicated Resident 53 was admitted in April 2025 with diagnoses that included chronic obstructive pulmonary disease (COPD, chronic lung disease causing difficulty in breathing) and obstructive sleep apnea (breathing pauses during sleep). Resident 53's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 53 had moderate cognitive impairment. During a review of Resident 53's physician order, dated 4/7/25, the order indicated, CPAP [continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in]: CHECK DISTILLED WATER RESERVOIR QPM [every night] IF NEED ADD WATER at bedtime . During a review of Resident 53's care plan, initiated on 4/9/25, the care plan indicated, [Resident 53] has Obstructive sleep apnea .Refer to MD [medical doctor] orders for care and instructions for CPAP. During a concurrent observation and interview on 5/6/25 at 10:19 a.m. with Resident 53 in his room, an opened, unlabeled, one gallon container of distilled water with less than 100 milliliters of liquid remaining was observed on the floor. Resident 53 stated he had CPAP treatment last night and the jug was being used for his CPAP treatments every night. During a concurrent observation and interview on 5/6/25 at 10:33 a.m. with the Infection Preventionist (IP), the IP observed and confirmed the opened, unlabeled gallon of distilled water on the floor. The IP stated it was okay for the jug to be on the floor and stated, It's in the bottle so it's still contained in there . During an interview on 5/6/25 at 10:42 a.m. with Licensed Nurse 5 (LN 5), LN 5 stated Resident 53 had CPAP treatments every night. LN 5 further stated distilled water was used as humidifier. During an interview on 5/6/25 at 10:45 a.m. with LN 2, LN 2 stated distilled water is used for CPAP and is used after opening until it is consumed. LN 2 further stated, We're not supposed to keep it on the floor, it is not sanitary . During a concurrent observation and interview on 5/7/25 at 10:47 a.m. with Resident 53 in his room, an opened and unlabeled one gallon container of distilled water with 3/4 of liquid remaining was observed on top of the nightstand. Resident 53 stated he had CPAP last night. During a follow up observation on 5/8/25 at 9:07 a.m. with Resident 53 in his room, the opened container of distilled water was still unlabeled. During an interview on 5/9/25 at 9:36 a.m. with the IP, the IP stated the expectation was for staff to not place the distilled water on the floor due to infection. The IP further stated she did not see any label on the distilled water and stated the expectation was to label the jugs upon opening to know if it is still good to be used. During an interview on 5/9/25 at 11:47 a.m. with the Director of Nursing (DON), the DON stated, We can't put it [distilled water jug] on the floor for infection control . During a review of the facility's policy and procedure (P&P) titled CPAP/BiPAP [Bilevel positive airway pressure, a device that pushes pressurized air into the lungs] Support, revised 3/2015, the P&P indicated, .5. Humidifier (if used): a. Use clean, distilled water only in the humidification chamber . During a review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, the P&P indicated, .1. Distilled water used in respiratory therapy must be dated and initialed when opened, and discarded per manufacturer guidelines .

Based on observation, interview and record review, the facility lacked a dedicated refrigerator for storing food brought for residents by family or visitors. This failure had the potential to limit food intake due to the inability to store preferred foods. Findings: During an interview on 5/8/25 at 8:40 a.m. with Certified Nursing Assistant 1 (CNA 1) on Hallway 2, CNA 1 stated that food could be brought in for residents. The food would be checked against the diet order as well as checked for safety before being given to the resident. The residents would have 2 hours to consume it and after that, the food would be considered unsafe and would be discarded. When asked if residents could store food, CNA 1 stated the facility does not store food as they do not have a resident refrigerator. During an interview on 5/8/25 at 8:45 a.m. on Hallway 1 with CNA 2 stated that food brought into the facility for residents would not be saved as there was no place to store the food. During an interview on 5/8/25 at 9:30 a.m. with Licensed Nurse 2 (LN 2) stated that leftovers of food from outside would be given back to the family or it will be thrown away after 2 hours. Review of facility provided policy titled Bringing In Food For A Resident (undated) indicated in the last bullet that A resident refrigerator and microwave is available if needed . 52669

Based on interview and record review, the facility failed to ensure professional standards of care were followed for three of 23 sampled residents (Resident 3, Resident 31, and Resident 45), for a census of 54, when: 1. Resident 3's weight change was not reported to the physician as ordered; 2. Resident 45's weight changes were not reported to the physician as ordered; 3. Resident 31's arm circumference and catheter length were not recorded during midline catheter (a thin, soft tube placed into a large vein in the upper arm) dressing change as ordered; 4. Resident 31's Midodrine (medication used to treat low blood pressure) doses were administered outside the blood pressure parameters; and, 5. Resident 31's Midodrine administration records were altered. These failures increased the risks for residents to not receive interventions in a timely manner and, medication administration was not accurately documented. Findings: 1. A review of the clinical record indicated Resident 3 was admitted [DATE] with diagnoses including chronic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). A review of Resident 3's physician order dated 3/10/25 indicated, Daily Weight monitoring .Weigh resident daily first thing in the morning. Notify MD [Medical Doctor] if weight change of 3 pounds or more in one day. A review of Resident 3's care plan dated 3/15/25 indicated, Resident 3 had congestive heart failure and the interventions included, Weight monitoring per MD orders. A concurrent interview and record review was conducted on 5/9/25 at 10:18 a.m. with the Director of Nursing (DON). Resident 3's physician orders and weights were reviewed with the DON. The DON stated daily weights are done for residents with CHF and the physician was to be informed when there was a weight loss or gain. The DON confirmed Resident 3's weight on 3/21/25 was 135.6 pounds and the weight on 3/22/25 was 127.2 pounds, a weight loss of 8.4 pounds in one day. The DON further stated for this weight change, the physician should have been notified. 48445 2. During a review of Resident 45's admission records, the records indicated Resident 45 was admitted to the facility in February 2025 with diagnoses that included Congestive Heart Failure(CHF). Resident 45's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 45 had severe cognitive impairment. During a review of Resident 45's care plan, initiated on 2/24/25, the care plan indicated, [Resident 45] has Congestive Heart Failure .Weight monitoring per MD orders . During a review of Resident 45's physician order, dated 2/10/25, the order indicated, Daily Weight monitoring R/T [related to] CHF: Weigh resident daily first thing in the morning. Notify MD if weight change of 3 pounds or more in one day . During a review of Resident 45's weight record, the following weights had changes of three pounds or more in one day: -4/11/25: 116.4 lbs and 4/12/25: 120 lbs = 3.6 lbs change; -4/18/25: 118 lbs and 4/19/25: 121 lbs = 3 lbs change; -4/27/25: 121 lbs and 4/28/25: 117.6 lbs = 3.4 lbs change; -5/2/25: 118 lbs and 5/3/25: 121 lbs = 3 lbs change; -5/3/25: 121 lbs and 5/4/25: 124 lbs = 3 lbs change; and -5/4/25: 124 lbs and 5/5/25: 120 lbs = 4 lbs change. During a concurrent interview and record review on 5/9/25 at 10:28 a.m. with Licensed Nurse 4 (LN 4), LN 4 confirmed Resident 45's physician order for weight monitoring and to notify physician for weight changes of three pounds or more in one day. LN 4 verified the reviewed weight changes were three pounds or more in one day and that the doctor should have been notified of the changes as ordered. LN 4 confirmed there was no documented evidence that the physician was notified of the weight changes and stated, The resident is at risk for fluid overload. During a concurrent interview and record review on 5/9/25 at 11:47 a.m. with the DON, the DON verified the physician order for daily weight monitoring was to notify physician for three pounds or more weight change in one day. The DON confirmed Resident 45 had multiple days weight change of three pounds or more in one day and stated, We do have a communication paper, we are supposed to have the doctor review [the weight] .I expect [staff] to chart it somewhere .If the resident needed the intervention at that time, he would not receive the intervention . During a review of the facility's policy and procedure (P&P) titled Heart Failure - Clinical Protocol, revised 11/2018, the P&P indicated, .Treatment/Management .1. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights, .etc.) to monitor, when to report findings to the physician, etc .Monitoring and Follow-Up .1. The physician will help monitor the progress of individuals with HF [heart failure], including ongoing evaluation and documentation of signs, symptoms, and condition changes . 3. During a review of Resident 31's admission records, the records indicated Resident 31 was admitted to the facility in April 2025 with diagnoses that included orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), hypoosmolality (a condition where levels of minerals, proteins, and nutrients in the blood are lower than normal), and hyponatremia (occurs when the concentration of the mineral sodium in the blood is abnormally low). Resident 31's MDS indicated Resident 31 had moderate cognitive impairment. During a review of Resident 31's physician order, dated 4/25/25, the order indicated, CHANGE MIDLINE DRESSING QWEEK [every week] AND PRN [as needed] FOR SOILED OR DISPLACED. Measure mid upper arm circumference [perimeter of a circle] and external catheter line length in cm [centimeter, a unit of measurement] .during IV [intravenous, through a vein] dressing change, Notify MD/NP[nurse practitioner] if any discrepancies noted compared to previous weeks measurements . During a concurrent interview and record review on 5/8/25 at 9:40 a.m. with LN 2, LN 2 confirmed Resident 31 had a midline on the left upper arm and confirmed the order for measuring arm circumference and catheter length during dressing change. LN 2 confirmed Resident 31 was scheduled to have the midline [upper arm] dressing changed on 5/1/25 and LN 2 verified she signed the administration and coded it as Hold/See Progress Notes. LN 2 verified there was no documentation on the measurements when the dressing was changed and LN 2 stated, I don't see it here .Important because if there was no measurement, there's nothing to compare it with . During a review of Resident 31's administration note, created 5/8/25 at 10:12 a.m., the note indicated an entry was made regarding the midline dressing change and measurement and had an effective date of 5/2/25. During a review of Resident 31's Medication Administration Notes (MAR), the MAR indicated measurements for arm and catheter length were entered on 5/2/25. During an interview on 5/8/25 at 11:37 a.m. with LN 2, LN 2 stated, .Thursday I was supposed to change [dressing], it was delivered Friday 5/2/25, measurement 9 cm, 22 cm arm circumference, I called ADON [Assistant Director of Nursing] .I did the measurements, we recalled it, I entered the measurements today [5/8/25]. LN 2 stated that the expectation was that the measurements should have been recorded on the day of the dressing change. During a concurrent interview and record review on 5/8/25 at 12:22 p.m. with the DON, the DON confirmed the note dated 5/2/25 was created on 5/8/25 as a late charting. The DON further stated staff should measure the arm and catheter during dressing changes and stated, .Important, then we can see if there are any discrepancies with the measurements, that the line is still intact . During a review of the facility's P&P titled Peripheral and Midline IV Dressing Changes, revised 10/2024, the P&P indicated, .8. For midline catheters, measure arm circumference and compare to baseline when clinically indicated to assess for edema [swelling] and possible deep-vein thrombosis [clot formation] . 4. During a review of Resident 31's physician order, dated 4/9/25, the order indicated, Midodrine .10 MG [milligrams, a unit of measurement] Give 1 tablet by mouth with meals for Orthostatic hypotension Hold for SBP [Systolic Blood Pressure, the higher number in the blood pressure reading representing the force of blood pushing against the artery walls when the heart beats] > [greater than] 130. During a review of Resident 31's care plan, initiated 4/9/25, the care plan indicated, [Resident 31] has hypotension .Give medications as ordered. Monitor for side effects and effectiveness. Follow hold parameters for medication if ordered . A review of Resident 31's MAR indicated Midodrine was administered on the following dates and times with their corresponding blood pressures: -4/15/25 8 a.m. - 139/86 mmHg (millimeters of Mercury, a unit of pressure measurement); -4/17/25 8 a.m. - 134/84 mmHg; -4/17/25 6 p.m. - 132/80 mmHg; -4/22/25 8 a.m. - 131/89 mmHg; -4/25/25 8 a.m. - 159/91 mmHg; -4/27/25 12 p.m. - 133/66 mmHg; -4/30/25 6 p.m. - 140/87 mmHg; -5/1/25 12 p.m. - 140/78 mmHg; and -5/4/25 6 p.m. - 156/88 mmHg. During a concurrent interview and record review on 5/8/25 at 4:28 p.m. with LN 3, LN 3 confirmed Resident 31 had an order for Midodrine and to hold the medication if SBP is more than 130 mmHg. LN 3 verified Resident 31 received Midodrine for multiple days with SBP more than 130 mmHg and stated, They [staff] did not follow the MD order because it was out of the parameter .If MD order was not followed, BP could get too high . During a concurrent interview and record review on 5/9/25 at 11:47 p.m. with the DON, the DON confirmed Resident 31 had an order for Midodrine and to hold the medication if SBP is more than 130 mmHg. The DON verified Resident 31 received Midodrine for multiple days with SBP more than 130 mmHg. The DON stated she spoke with one of the nurses who administered Midodrine and the nurse stated, I was clicking too fast. The DON further stated, [Staff] said they didn't give it .They really need to take their time .They need to document correctly .If they gave it, the BP will be higher . During a review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed . 5. During a concurrent interview and record review on 5/8/25 at 4:28 p.m. with LN 3, LN 3 confirmed Resident 31 had an order for Midodrine and to hold the medication if SBP is more than 130 mmHg. LN 3 verified Resident 31 received Midodrine on 4/30/25 at 6 p.m. with blood pressure of 140/87 mmHg, and on 5/4/25 at 6 p.m. with blood pressure of 156/88 mmHg. LN 3 stated, Expectation is to pay attention with charting, what you wrote is what you did . During a review of Resident 31's administration notes, created 5/9/25, the notes indicated entries were made for the administration of Midodrine with effective dates of 4/30/25 and 5/4/25. During a review of Resident 31's MAR, the MAR indicated Midodrine was changed from administered to Vitals Outside of Parameters for Administration for 4/30/25 at 6 p.m. and 5/4/25 at 6 p.m. During an interview on 5/9/25 at 3:42 p.m. with LN 3, LN 3 stated, I looked back and it was me that did incorrect documentation .I needed to pay close attention .I went back and fixed it .Changed it from administered to hold .I thought it was okay since I remember not giving it. LN 3 stated she spoke with the DON and stated, She said that we can fix it, to backdate what I actually did instead of what I did when I was rushing .It's not something I should always do .It's important to document accurately and timely as well . During an interview on 5/9/25 at 3:47 p.m. with the DON, the DON stated, I followed up with [LN 3] and we looked at the MAR together .I told her to fix her charting .[LN 3] said she held it .[LN 3] changed it from administered to hold .[LN 3]'s telling me she didn't give it .I don't think this is falsification, they know their patients. During an interview on 5/9/25 at 3:49 p.m. with the Nurse Consultant (NC), the NC stated, .We want it to reflect what was already done .Anything more than 30 days, it's going to be hard to remember . During a review of the facility's P&P titled Charting and Documentation, revised 7/2017, the P&P indicated, .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . During a review of the facility's P&P titled Charting Errors and/or Omissions, revised 12/2006, the P&P indicated, Accurate medical records shall be maintained by this facility .3. If it is necessary to change or add information in the resident's medical record, it shall be completed by means of an addendum and signed and dated by the person making such change or addition .5. No erasures or deletions shall be made in the medical record .

Based on observation, interview and record review food was not prepared by methods that conserve nutritive value, flavor, and appearance when 1) recipes were not followed, and 2) hot food was not consistently provided to residents in the 2nd hall. This failure had the potential to lead to poor intake, nutrient deficiencies, and malnutrition for the 51 residents eating facility-prepared foods. Findings: 1. During a visit to the kitchen on 5/7/25 at 9:30 a.m. Dietary [NAME] (DC) was preparing the lunch meal which consisted of Sweet and Sour Chicken, Sesame Noodles, Stir Fry Vegetables, Mandarin Asian Salad, and a Lemon Snow Bar. Review of facility provided recipe Sweet & Sour Chicken (Healthcare Menus Direct, LLC, 2024) was reviewed with DC. DC stated that since not everyone was eating the main entree, she would be following the recipe to make 48 servings. For the chicken the recipe required 12 pounds of chopped chicken, sugar, low sodium soy sauce, egg, carrots, garlic, onions, green pepper, red pepper, oil, and pineapple. The sauce recipe included pineapple juice, cornstarch, brown sugar, rice vinegar, soy sauce, and ground ginger. DC had two 5-pound (lb., a unit of measure) packages of thawed, cooked, diced chicken on the counter. DC started the entree preparation by warming the diced chicken (1/2 bag at a time), in a heated, oiled pan on the stove. Once the diced chicken was warm, DC transferred the diced chicken into a steam table pan and placed the steam table pan on the heated steam table. Once all the diced chicken was warmed and transferred, DC added an unmeasured amount of canned pineapple into the steamtable pan with the chicken (approximately 1/6 of a 96 ounce can or two cups). Lastly, DC poured an unmeasured amount of bottled sweet and sour sauce on the chicken (approximately 1/2 of the 128-ounce bottle or 64 ounces). Note: The actual preparation included only chicken, oil, pineapple and bottled Sweet & Sour sauce (4 ingredients) versus the 17 ingredients included in the recipe. DC next removed 4 ounces of the sweet and sour chicken and placed it in the blender to create a pureed (smooth consistency for those with swallowing difficulty) version of the entree. DC took the blender to the water Faucet and added an unmeasured amount of water. After blending the chicken/water mixture for around 5 seconds, DC stated that it needed more fluid. The surveyor asked if water was the best fluid for the entree. Instead of water, DC added an unmeasured amount of sweet and sour sauce and blended the mixture for a few seconds, again not finding it to be the proper consistency. DC added more tap water (unmeasured) plus 1 plastic spoonful of thickener (aka. stabilizer) and blended the mixture, finding the consistency acceptable. Review of facility provided recipe Pureed (IDDSI Level 4) Meats (Healthcare Menus Direct, LLC. 2024) included the following directions: 1. Complete a regular recipe. Measure out the total number of portions . needed . 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy. See above for recommended amounts of liquid, starting with the small amount and adding in more as needed to achieve the desired consistency. 4. Add a stabilizer to increase the density of the pureed food if needed. DC moved on to puree the vegetables by adding 4 ounces of the stir fry vegetables and an unmeasured amount of chicken broth to the blender. After blending, DC found the consistency too thin and added a plastic spoonful of thickener. After blending, DC added another half of plastic spoonful of thickener and blended. DC poured the pureed items into a steam table pan on the steam table. Review of facility provided recipe Pureed (IDDSI Level 4) Vegetables (Healthcare Menus Direct, LLC. 2024) indicated the following directions: 1. Complete a regular recipe. Measure out the total number of portions . needed . 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or milk) if needed. See above for recommended amounts of liquid, start with the smaller amount and adding in more as needed to achieve the desired consistency. 4. Puree on low speed, adding stabilizer where needed. See above for amounts. During an interview on 5/8/24 at 11:40 a.m. with the Registered Dietitian (RD), the RD stated that the Dietary [NAME] should follow the recipe including using all ingredients to ensure that the calculated nutrients were provided. The RD further stated that measuring ingredients was also expected so that the right amount of nutrients was provided. Leaving out ingredients or not measuring ingredients could also change the flavor and the Dietary Cooks need to be consistent in food preparation. The RD also expected the Dietary Cooks to follow the recipe for the pureed diet for the consistency of the food to be correct. The Dietary [NAME] shouldn't be using water, it should be the sauce from the food or a broth but should avoid water as it is not a safe way to make it. It alters the nutrients and flavors as it dilutes the product. During an interview on 5/8/25 at 3:20 p.m. with the Dietary Supervisor (DS), the DS stated that the Dietary Cooks need to follow the instructions of recipes as well as the measurements. The problem is that the nutrients won't be correct, and the taste won't be consistent. 2. During the initial interview on 5/6/25 at 8:43 a.m., Resident 50 stated she can't eat the food here as it is not hot across the board. During the initial interview on 5/6/25 at 10:15 a.m., Resident 8 complained about the food not being hot, especially the grilled cheese sandwich. During the initial interview on 5/6/25 at 1:20 p.m., Resident 15 stated, Food is not hot, and cold food is not cold. During an interview on 5/8/25 at 3:20 p.m. with the Dietary Supervisor (DS), the DS stated he had heard some complaints regarding the temperature of the food. In general, when this occurs, he looks for a root cause though unsure of the reason for this hallway's food complaints. 49849 52669

Based on interview and record review, the facility failed to ensure proper treatment to maintain vision ability was provided for one of 23 sampled residents (Resident 24) when Resident 24's prescription was not carried out as ordered by the eye doctor. This failure had the potential to cause deterioration of Resident 24's vision. Findings: During a review of Resident 24's admission records, the records indicated Resident 24 was admitted in July 2022 with diagnoses that included dry eye syndrome of lacrimal gland (a condition where the gland located behind the eyelids does not produce enough tears to adequately lubricate the eyes). Resident 24's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 24 had moderate cognitive impairment. During a review of Resident 24's care plan, initiated on 12/6/23, the care plan indicated, [Resident 24] has impaired visual function r/t [related to] dry eyes .Review medications for side effects which affect vision . During a review of Resident 24's eye doctor consultation notes, dated 3/12/25, the notes indicated Resident 24 had Entropion (an eyelid malposition where the eyelid turns inward, causing the eyelashes to rub against the eye) on the right lower eyelid. The notes further indicated an order for Theratears (used to relieve dry, irritated eyes) three times daily on the right eye. During a review of Resident 24's list of active physician orders, the list did not indicate Theratears was added to Resident 24's medications. During an interview on 5/9/25 at 11:41 a.m. with Licensed Nurse 4 (LN 4), LN 4 stated, If there are new orders from eye doctors or from appointments, I verify with the doctor and carry out, and notify DON [Director of Nursing] for new orders. During a concurrent interview and record review on 5/9/25 at 11:47 a.m. with the DON, the DON confirmed the eye doctor notes dated 3/12/25 indicated a new order for Theratears and that it was not carried out when it was ordered. The DON confirmed there was no documentation of the reasons why the order was not carried out. During a review of the facility's policy and procedure (P&P) titled Sensory Impairments - Clinical Protocol, revised 3/2018, the P&P indicated, .4. The physician will identify and order appropriate consultations to help manage the causes, complications, and risks of sensory impairment .Monitoring .2. The physician and staff will adjust interventions based on the results of these interventions and on subsequent changes in the resident's condition, prognosis, and function.

Based on observation, interview, and record review, the facility failed to ensure the care plan for the use of anticoagulant (medication that prevent or delay formation of blood clots) was implemented for one of 23 sampled residents (Resident 3), for a census of 54. This failure increased the risk for Resident 3 to experience serious side effects. Findings: A review of the clinical record indicated Resident 3 was admitted [DATE] with diagnoses including chronic atrial fibrillation (persistent irregular heartbeat) and long term (current) use of anticoagulant. Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/13/25 indicated Resident 3 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS - an assessment tool to screen and identify memory, orientation, and judgement status) score of 2 of 15. Further review of Resident 3's clinical records indicated the following: - a physician order dated 4/22/25 for Warfarin sodium (anticoagulant, blood thinner) 4 milligram (unit of measurement) 1 tablet by mouth at bedtime for atrial fibrillation; - a weekly nursing summary dated 5/6/25 did not indicate presence of bruises in the skin check; and - a care plan dated 3/10/25 indicated [Resident 3] was on anticoagulant therapy and interventions included to monitor/document/report adverse reactions of anticoagulant therapy such as bruising. A concurrent observation and interview was conducted on 5/6/25 at 10:15 a.m. inside Resident 3's room. Resident 3 was sitting in the middle of her bed facing the door, noted blackish discoloration on her right arm. Resident 3 stated she bruises easily and she bangs her arm around. A concurrent observation and interview was conducted on 5/8/25 at 1:34 p.m. with Licensed Nurse 1 (LN 1) inside Resident 3's room. LN 1 was asked to check Resident 3's arms. LN 1 confirmed Resident 3 had bruises on both arms and LN 1 stated it was due to blood draw. In a subsequent interview and record review on 5/8/25 starting at 1:37 p.m., LN 1 checked Resident 3's physician's order and Medication Administration Record (MAR). LN 1 stated Resident 3 was taking Warfarin and had blood draw twice a week. LN 1 further stated they usually document for bruising on the blood draw site. LN 1 confirmed there was no current monitoring for Resident 3's bruises. LN 1 added she did not get a report this morning of Resident 3's bruises on both arms. A concurrent interview and record review was conducted with the Director of Nursing (DON) on 5/9/25 at 10:42 a.m. The DON confirmed Resident 3's care plan for the use of anticoagulant included to monitor adverse reactions and the weekly nursing summary dated 5/6/25 did not indicate Resident 3 had bruising. The DON stated her expectation was to care plan that Resident 3 bruises easily due to use of anticoagulant or blood draw. There was no documented evidence Resident 3's bruising was documented or reported prior to 5/8/25 in the clinical records. A review of the facility's policy revised March 2022 and titled, Care Plans, Comprehensive Person-Centered indicated, .The comprehensive, person-centered care plan .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview and record review, the facility failed to ensure a clean and homelike environment was provided for one of 23 sampled residents (Resident 5), when the floor in Resident 5's room was left sticky, stained, and dirty. This failure increased the potential for Resident 5 not attaining her highest practicable well-being. Findings: During a review of Resident 5's admission records, the records indicated Resident 5 was admitted to the facility in July 2022 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident 5's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 5 had moderate cognitive impairment. During a review of Resident 5's care plan, initiated on 2/29/24, the care plan indicated, [Resident 5] Overall condition requires long term care .Assist resident/RP [responsible party] in furnishing of room to enhance home-like environment . During a concurrent observation and interview on 5/6/25 at 9:46 a.m. with Resident 5 in her room, dried stains that were sticky when walked on were observed on the left side of Resident 5's bed. Resident 5 stated, This is dirty, they don't clean it .it really does bug me .this area right here has not been cleaned . During a concurrent observation and interview on 5/7/25 at 4:08 p.m. with Resident 5 in her room, dried stains that were sticky when walked on were observed on the left side of Resident 5's bed. Resident 5 stated no one came to clean it. During a concurrent observation and interview on 5/8/25 at 9:25 a.m. with Resident 5 in her room, dried stains that were sticky when walked on were still observed on the left side of Resident 5's bed. Resident 5 stated housekeeping came but did not do a good job, and that she was not okay if the floor was still dirty. During an observation on 5/8/25 at 10:54 a.m. in Resident 5's room, Housekeeping Staff 1 (HS 1) was observed cleaning the room. HS 1 was observed mopping the floor with a wet mop, went under the bed but did not mop the floor on the left side of the bed. During a concurrent observation and interview on 5/8/25 at 11:02 a.m. with HS 1, HS 1 stated housekeeping clean every room everyday and if spills come out and stated, Important because stuff starts building up in corners .If it's stuck for a long time, it's harder to remove. HS 1 confirmed the dirt and stains on Resident 5's floor and stated he will try if it comes off. During an interview on 5/9/25 at 9:21 a.m. with the Housekeeping and Laundry Supervisor (HLS), the HLS stated her expectation was that all surfaces should be cleaned, including the sides of the bed and under it. The HLS further stated, Important because it's their home, we want to provide the best care and to make it as homelike as possible . During an interview on 5/9/25 at 11:47 a.m. with the Director of Nursing (DON), the DON stated her expectation was that resident should have a clean and homelike environment. When photos of Resident 5's floor were shown, the DON stated, That needs to be cleaned. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, revised 2/2021, the P&P indicated, .2. The facility staff and management provides, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics may include: a. Clean and sanitary environment .

Based on observation, interview and record review, the facility failed to ensure professional standards for medication administration were provided to one of three residents (Resident 1) when medications were found on Resident 1's bedside stand. This failure had the potential to result in Resident 1 not receiving medication as ordered, or medication to be ingested by the wrong resident. Resident 1 was admitted in late 2022 with diagnoses which included myocardial infarction (heart attack), heart failure (heart doesn't pump blood as well as it should), hypertensive heart disease (high blood pressure increases the workload on the heart) and Type 2 Diabetes Mellitus (affects the way the body processes blood sugar). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 12/20/22, the MDS indicated that Resident 1 has no memory impairment. During an observation and interview on 12/21/22, at 11:50 a.m., with Resident 1 in Resident 1's room, a medication cup containing 3 pills was found on Resident 1's bedside stand. Resident 1 said they were left there earlier in the morning. During a concurrent observation and interview on 12/21/22, at 11:55 a.m., with Licensed Nurse (LN) 1, LN 1 acknowledged that the pills were on Resident 1's bedside stand. LN 1 stated that medications should not be left at the bedside. During an observation, interview and record review on 12/21/22, at 11:58 a.m., with LN 1 at the medication cart, LN 1 identified the medications in the cup as Gabapentin (used to treat nerve pain caused by certain diseases such as diabetes) 100 mg (milligram, a unit of measure), Furosemide (used to treat fluid build-up due to heart failure) 20 mg and Colchicine (an anti-inflammatory used to treat a variety of conditions) 0.6 mg. LN 1 concurred that these three medications were signed out on the medication administration record (MAR) at 8:00 a.m. for Resident 1 by LN 1. During an interview with LN 2 on 12/21/22, at 12:50 p.m., at the medication cart, LN 2 stated that she would always make sure that the resident took the medications while she was in the room to make sure that the resident swallowed the pills without complications. She stated, never leave a medication at the bedside. During an interview with the Director of Nursing (DON) on 12/21/22, at 1:15 p.m., in the Administrator's Office (ADM), DON stated that the expectation for medication administration would be to make sure that the medications are taken before leaving the resident. It is not acceptable to find medications at the resident's bedside. During a review of the facility's policy and procedure (P&)) titled, Administering Medications, dated April 2019, indicated .medications are administered in a safe and timely manner.

Based on observation, interview and review of facility documents, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when: 1. A ten-pound chub of frozen hamburger was thawed improperly, 2. Two large pork roasts were cooled down improperly, 3. No beard guard was covering facial hair, and 4. Foods were not labeled accurately in dry storage. Findings: 1. During a concurrent observation and interview with Cook 1 on 6/14/21 at 8:20 a.m., a ten pound chub of frozen ground beef was half submerged with water running over the bottom half. The top half was frozen hard. Cook 1 said, Normally we submerge five-pound chubs. The basin is too small to submerge the ten-pound chubs. During an interview with the Dietary Manager (DM) on 6/14/21 at 8:47 a.m., the DM was asked what his expectations were for thawing the 10-pound frozen hamburger chub and he said, It has to be [submerged] under running water. Review of the facility policy and procedure titled, THAWING OF MEATS, dated 2018, indicated, Submerge under running, potable [safe to drink] water at a temperature of 70 [degrees Fahrenheit, a temperature scale] or lower, with pressure sufficient to flush away loose particles . 2. During a concurrent observation and interview with Cook 2 on 6/16/21 at 11:12 a.m., two large 10 pound pork roasts were in a pan of water with ice partially covering the roast. A thermometer was inserted in each roast. One thermometer indicated 100 degrees F (Fahrenheit, a temperature scale) and the other thermometer indicated 110 degrees F. Cook 2 indicated they were being cooled down for lunch tomorrow (6/17/21). During an observation of both roasts on 6/16/21 at 1 p.m., the pan was filled with water. There were a few unmelted ice cubes. The temperature of both roasts were over 70 degrees Fahrenheit. During an interview with Registered Dietitian (RD) on 6/16/21 at 1:16 p.m., the RD was asked what her expectations were for the cooling of the cooked pork roasts. RD said, The temperature .should be at 70 within 2 hours and 40 degrees within another 4 hours. During an interview with Cook 2 on 6/16/21 at 1:20 p.m., Cook 2 verified the two roasts were taken out of the oven at 10:30 a.m. and they were still not down to 70 degrees Fahrenheit at 1 p.m., two and 1/2 hours after removal from the oven. During an interview with the RD on 6/16/21 at 1:37 p.m., the RD said, If it [the temperature] didn't reach 70 degrees [F] within two hours, it should be tossed. Review of the facility policy and procedure titled, COOLING AND REHEATING POTENTIALLY HAZARDOUS FOODS (PHF) also called Time/Temperature Control for Safety (TCS), dated 2018, indicated, Potentially hazardous foods include: a food of animal origin that is raw .When potentially hazardous cooked food will not be served right away it must be cooled as quickly as possible .Cool cooked food from 140 [degrees] F to 70 [degrees] F within two hours . 3. During an observation on 6/16/21 at 11:17 a.m., the facial hair of Dietary Aid 1(DA 1) was visible outside of his surgical mask. During an interview with the RD on 6/16/21 at 11:24 a.m., the RD was asked what her expectations were for the covering of staff facial hair while working in the kitchen and the RD said, We technically have to have a beard net and then they put the surgical mask over it. Review of the facility policy and procedure titled, DRESS CODE, dated 2018, indicated, Beards and mustaches (any facial hair) must wear a beard restraint. 4. During an observation of a kitchen refrigerator on 6/14/21 at 8:23 a.m., a one gallon container of mayonnaise and a one gallon container of fat free Italian dressing were open, partially used, with no open date indicated. During an interview with DA 1 on 6/14/21 at 8:24 a.m., DA 1 said, I opened the mayonnaise on Saturday [6/12/21]. It slipped my mind that day. During interview with Cook 1 on 6/14/21 at 8:25 a.m., Cook 1 verified both containers had no open date written on them. During a concurrent observation and interview with the DM on 6/16/21 at 10:20 a.m., two partial loaves of bread had no open date. The DM verified the observation and said, The bread should have an open date. During an concurrent observation and interview with DM on 6/16/21 at 10:23 a.m., an eight ounce can of food thickener and eight five-pound boxes of buttermilk biscuit mix had a received date of 7/7/21. DM verified the observation and said, It's supposed to be labeled with the correct received date. It should be June. Review of the facility policy and procedure titled, LABELING AND DATING OF FOODS, dated 2020, indicated, Food delivered to the facility needs to be marked with a received date .Newly opened food items will need to be .labeled with an open date .

Based on observation, interview, and record review, the facility failed to provide the needed care or services for one of 17 sampled residents (Resident 27) when, 1. Resident 27's toenails were not trimmed, 2. No toenail care plan was done for Resident 27, and, 3. No referral for a podiatrist was done for Resident 27. These failures had the potential for Resident 27 to not meet her highest practicable well-being. Findings: Resident 27 was admitted to the facility in early 2021 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 27's most recent Minimum Data Set (MDS, an assessment tool), dated 4/24/21, the MDS indicated Resident 27's cognition (process of gaining knowledge and comprehension) was moderately impaired. The MDS indicated no disorganized thinking or altered level of consciousness. 1. During a concurrent observation and interview on 6/17/21, at 8:54 a.m., Resident 27 was sitting in a wheelchair with both legs wrapped with gauze bandages. Resident 27's toenails on both feet were approximately 1-1/2 inches long, curving downwards, untrimmed, with black substances underneath. When asked regarding trimming and cleaning her toenails, Resident 27 stated, I would like my toenails trimmed and cleaned but I can't reach them. When asked if she would allow a podiatrist (foot doctor) to evaluate and possibly trim her toenails, Resident 27 stated, Yes. 2. During an interview on 6/17/21, at 9:15 a.m., Licensed Nurse (LN) 2 confirmed that Resident 27 didn't want anyone touching her toenails. LN 2 stated, There should be a care plan for resident's [27] preference for trimming her toenails . LN 2 acknowledged, no documented evidence of toenail care plan. During an interview on 6/17/21, at 9:25 a.m., the Director of Nursing (DON) confirmed no documented evidence of toenail care plan was done. The DON stated, [There] should have been a [toenail] care plan [for Resident 27]. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised December 2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed .for each resident. 3. During an interview on 6/17/21, at 9:15 a.m., LN 2 confirmed, .There should be a referral [done for Resident 27] for [a] foot doctor. LN 2 acknowledged there was no documented evidence of a podiatrist referral. During a concurrent observation and interview on 6/17/21, at 9:19 a.m., located at the Director of Social Services' (DSS) office, it was noted on the scheduling board Resident 27 was not in the schedule for referral for podiatrist services. The DSS confirmed, No referral [podiatry] for this resident [27]. During an interview on 6/17/21, at 9:25 a.m., the DON confirmed no documented evidence of a podiatrist referral. The DON stated, [There] should have been a . podiatrist referral [done for Resident 27]. During a review of the facility's policy and procedure (P&P) titled, Referral for Outside Services, revised October 2008, indicated, .To facilitate referrals, the facility will arrange needed services with [outside] agencies that will provide specialized care for our residents.

Based on interview and record review, the facility failed to conduct a medication regimen review (MRR) for one of 17 sampled residents (Resident 27) when Resident 27 was receiving an anti-coagulant (blood thinner) medication. This failure had the potential for Resident 27 to experience a negative outcome from medication administration. Findings: Resident 27 was admitted to the facility in early 2021 with multiple diagnoses which included fractures of both feet. During a record review of Resident 27's medical record, the medical record indicated Resident 27 was receiving [MEDICATION(S)] (a blood thinning medication) for [CONDITION(S)] (DVT-blood clot usually in the legs) prophylaxis (preventive treatment). The medical record indicated there was no documented evidence of MRR for [MEDICATION(S)]. During an interview on 6/16/21, at 7:42 a.m., the Director of Nursing (DON) confirmed there was no documented evidence of MRR for [MEDICATION(S)]. The DON stated, it was expected that the pharmacist should have conducted an MRR. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, revised May 2019, the P&P indicated, .The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication .Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter .

Based on observation, interview, and record review, the facility did not ensure the medication error rate was less than 5% when a resident (Resident 40) was not given the prescribed amount of water when receiving medications via a gastrostomy tube (medical device inserted into the stomach to provide nutrients, medication, and hydration). This failure resulted in two medication errors being identified out of 35 opportunities, resulting in a medication error rate of 5.71% for the facility. Findings: Resident 40 was admitted to the facility in Spring of 2021 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 40's physician orders, dated 4/27/21, indicated, Flush with 30 cc [cubic centimeter, a unit of measurement] H20 [water] before medications and 30 cc after medication. During a review of Resident 40's minimum data set (MDS, an assessment tool), dated 5/4/21, indicated Resident 40 had a, Feeding tube (gastrostomy tube). During a review of Resident 40's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview with Licensed Nurse (LN) 4, on 6/16/21 at 9:12 a.m., LN 4 flushed Resident 40's gastrostomy tube with 50 cc water before giving [MEDICATION(S)] (medication to treat an enlarged prostate), [MEDICATION(S)] (medication to treat cardiac conditions), multivitamin with minerals, and [MEDICATION(S)] B1 (vitamin), via gastrostomy tube and flushed the gastrostomy tube again with 50 cc of water after giving the medications. LN 4 stated, [Resident 40] gets 50 cc before and after medication administration . LN 4 further stated, I don't know their specific policy [on G Tube medication administration]. During a concurrent interview with the Director of Nursing (DON) and record review of Resident 40's medical record on 6/17/21 at 8:10 a.m., the DON stated, The nurses have to follow whatever the order says . During an interview with the Registered Dietician (RD) on 6/16/21 at 9:52 a.m., the RD reported that Resident 40 could be at risk of overhydration from, So much fluids/flushes. During an interview with the Registered Pharmacist (RPH) on 6/17/21 at 10:28 a.m., the RPH stated, G (gastrostomy) tubes are flushed with 30 ml [milliliter, unit of measurement] before and after medications. During a review of the facility's policy, revised April 2019, titled, Administering Medications, indicated, .Medications are administered in accordance with prescriber orders . During a review of the facility's policy, revised November 2018, titled, Administering Medications through an Enteral Tube, indicated, The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube and .Stop feeding and flush tubing with at least 15 ml warm purified water (or prescribed amount).

Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment for two of four residents (Resident 1) when shared bathroom toilet was found filthy and unclean. This failure resulted to the residents not having a clean and comfortable environment. Findings: Resident 1 was admitted late 2020 with diagnoses which included aftercare following hip replacement surgery. Resident 2 was admitted late 2020 with diagnoses which included memory impairment. A review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 9/29/20, indicated severe memory impairment and needed extensive assistance with activities of daily living (ADLs). A review of Resident 1's MDS, dated [DATE], indicated no memory impairment and needed limited assistance with ADLs. A review of Resident 1's complaint allegations, dated 11/9/20, indicated, The tiny toilet area was filthy. The toilet was full of a brown/yellow filth. During an observation on 11/19/20 at 10:30 a.m., Resident 2's shared bathroom was inspected and the toilet was observed with streaks of yellow-brown stools on the toilet seat, not flushed or cleaned. During a concurrent observation and interview on 11/19/20 at 10:32 a.m., the Director of Nursing (DON) verified the condition of Resident 2's bathroom, and stated, The bathroom is not shared by the male residents on the other side because they are bed bound. I agree, the toilet is not clean and it doesn't look good. The resident in this room does not go to the bathroom without assist. She is wheelchair bound. I know the housekeeper cleans bathrooms every morning. During an interview on 11/19/20 at 10:38 a.m., Certified Nursing Assistant 1 (CNA 1) stated, If the bathroom was messed up, we call the housekeeper to clean. Housekeeping cleans the bathrooms all the time. During an interview on 11/19/20 at 11:04 a.m., when asked if Resident 4 used the bathroom, CNA 2 stated, I helped [Resident 2] between 6 and 8 am. I am not sure who used the bathroom. I would have known that. We have not actually used the bathroom this morning .If I saw the unclean bathroom, I would have cleaned it. I would sanitize it or call the housekeeper to clean it. During an interview on 11/19/20 at 11:06 a.m., the Director of Staff Development (DSD) stated, [Resident 2] is not able to walk to the bathroom. During an interview on 11/19/20 at 11:09 a.m., Housekeeper 1 (HK 1) stated, We clean the rooms between 8 to 10 a.m. I haven't clean [sic] the room this morning yet. Nobody told me the bathroom was dirty. During an interview on 11/19/20 at 12:51 a.m., the Administrator (ADM) stated, The bathrooms are cleaned by housekeeping every morning and they are supposed to be sanitized and cleaned after every use by the CNAs. If the bathroom needed deep cleaning, the CNAs would tell the housekeeper to deep clean the bathroom. A review of facility policy and procedure titled, BATHROOM CLEANING TO BE COMPLETE THROUGHOUT SHIFT, revised 10/16, indicated Sanitize commode, tank, bowl and base. Use brush for inside of bowl.

Based on observation, interview and record review, the facility, with a census of 52, failed to cohort newly admitted residents (with unknown COVID-19 status) separate from asymptomatic residents with confirmed negative COVID-19 test results. This failure placed residents in the facility at risk of development and transmission of COVID-19. Findings: During an interview with the Director of Staff Development (DSD)/Infection Preventionist (IP), on 8/28/20, at 1:10 p.m., the DSD/IP stated the yellow zone for residents under observation included rooms 24-30. During a review of the facility's floor plan identifying cohorting zones, contained within the facility's Facility Mitigation Plan Manual, dated 5/17/20, the green zone was identified as including rooms 1-19. During an observation on 8/28/20, at 1:35 p.m., in the designated green zone of the facility, droplet precautions (infection prevention and control interventions to be used to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions) signage was posted outside of rooms [ROOM NUMBER]. During an interview on 8/28/20, at 1:35 p.m., with the Staffing Manager (SM), the SM stated a resident in room [ROOM NUMBER] was a new resident and was under investigation for COVID-19. During an interview on 8/28/20, at 1:40 p.m., with the Certified Occupational Therapy Assistant (COTA), the COTA stated a resident in room [ROOM NUMBER] was under 14-day observation for COVID-19. She also stated that room [ROOM NUMBER] was in the green zone and she did not think the other resident in the room was under investigation. During an interview with the Certified Nursing Assistant (CNA), on 8/28/20, at 1:45 p.m., the CNA stated a resident in room [ROOM NUMBER] was on droplet precautions because the resident was a new admit to the facility. She stated the room was located in the green zone. During an interview with the Facility Administrator (FA), on 8/28/20, at 2:05 p.m., the FA stated the yellow zone is established for residents under investigation for COVID-19, which included new admits to the facility. The green zone was designated for residents confirmed to be negative for COVID-19. During a review of the facility's Facility Mitigation Plan Manual, dated 5/17/20, the document indicated, 1. Introduction .This mitigation plan was developed by utilizing resources obtained from the Centers for Disease Control (CDC), California Association for Healthcare Facilities (CAHF), and (California Department of Public Health) CDPH .3.5 Cohorting Unknown (COVID-19 status) (Yellow) .Residents in yellow zone will only be cohorted with other asymptomatic unknown (COVID-19 status) residents if no single room is available .Residents in yellow zone will be restricted to the yellow zone until they have been cleared to enter the green zone .3.6 Cohorting Residents COVID Naive (confirmed negative COVID-19 status) (Green) .Resident in the green zone will consist of confirmed negative residents or residents recovered from COVID-19 .Residents will be moved to green zone only after they have received a negative test or they have met the criteria for removal of transmission-based precautions per current CDC guidance . During a review of the Centers for Disease Control and Prevention (CDC) document titled, Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/20, the document indicated, .Considerations for new admissions or readmissions to the facility .Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19.

Based on observation, interview and record review, the facility failed to appropriately use personal protective equipment supplies when staff failed to wear masks and maintain a 6 foot social distancing while inside the facility for the census of 55 residents. This deficient practice had the potential to place the residents at risk of development and transmission of communicable diseases and infections during a global pandemic. Findings: During a concurrent observation and interview on 4/18/20 at 8:05 a.m., Certified Nursing Assistant 1 (CNA 1) was not wearing a mask. She was standing beside CNA 2 and not [MEDICATION NAME] social distancing while working in the Nurse's Station, Station 2. CNA 1 stated, yes, I'm not wearing a mask. She further indicated yes, I'm not 6 feet away from CNA 2. During a concurrent observation and interview on 4/18/20 at 8:07 a.m., CNA 2 was not [MEDICATION NAME] social distancing while working in the Nurse's Station, Station 2. CNA 2 stated, yes, I'm not 6 feet away from CNA 1 and CNA 3. She further indicated I should be 6 feet away from them. During a concurrent observation and interview on 4/18/20 at 8:09 a.m., CNA 3 was not [MEDICATION NAME] social distancing with CNA 2 while working in the Nurse's Station, Station 2. CNA 3 stated, yes, I'm not 6 feet away from CNA 2. During a concurrent observation and interview on 4/18/20 at 8:13 a.m., the Housekeeper was standing beside the housekeeping cart by the hallway near Station 2. She was wearing a mask but it was not covering her nose. The Housekeeper stated, yes, my mask is not covering my nose, She acknowledged her mask should be covering her nose too. During a concurrent observation and interview on 4/18/20 at 8:20 a.m., the Activity Assistant (AS) was walking in the hallway near Station 2. He was wearing a mask but not covering his nose. AS stated, yes, my mask is not covering my nose. He also acknowledged his mask should be covering his nose. During a concurrent observation and interview on 4/18/20 at 8:25 a.m., Licensed Nurse 2 (LN 2) was talking and standing side by side with CNA 4 beside the medication cart in Station 1. LN 2 and CNA were not [MEDICATION NAME] social distancing. LN 2 stated, yes, I'm not 6 ft. away from CNA 4. She further indicated, I should be 6 ft. apart from CNA 4. During a concurrent observation and interview on 4/18/20 at 8:27 a.m., CNA 4 was talking and standing side by side with LN 2 beside the medication cart in Station 1. CNA 4 and LN 2 was not [MEDICATION NAME] social distancing. CNA 4 stated, yes, I'm not 6 feet away from LN 2. She further indicated, yes, I should be 6 feet away from LN 2. During an interview on 4/18/20 at 9 a.m., the Central Supply Manager (CSM) stated, yes, the staff should be 6 feet away from each other. She also indicated, the staff should wear mask and should it cover their nose. During an interview on 4/21/20 at 11 a.m., the Director of Nursing (DON) stated, the staff should practice social distancing. She further indicated, the staff should wear a mask and it should cover their nose. During a review of the facility's policy and procedure titled, Coronavirus (COVID-19), revised 4/2/20, indicated, .Social Distancing will be observed ., Use a mask at all times when working in facility .

Based on interview and record review, the facility failed to protect 1 of 2 residents (Resident 1) from abuse when a staff person threatened to punch Resident 1 in the face when he grabbed her breast. This failure escalated Resident 1's agitation and had the potential to cause psychosocial harm to a cognitively impaired resident by a person in authority. Findings: During an interview with the Director of Nursing (DON) on 12/20/19 at 3:30 p.m., the DON denied knowledge of an allegation of abuse towards Resident 1. The DON confirmed there was an altercation with Resident 1 on 12/18/19 when the staff moved Resident 2 into the room. The DON further stated Resident 1 has been resistant to roommates in the past. On 12/20/19, the Department received an anonymous voicemail stating the following, I want to leave an anonymous complaint of (Facility Name). It was observed by several managers that the administrator (ADM), (ADM Name) threatened to punch (Resident 1) in his face because he grabbed her breast. To repeat, the administrator was observed by several managers that she was going to punch him in the face because he grabbed her boob. According to the facility document titled Physician Orders, Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 12/20/19, at 4 p.m., an interview was conducted with Resident 1. Staff 1 translated, as English was not Resident 1's primary language. Resident 1 was observed speaking in an angry tone to Staff 1 in his native language. Staff 1 stated the resident was very angry he had a roommate in his room, he had been in his room for 4 years. When Staff 1 asked Resident 1 about the altercation that occurred when the new roommate moved in, Staff 1 stated, (Resident 1) doesn't want to talk about it. Resident 1 stated, It's OK and waved his hand. Resident 1 was observed, again, speaking in an angry tone to Staff 1 in their native language. Resident 1 then asked Staff 1 if the Department could help remove the roommate from his room, and when the surveyor explained we could not, Resident 1 became agitated again. Staff 1 then stated He is talking about her and not being appropriate . He is very angry. Then Staff 1 asked Resident 1 if he grabbed the ADM and the resident nodded yes. When Staff 1 asked what the ADM said or did when he grabbed her, Resident 1 said in English, She gonna punch me. The Department confirmed with resident that he was not physically punched. Resident 1 stated he hit another staff and the police came to talk to him. Staff 1 then stated again that Resident 1 was still very angry. During an interview on 12/24/19 at 2:00 p.m. Staff 2 acknowledged awareness of the altercation on 12/18/19 involving Resident 1. Staff 1 confirmed working the day of the incident, but did not hear anything except staff trying to calm resident down and Resident 1 yelling. At 2:15 p.m. on the same date, after other staff left the area, Staff 2 slid a yellow note with the words hand written I did hear it, but afraid to say! If you want to talk in private. The Department gave Staff 2 contact information to contact the Department away from the facility. During a telephone interview on 12/31/19 at 12:30 p.m., Staff 2 stated while entering a room located near Resident 1's room, they heard yelling. Staff 2 moved to the doorway to observe the altercation. Staff 2 stated, .they needed to move him (Resident 1) away from the room because he was throwing things and grabbed the ADM in the chest . she brought her arm up to pull away to protect herself. Staff 2 stated, I heard the ADM say ' I will punch you in the face . ' when he wouldn't let go of her. The (Social Services Director/ Activities Director (SSD/AD)) tried to step in between the (ADM) and (Resident 1). Staff 2 added the MDSD (MDS Director) reached his arm out and Resident 1 hit the MDSD while he was trying to move Resident 1 away. Staff 2 stated, They were all trying to protect the (ADM) and separate them. Staff 2 then stated, I heard the ADM, talking out loud to herself as she walked away and say something to the effect of ' What? Do you think you can grab my breast dirty old man, and I am not supposed to do anything?' Staff 2 then added the ADM was at the nurses' station talking to the CNAs, crying and saying she was going to call the police. During a telephone interview on 1/2/2020 at 2:45 p.m., Staff 3 stated Resident 1 had roommates in the past, but he would increase his negative behaviors. Staff 3 gave a more recent example when Resident 1 kept turning off the new roommate's oxygen concentrator (device that concentrates the oxygen from room air to supply an oxygen-[MEDICATION NAME] gas for patient use). Staff 3 added, Without roommates, he does OK . (ADM name) stated Resident 1 agreed to the new roommate, but the staff all knew it wasn't going to be OK. Staff 3 continued and stated on the day of the altercation, when Resident 1 saw Resident 2's bed, he became agitated and Resident 1 was pulling Resident 2's bed out of the room. Resident 2 kept saying he didn't want to stay in the room and that he didn't feel safe. Staff 3 stayed in the room with Resident 2. When Resident 2 kept asking to move out of the room, Staff 3 stated, (ADM name) said 'No, we have already crossed a bridge . If we let him (Resident 1) get his way, then we will never get someone in here'. During an a concurrent observation and interview on 1/14/2020 at 7:30 a.m. Resident 2 was observed, sitting up in bed waiting for his breakfast. When asked how he was doing in his new room with his new roommate, Resident 2 replied, He (Resident 1) thinks everything in the room is his, he opens my drawers, looks in my stuff, takes my phone. When asked about the day he moved in, he stated, It was not good .he (nodding toward resident 1) did not want someone in his room .pushing my bed out .yelling stuff in his language .NO! NO! He got real angry. They took him off in the hallway. When asked if he was okay to stay in the room, Resident 2 stated, They told me I had to stay. When asked to clarify who told him, Resident 2 replied, They (ADM) told me I had to stay. Resident 2 then said, She (the ADM) told me I had just as much right to stay in the room, but I didn't want to stay in the room . I heard his last roommate, he kept turning off his oxygen . I got this PICC line . I don't want him messing with it. When the Department inquired if he asked again to be moved, Resident 2 stated he didn't want to push it . she already threatened to punch him, again nodding towards Resident 1. When asked if he felt safe in his room, Resident 2 replied, I don't feel safe anywhere in this building. During an interview on 1/14/2020 at 8:00 a.m., Staff 4 indicated being in a room close to Resident 1's room during the altercation. Staff 4 expressed concern regarding retaliation for talking about the altercation and asked for anonymity. Staff 4 stated I heard everything .I heard all of the yelling, Resident 1 speaking in his language and yelling. Staff were trying to calm him down. I then heard a loud yelp and heard (ADM name) say 'Let go of me .I can punch you in the face' .I know she can't say stuff like that. On 1/17/2020 at 3:38 p.m., the Facility Owner hand delivered additional interviews he conducted. Review of the interviews included the following interview from Staff 5: (Resident 1) does not want anyone in his room including employees. He throws things at employees regularly. (Staff 5) did not see anyone get hit. (Staff 5) was in (Resident 1's room) with (Resident 2) as the door was closed almost all the way and the commotion happened in the hallway. I only heard the commotion. 3 or 4 people were trying to calm down patient. (Staff 5), stated my main goal was to calm (Resident 2) down. (Staff 5) heard (the ADM) say, 'don't you know I could punch you in the face, don't do that.' (Staff 5) states she reported the incident. Review of the facility document progress notes for Resident 1, an entry written by the SSD/AD, dated 12/19/19 at 10:10 a.m., indicated it was a late entry for 12/18/19, 4:00 p.m. The SSD/AD entry noted the altercation with Resident 1 when the new roommate was transferred into his room. It further documented To insure both residents will adjust well to the move there will be a one on one person in the room for the next 24 hours. Review of the facility policy titled Recognizing signs and Symptoms of Abuse/ Neglect, dated (MONTH) 2006, stipulated Our facility will not condone any form of resident abuse or neglect .'Abuse' is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Review of the facility policy titled Abuse Prevention Program, dated 2006, stipulated Our residents have the right to be free from abuse by anyone including, but not limited to: facility staff, other residents, consultants .or any other individual .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED].

Based on interview and record review, the facility failed to report an allegation of abuse within 24 hours as required for 1 of 2 sampled residents (Resident 1). The facility was made aware of the allegation on 12/20/19 at 4:00 p.m. The facility report of the allegation was received on 12/24/19 at 10:44 a.m. This failure resulted in a 4-day delay of the investigation and had the potential to place residents at risk of potential harm when the accused staff member was not immediately removed from patient access. Findings: During an interview with the Director of Nursing (DON) on 12/20/19 at 3:30 p.m., the DON denied knowledge of an allegation of abuse towards Resident 1. The DON confirmed there was an altercation with Resident 1 on 12/18/19 when the staff moved Resident 2 into the room. The DON further stated Resident 1 has been resistant to roommates in the past. On 12/20/19, the Department received an anonymous voicemail stating the following, I want to leave an anonymous complaint of (Facility Name). It was observed by several managers that the administrator (ADM), (ADM Name) threatened to punch (Resident 1) in his face because he grabbed her breast. To repeat, the administrator was observed by several managers that she was going to punch him in the face because he grabbed her boob. According to the facility document titled Physician Orders, Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. On 12/20/19, at 4 p.m., an interview was conducted with Resident 1. Staff 1 translated, as English was not Resident 1's primary language. Resident 1 was observed speaking in an angry tone to Staff 1 in his native language. Staff 1 stated the resident was very angry he had a roommate in his room, he had been in his room for 4 years. When Staff 1 asked Resident 1 about the altercation that occurred when the new roommate moved in, Staff 1 stated, (Resident 1) doesn't want to talk about it. Resident 1 stated, It's OK and waved his hand. Resident 1 was observed, again, speaking in an angry tone to Staff 1 in their native language. Resident 1 then asked Staff 1 if the Department could help remove the roommate from his room, and when the surveyor explained we could not, Resident 1 became agitated again. Staff 1 then stated He is talking about her and not being appropriate . He is very angry. Then Staff 1 asked Resident 1 if he grabbed the ADM and the resident nodded yes. When Staff 1 asked what the ADM said or did when he grabbed her, Resident 1 said in English, She gonna punch me. Confirmed with resident that he was not physically punched. Resident 1 stated he hit another staff and the police came to talk to him. Staff 1 then stated again that Resident 1 was still very angry. During an interview on 12/20/19 at 4:20 p.m., the Department informed the DON and the Social Services Director (SSD) an allegation of abuse, with Staff 1 translating the interview, was confirmed with Resident 1 and the facility should begin its process for abuse allegations. During a telephone interview on 12/23/19 at 4:45 p.m., the ADM was informed the Department had not received the required report of an allegation of abuse. The ADM stated the DON was new .I am sure, I promise you, she did not understand what you were asking for . The ADM then confirmed the DON had been working in skilled nursing facilities as an Assistant DON prior to this facility and acknowledged all employees of the facility should know required 24-hour reporting period. The ADM asked if the facility still need to file the report and was informed by the Department, yes per the regulations. During an interview on 12/24/19 at 1:00 p.m. with the DON and the ADM, the ADM stated again the DON misunderstood the need to report the allegation of abuse. The Department then informed the ADM the facility report had not been received, per the telephone conversation on 12/23/19. The ADM stated she would begin the process now. During a telephone interview on 12/31/19 at 9:00 a.m., the owner of the facility acknowledged the 24-hour reporting state mandated time frame was not met. Review of the facility policy titled Abuse Prevention Program, dated (MONTH) 2006, indicated Our residents have the right to be free from abuse .Comprehensive policies and procedures have been developed to aid in preventing abuse .Our abuse prevention program provides policies and procedures that govern, at a minimum: .Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting The reporting and filing of accurate documents relative to incidents of abuse . Review of the facility policy titled Reporting Abuse to State Agencies and Other Entities/Individuals, dated (MONTH) 2009, stipulated All suspected violations and incidents of abuse will be immediately reported to the appropriate state agencies and other entities or individuals as may be required by law .Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown origin, abuse be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: The state licensing/ certification agency responsible for surveying/licensing the facility, the local/State Ombudsman, The Residents Representative of Record, Adult Protective Services, Law enforcement officials .Verbal/written notices to agencies will made within twenty-four (24) hours of the occurrence of such incident .

Based on staff interview, medical record and document review, the facility failed to report an allegation of staff verbal abuse of Resident 1 to the Department and to the Ombudsman within 24 hours. This failure could have potentially caused a delay in the Department's or Ombudsman's investigation of the alleged incident. Findings: In a 12:34 p.m., 2/13/19 interview, the facility Business Office Manager (BOM) stated she met with the daughter of Resident 1 on 2/2/19. During the meeting, the daughter indicated that on 2/1/19, the resident's roommate told the daughter that Resident 1 had been verbally mistreated by a Certified Nurse Assistant. Review of a 2:58 p.m., 2/2/19 nursing note reflected, Late Entry for 02/02/2019 10:45 AM .Resident's daughter reported to the business office manager that resident's roomate (sic) told her resident is allegedly being abused by a staff member.Writer went to the resident along with the business office manager to interview .Per resident it happened on multiple occasions where resident would have to use the bathroom and wait 1/2 hour - hour stated (sic) that staff member would tell her 'she is not the only one on call light (sic), there are other resident (sic) she needs to attend too (sic)' .Administrator notified. DON (Director of Nursing) made aware Review of a facility report to the Department, reflected a stamped FAX transmittal time of 7:44 a.m., 2/4/19. In a 12:08 p.m., 2/13/19 interview, the Administrator confirmed the BOM did not FAX the report to the Department on 2/2/19 and indicated, Looks like it was late to you guys. Review of the facility's 12/16 Abuse Prevention Program policy reflected, As part of the resident abuse prevention (sic), the administration will .Report any allegations of abuse within timeframes as required by federal requirements The (MONTH) (YEAR) Abuse Investigation and Reporting policy indicated, All reports of resident abuse, neglect .shall be promptly reported to .state (sic) .agencies (as defined by current regulations) .All alleged violations involving abuse, neglect .will be reported by the facility Administrator, or his/her designee, to the following .agencies .An alleged violation of abuse, neglect .will be reported immediately, but not later than .Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury

Based on staff interview, medical record and document review, the facility failed to protect 1 of 45 residents (Resident 1) from physical abuse when rough handling during care caused facial bruising and swelling. This failure caused physical harm and discomfort to Resident 1 and had the potential to result in harm to all residents in the facility, for a census of 45. Findings: During a 12:16 p.m., 1/6/18 interview, Licensed Nurse 1 (LN 1) stated she observed Certified Nurse Assistant 1 (CNA 1) providing care to female Resident 1 in the resident's room near the end of evening shift, 12/19/17. LN 1 indicated the CNA turned (Resident 1) roughly and abruptly. (The resident) isn't very big. If (the CNA) had been paying attention, he would have noticed her face was in the siderail. It was careless and neglectful. He was in a hurry .It did cause harm .She was grimacing. It caused bruising. LN 1 indicated the incident left her in shock .I couldn't believe it happened or that (CNA 1) didn't notice (the resident's face pressing against the siderail). I was so traumatized by it. LN 1 stated she called the Interim Director of Nursing Services (IDNS) after her shift ended with a request to meet the next day. A licensed nursing Interdiscplinary Progress Note entry by LN 1 revealed the following entry dated 12/21/17 at 2:19 p.m.: Late entry: MD (Medical Doctor) and family notified of witnessed incident of Resident being repositioned with undue force by CNA causing resident to hit left side of face against the bed railing causing left check swelling and bruising. Another licensed nursing Interdiscplinary Progress Note dated 12/20/17 at 2:05 a.m. noted: Facial swelling to left cheek, bruising starting to diffuse to left periorbital (around the eye) corner. A 3 p.m., 12/20/17 a nursing progress note read, Facial swelling to the left upper cheek and small purple discoloration diffused to periorbital corner .Facial grimacing noted In a 2:47 p.m., 1/5/18 interview, the IDNS described Resident 1 as being nonverbal, expressionless and dependent on staff for meeting basic care needs. The IDNS acknowledged receiving a call from RN 1 on 12/19/17 asking to talk the next day. The IDNS stated the specific incident was not reported to her, however, until a meeting on 12/20/17. Resident 1's physician described the resident as a [AGE] year-old with multiple chronic medical problems including a history of stroke (loss of blood flow to an area of the brain which can cause damage to body functions controlled by that area) in a 12/16/17 progress note prior to the incident. Review of CNA 1's personnel file revealed an Elder Abuse & Abuse Reporting policy statement signed by the employee on 1/30/17 which read in part, Elder abuse is the mistreatment or neglect of an older person, usually by a caregiver .The types of abuse (with examples) include .Physical: .rough handling during care giving In a follow-up letter to the State dated 12/26/17, the facility Administrator wrote, Prior to this incident .(Resident 1) had an incident of bruising from a [MEDICAL CONDITION] where she hit her head and hand against the side rail (Resident 1's) skin condition has been monitored very closely. (CNA 1) was aware of (Resident 1's) condition and history of prior bruising and should have used extra caution when providing care for (Resident 1).

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1), was provided medications necessary to reach her highest practicable physical, mental and psychosocial well-being, when Resident 1's pain medication was not available and not given as ordered, and her blood pressure medication was not given as ordered. This failure resulted in Resident 1 experiencing unrelieved severe pain, anxiety, and elevated blood pressure. Findings: 1. According to the Record of Admission, Resident 1 was admitted to the facility in late summer of 2017 following an operation to replace the resident's left hip, after sustaining a fall in which the hip was broken. Resident 1 also had a [DIAGNOSES REDACTED]. Review of Resident 1's clinical record included: A general acute care hospital (GACH) Medication Discharge Report, dated 8/6/17 at 7:39 a.m., which included a physician's orders [REDACTED]. extreme pain). The report also directed Resident 1 to be given [MEDICATION NAME] (a medication used to lower blood pressure) 40 mg, 1 tablet by mouth twice daily. A GACH Medication Administration Record, [REDACTED]. Resident 1's last blood pressure medication, [MEDICATION NAME] 40 mg, was given on 8/6/17 at 8:29 a.m., and was scheduled to be given again at 5 p.m. A GACH Inter-Facility Transfer Record, dated 8/6/17, indicated Resident 1 was discharged alert and oriented to a facility in the same city at 2 p.m., via ambulance. A facility Physician order [REDACTED]. The order was transcribed by Licensed Nurse 1 (LN 1) on 8/6/17 at 6:14 p.m. A facility Physician order [REDACTED]. The order was transcribed by LN 1 on 8/6/17 at 6:16 p.m. A facility Physician order [REDACTED]. The order was transcribed by LN 1 on 8/6/17 at 6:20 p.m. The facility Medication Record (MR), dated 8/6/17-8/7/17, indicated [MEDICATION NAME] 40 mg tablet was ordered twice a day for hypertension and was scheduled to be given at 5 p.m. on 8/6/17. There was no documented evidence [MEDICATION NAME] was administered. The facility Medication Record, dated 8/6/17-8/7/17, indicated [MEDICATION NAME]-[MEDICATION NAME] 2 tablets by mouth every 4 hours as needed for severe pain, was documented as held (not given) by LN 4 at 8 p.m. A PRN Results and Documentation Report, dated 8/6/17 at 11:13 p.m., indicated LN 4 documented [MEDICATION NAME]-[MEDICATION NAME] medication was, Held due to medication not available. On an Admissions Nursing Assessment, dated 8/6/17 at 7:30 p.m., LN 1 indicated that Resident 1 was alert and oriented with quick comprehension and in frequent pain with any movement. LN 1 documented Resident 1 had bowel and bladder control. LN 1 documented Resident 1's pain level as 8/10 (8 out of 10). LN 1 documented that she instructed Resident 1 to, Practice deep breathing exercises and meditating to chase pain away. During an interview on 8/25/17 at 3:15 p.m., upon examination of this documented pain level, LN 1 verified no medications were given to Resident 1 at the facility. A facility Physical Therapy Initial Assessment, dated 8/6/17, indicated Resident 1, required the assistance of two or more helpers to achieve a sitting position from laying down .required the assistance of two or more helpers to complete a bed-to-chair transfer, and sit to stand was not attempted due to medical condition or safety concerns. A facility Physical Therapy Plan of Care, dated 8/6/17, indicated Resident 1 was alert and oriented, reported pain with movement of her left leg at a level of 8/10, and required 100% assistance to transfer from the bed to a chair. Precautions for Resident 1 were, Weight-bearing as tolerated for her left leg, and she was a high fall risk. A facility Interdisciplinary Progress Note, dated 8/7/17 at 2:41 a.m., LN 2 documented Resident 1 was alert and verbally responsive, and complaining of pain. The note included Resident 1 refused ([MEDICATION NAME]/[MEDICATION NAME]) from the E-Kit (emergency medication supply.) During an interview on 8/23/17 at 10:15 a.m., the Physical Therapist (PT 1) stated Resident 1 reported 8/10 pain with left leg movement during physical therapy on the evening of 8/6/17. PT 1 stated pain was prohibiting Resident 1 from participating in physical therapy activities, including getting up to a wheelchair. A Narcotic Emergency Drug Kit inventory sheet issued on 7/26/17, and delivered to the facility on [DATE], showed the E-Kit contained [MEDICATION NAME]/APAP ([MEDICATION NAME]-a non-aspirin pain reliever) 5 mg/325 mg tablets, 8 tablets, and [MEDICATION NAME]/APAP 10 mg/325 mg tablets, 8 tablets. An observation of the Station 1 E-Kit on 8/29/17 at 10:30 a.m., showed the kit was sealed with a locking mechanism, and had an issue date of 7/26/17 and a delivery date of 8/2/17. The E-Kit was observed to contain 8 sealed tablets of [MEDICATION NAME]-[MEDICATION NAME] 5/325, and 8 sealed tablets of [MEDICATION NAME]-[MEDICATION NAME] 10/325. Review of the yellow E-Kit sign-out sheets revealed no medication was withdrawn from the E-Kit for Resident 1. During an interview on 8/29/17 at 10:35 a.m., LN 1 acknowledged the Station 1 E-Kit contained [MEDICATION NAME]-[MEDICATION NAME] 10/325, 8 tablets, and [MEDICATION NAME]-[MEDICATION NAME] 5/325, 8 tablets. LN 1 stated, upon visual inspection of the E-Kit, it did not appear to have been opened since its issue date of 7/26/17. LN 1 stated this was the only narcotic E-Kit in the facility. Review of E-Kit Log--August revealed no documented evidence that any [MEDICATION NAME]/APAP was removed between 8/2/17 and 8/29/17. In an interview with Resident 1's Family Member (FM) on 8/14/17 at 9:15 a.m., FM stated Resident 1, .kept asking for pain medicine. FM stated Resident 1 continued to ask for pain medicine and was told the pharmacy was closed and she would have to wait until tomorrow morning for medications. At this time, FM stated Resident 1 was offered plain [MEDICATION NAME] (Tylenol, an over-the-counter medication). During an interview on 8/16/17 at 8:30 a.m., LN 2 stated at approximately 11:30 p.m. on 8/6/17, Certified Nursing Assistant 1 (CNA 1) told her Resident 1 was upset and asking for pain medication. LN 2 stated she had offered Resident 1 plain [MEDICATION NAME] once, which the resident refused. LN 2 stated she offered ([MEDICATION NAME]) at approximately 1 a.m. LN 2 stated Resident 1 was very angry and stated she did not want the medication and wanted to go back to the hospital. There was no documented evidence the medication had been removed from the E-Kit for Resident 1. During an interview on 8/23/17 at 1:15 p.m., CNA 1 stated Resident 1 was in a lot of pain, and she must have answered Resident 1's call light, 20 times, on the night shift (10:30 p.m. to 6:30 a.m.). CNA 1 stated there were 3 nurses at the desk whom she informed of Resident 1's pain, stating Resident 1, Needed help and was having a really hard time. CNA 1 stated that it seemed like there was an issue with getting the medication and that no one was giving Resident 1 her pain medication. CNA 1 stated a couple of hours were spent going back and forth between Resident 1 and the nurses. CNA 1 stated that Resident 1, Got to the point where she just wanted out, with Resident 1 stating she wanted to go back to the hospital where they could give her pain medicine. CNA 1 stated Resident 1 requested several times to call her family and was, Really suffering. CNA 1 stated Resident 1 was shaking and incontinent of urine on one occasion due to pain, and tried to get out of bed herself stating, I'm going to walk out of here. CNA 1 informed the nurses that Resident 1 was demanding to get up to use the phone. CNA 1 got Resident 1 out of bed and took her to the nurse's station to use the telephone where Resident 1 left a message for her family and then called 911 at approximately 2 a.m., and requested to return to the hospital where she had been discharged 12 hours earlier. Review of GACH Prehospital Call Report, dated 8/7/17 at 2:17 a.m., indicated Resident 1's blood pressure while in transit back to the hospital was 159/87 (normal systolic (top number) range is 100-140, normal diastolic (lower number) range is 60-90) and her pulse was 120 (normal range is 60-90.) The report further indicated Resident 1's pain level was 10 out of 10 and a re-take of her pulse was 126. Review of GACH Emergency Documentation - MD, dated 8/7/17 at 2:20 a.m., indicated Resident 1 arrived in the emergency room alert and oriented, complaining of left hip pain at a level of 10 out of 10, which started 3 hours earlier, and was worsening and constant. Resident 1's blood pressure on arrival was 142/116. The note further indicated Resident 1 told the GACH staff, The staff at (the facility) tried to give her 'pills that weren't hers.' At the time of her re-admission back into the hospital, Resident 1 had been without pain medication for over 13 hours. During an interview on 8/25/17 at 8:30 a.m., LN 2 stated she introduced herself to Resident 1 between 12 a.m. and 12:30 a.m. and Resident 1 was not agitated at that time. LN 2 stated CNA 1 came to her with the resident's pain medication request at approximately 12:30 a.m. LN 2 stated she took the bubble pack (packaging in which a card holds multiple, individual doses of medication in plastic bubbles) from the E-Kit into the room to show Resident 1 it was [MEDICATION NAME]-[MEDICATION NAME]. LN 2 stated it was approximately 1 a.m., when Resident 1 refused the medication and stated she wanted to go to the hospital and to call her family. LN 2 stated she explained to the resident she would need to get up in a wheelchair to use the phone at the nurse's station. LN 2 stated Resident 1 tried to get up by herself and was very agitated. LN 2 stated she asked CNA 1 to get Resident 1 up in a wheelchair and take her to the phone. LN 2 stated the Director of Nursing (DON) was called three times during this event and, was very angry. LN 2 stated DON said, Oh my God. She hasn't had pain medicine? What are you guys doing? An undated, facility Pain Assessment and Management policy indicated under the heading, Purpose: To assess, evaluate, and manage the resident's pain and discomfort. California Code of Regulations (CCR), Title 22, Section (a)(1)(B)(C) indicated, .drugs used to treat severe pain, nausea, agitation, diarrhea or other severe discomfort shall be available and administered within four hours of the time ordered .all new drug orders shall be available on the same day ordered unless the drug would not normally be started until the next day. During an interview on 10/16/17 at 12:30 p.m., the DON verified Resident 1 did not receive any pain medication or [MEDICATION NAME] during the stay. The DON described moderate pain as level 4 to 6 out of 10, and severe pain as level 7 to 10. The DON stated she did not understand the staff's hesitation to open the E-Kit to give the medication, which had been ordered and was available in the facility.