Every finding on record at Skyline Healthcare Center - San Jose

Based on interview and record review, the facility failed to prevent abuse for one of three residents (Resident 1) when Licensed Vocational Nurse A (LVN A) hit and punched Resident 1's wound with his fist. This failure resulted in pain to Resident 1 and affected the resident's psychosocial well-being.Findings: Review of Resident 1's Face Sheet indicated the resident was admitted to the facility with diagnoses including osteomyelitis (bone infection) of the vertebra (backbone). Review of Resident 1's Minimum Data Sheet (MDS, an assessment tool) indicated his Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 15, meaning he was cognitively intact. Review of Resident 1's Physician Order Report indicated he had treatment orders for a coccyx (tailbone, small bone at the base of the spine) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) and a left buttocks open wound. The report indicated Resident 1's treatment order, dated 2/24/26 indicated to cleanse the coccyx pressure injury with normal saline (a saltwater solution), apply Santyl ointment (used for wound care to help remove dead tissue), moistened gauze, and cover with foam dressing twice a day or as needed if soiled. The report also indicated Resident 1's treatment order, dated 2/24/26 indicated to cleanse the left buttocks wound with Dakins solution (used to clean wounds), apply Santyl ointment, collagen (protein used to encourage tissue growth for wound healing), and calcium alginate (absorbent dressing), cover with foam dressing twice a day or as needed. Review of a fax from the facility, Report of Suspected Dependent Adult/Elder Abuse, dated 2/25/26 indicated Resident 1 alleged a nurse providing treatment for his wound hit his wound with his hand a few days ago. During an interview on 3/26/26 at 9:42 a.m., the administrator (ADM) stated Resident 1's allegation was substantiated. The ADM stated Resident 1 provided a video recording of the incident which showed LVN A hitting Resident 1's wound. The ADM stated they were going to terminate LVN A, but LVN A decided to resign. The ADM stated LVN A has been reported to the Board of Nursing. During a concurrent review of Resident 1's video recording on the ADM's phone showed LVN A standing on left side of Resident 1's bed while Resident 1 was lying on the bed face down. LVN A had gloves on both hands and was using his fingers on both hands to press down the tape around the wound dressing. LVN A used the back side of the fingers of his right hand to smooth out the tape on the dressing. Then LVN A made a fist with his right hand and punched Resident 1's wound on top of the dressing. Resident 1 screamed out in pain and shouted obscenities. LVN A pulled Resident 1's underwear and pants over his dressing. During an interview on 3/26/26 at 11:49 a.m., Resident 1 described how LVN A hit or punched him on his wound site when providing treatment for his wound. He stated prior to setting up the video recording on his cellphone, LVN A punched his wound three or four times. Resident 1 stated other times, LVN A would slap his wound. He stated he was afraid to report LVN A hitting his wound. Resident 1 stated another resident also witnessed LVN A hitting his wound multiple times. Resident 1 stated he told LVN A to stop and warned him, but LVN A still proceeded. Resident 1 stated sometimes LVN A would do his wound treatment and just leave. Resident 1 stated his pants would be down and LVN A would leave the curtain open and the door open, which would be humiliating. During an interview on 3/26/26 at 11:55 a.m., Resident 2 explained that he witnessed LVN A hitting Resident 1's wound. He stated LVN A would hit Resident 2 across the backside. Resident 2 stated LVN A would also squeeze Resident 1's wound or slap Resident 1's wound. He stated he cannot put a number on how many times LVN A abused Resident 1 because he did not want to lie. Review of the facility's undated policy, Abuse Prevention Program indicated, Our residents have the right to be free from abuse . It also indicated the administration will protect residents from abuse from anyone including staff, residents, family members, visitors, or any other individual.

3. During an observation and concurrent interview with nurse supervisor H (NS H) on 6/23/25, at 8:55 a.m., one of the facility's medication rooms was inspected. There was a refrigerator inside this medication room, which was designated to store the residents' food. There was one pitcher of pinkish-red fluid and one unopened container of applesauce in this refrigerator. The thermometer inside this refrigerator had a temperature reading of 60 degrees Fahrenheit (F, unit of temperature measurement). NS H confirmed this observation and confirmed the temperature of the food refrigerator should be maintained between 35 and 41 degrees F. During a follow-up observation and concurrent interview with NS H on 6/23/25, at 9:03 a.m., the thermometer inside the refrigerator was checked again. At this time, the refrigerator door had been closed for eight minutes. The thermometer inside the refrigerator still had a temperature reading of 60 degrees F. NS H confirmed this observation. During another follow-up observation and concurrent interview with NS H on 6/23/25, at 9:12 a.m., the thermometer inside the refrigerator was checked again. At this time, the refrigerator door had been closed for an additional nine minutes. The thermometer inside the refrigerator still had a temperature reading of 60 degrees F. NS H confirmed this observation. The facility's document titled REFRIGERATOR TEMPERATURE LOG (FOR FOOD), dated 6/2025, indicated, Normal Temperature: 35-41 DEGREES F. The document further indicated, NOTIFY DON [director of nursing] IF TEMPERATURE IS NOT WITHIN RANGE. Based on observation, interview, and record review, the facility failed to ensure food items were labeled and stored in accordance with professional standards for food safety when: 1. Ten cups of cottage cheese that were past their use by dates, were still stored in the kitchen refrigerator; 2. A pitcher of colored fluid with no label and an open container of thickened water were found in the refrigerator inside two medication storage rooms. 3. The temperature of one refrigerator designated to store residents' foods which was located in one of the medication rooms was above the desired temperature. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the two hundred thirty-four residents who received foods from the facility kitchen. Findings: 1. During the initial kitchen tour observation on 6/23/25 at 8:10 a.m., there were ten cups of cottage cheese that had use by dates of 6/22/25 and they were all past by the date already, that were still stored in one of the kitchen refrigerators. During the interview with the dietary manager (DM), who was assisting me with the kitchen tour observation on 6/23/25 at 8:11 a.m., the DM verified that the ten cups of cottage cheese were past their use by dates and should not be stored anymore in the kitchen refrigerator and he removed them right away. During the interview with the registered dietitian (RD), on 6/25/25 at 1:15 p.m., the RD verified that the cups of cottage cheese that were past their use by dates should not be kept in the kitchen refrigerator and should have been discarded already. RD further verified that she would follow up on this concern. Review of the undated facility's policy titled, Food Storage Principles, indicated, Proper food storage is essential for preserving food quality Discard foods that have exceeded their expiration date 2a. During a concurrent observation and interview with Minimum Data Set Coordinator (MDSC) A, on 6/23/25 at 8:26 a.m., medication storage 5 was inspected. The refrigerator inside the room, which was designated to store food for residents, contained one pitcher with brown-colored fluid with no label and a container of Lemon Flavored Thickened Water with open date of 6/19/25. The pitcher with brown-colored liquid with a date made label on the lid, indicated June 17. MDSC A stated the pitcher should be labeled and discarded after 2 days. The MDSC A stated the thickened water should be discarded 24 hours after opening. Review of the facility's Food Storage Principles policy and procedure (P&P), undated, indicated Procedure .2. Label each package, box, can, etc. with the expiration date, date of receipt, or when the item was stored after preparation .b. Discard leftover food that have not been used within 48 hours of preparation . Review of facility's Labeling and Dating Food/Beverages in Refrigerators P&P, undated, indicated To ensure the safe storage of food and beverages in facility refrigerators by requiring proper labeling and dating in accordance with health regulations and infection control standards. All foods and beverages stored in the facility refrigerators must be clearly labeled and dated to ensure safety, prevent spoilage, and reduce the risk of foodborne illness. Review of facility's Labeling and Dating Food/Beverages in Refrigerators P&P, undated, indicated Dating & Discard Guidelines: Thickened liquids (premixed), 24 hours max shelf life after opening, after opening discard unused portion. 2b. During an observation and concurrent interview with nurse supervisor H (NS H) on 6/23/25, at 8:55 a.m., medication storage 2 was inspected. One refrigerator inside the room, which was designated to store food for residents, contained one pitcher of pinkish-red fluid. The pitcher was not labeled. NS H confirmed the pitcher was not labeled. The facility's undated policy, titled Labeling and Dating Food/Beverages in Refrigerators, indicated all food and beverages stored in facility refrigerators must be clearly labeled.

Based on observation, interview and record review, the facility failed to ensure that garbage was stored properly when two out of four outside dumpsters were overfilled of garbage, with their lids, not fully closed and plastic bags with trash were not placed in the covered dumpsters. These failures had the potential to attract insects, rodents, and other pests to the facility that could affect the two hundred thirty-eight residents residing in the facility. Findings: During the concurrent observation of the dumpster area and interview with maintenance assistant E (MA E) on 6/25/25 at 2:30 p.m., two out four dumpsters were overfilled with garbage and their lids were not completely closed. There were also plastic bags with trash that were not put in the covered dumpsters. MA E acknowledged that these dumpsters should not be overfilled with garbage and should be properly covered. MA E further acknowledged that plastic bags with trash should be put in the covered dumpsters. He then stated that he would endorse them to have the garbage picked up. During the interview with the maintenance director (MD) on 6/25/25 at 2:40 p.m., the MD also verified that the dumpsters should not be overfilled with garbage and their lids should be properly closed. The MD further verified that the plastic bags with trash should be placed in the covered dumpsters. He then stated that he would have the garbage, be picked up right away. During the interview with the director of nursing (DON) on 6/27/25 at 8:17 a.m., the DON acknowledged the above concerns and then stated that she would check on it. Review of the undated facility's policy titled, Pest Control, indicated, Keep the dumpster area clean and the lid closed The United States Food and Drug Administration's 2022 Food Code 5-501.110 indicated, Refuse (waste), recyclable and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. The Food Code further indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

4. During an observation on 6/25/25, at 1:41 p.m., certified nursing assistant C (CNA C) was feeding lunch to Resident 163, who was lying in bed with the head of the bed slightly elevated. CNA C was standing over Resident 163 while feeding her. During an observation and concurrent interview with nurse supervisor D (NS D) on 6/25/25, at 1:41 p.m., NS D confirmed the above observation and stated CNA C should sit at eye level while feeding the resident. During an interview with the director of staff development (DSD) on 6/27/25, at 8:16 a.m., the DSD explained staff should sit at eye level while feeding the residents in order to maintain the residents' comfort and dignity. The facility's undated policy titled Assisting the Resident to Eat indicated, Sit at eye level in front of the resident. Based on observation, interview, and record review, the facility failed to ensure respect and dignity were maintained for 2 of 36 sampled residents (Residents 103 and 163) and two non-sampled residents (Residents 381 and 168) when: 1. For Resident 381, the meal tray was served late and not at the same time as with the other residents on the same table at the big dining room; 2. For Resident 168, his food was also served late and not at the same time as the other residents seated in th same table in the big dining room; 3. For Resident 103, his drainage bag was not covered from public view and 4. For Resident 163, certified nursing assistant (CNA) was standing over this resident while feeding her. These failures had the potential to affect the emotional and psychosocial well-being of the residents. Findings: 1. During the big dining room observation on 6/23/25 at 11:58 a.m., three residents (Residents 381, 168 and 200), were seated at the same table for lunch. Resident 200 was already eating his lunch while Residents 381 and 168 were still waiting for their meal trays and looking hungry. During the concurrent observation and interview with Resident 381 on 6/23/25@12:10 p.m., Resident 381 finally received his lunch meal tray. Resident 381 was alert and verbally responsive and verified that his meal tray was served late while the other resident in the same table had been eating his lunch already and almost done with it. He further stated that he was already hungry. During the interview with the activity director (AD) on 6/27/25 at 1:55 p.m., the AD acknowledged that for residents sitting in the same table, they should be served with their meal trays at the same time or one after the other, before serving the next table. During the interview with the assistant director of nursing (ADON) on 6/27/25 at 2:04 p.m., the ADON verified that for residents eating in the same table, their meals should be served at the same time or finish serving them first before serving other residents on the next or different table. 2. During the big dining observation on 6/23/25 at 11:58 a.m., Resident 168 was sitting in one of tables in the big dining room waiting for staff to serve his lunch. Another resident (Resident 200), in the same table, was already eating his lunch. Resident 381, who was also in that same table was also waiting for his meal tray to be served. During an interview with Resident 168 on 06/23/25 at 12:00 p.m., Resident 168 verified that he was waiting for his lunch tray for 5 minutes now and was already hungry while looking at the other resident in front of him, Resident 200 who was already eating lunch at 11:55 a.m. During an interview with the director of nursing (DON) on 6/26/25 at 4:12 p.m., the DON verified the above observation and stated that the food should be served in short interval not having to wait for a long time. The DON also stated, the resident might not feel good and get impatient when he would wait for a long time for his food while others had been served for their meals already. Review of the undated facility's policy and procedure (P&P) titled, Resident Dining Program, the P&P indicated, The goal is to ensure that all residents in the facility receive meals that are nutritionally appropriate and served in a respectful, safe, and timely manner, in accordance with their care plans, physician orders, and federal/state regulations Meals will be served in a manner that promotes dignity, autonomy, and social interaction among residents C. Meal service Protocol:1. Food trays are delivered by table order to ensure fairness and minimize cold meals 3. Review of Resident 103's clinical record indicated, Resident 103 was admitted on [DATE] with diagnoses that include urinary tract infection(an infection in any part of urinary system), retention of urine, obstructive and reflux uropathy (a condition in which the flow of urine is blocked), benign prostatic hyperplasia (a non-cancerous condition where the prostate gland grows larger than normal) with lower urinary tract symptoms, acute kidney failure(a sudden and rapid decrease in kidney function) . During an observation on 6/24/25 at 8:26 a.m., Resident 103 was lying in bed, with indwelling foley catheter connected to drainage bag positioned lower than the bladder. The drainage bag was not covered, and the contents were visible. During a concurrent observation and interview on 6/24/25 at 8:31 a.m., with the Infection Preventionist (IP), the IP inside Resident 103 room's, confirmed Resident 103's drainage bag was not covered and visible. The IP stated the drainage bag should have privacy bag to cover. During a review of the facility's policy and procedure (P&P) titled, Quality of Life- Dignity , undated, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: e. Helping the residents to keep urinary catheter bags covered.

Based on observation, interview and record review, the facility failed to ensure that the residents would know and be reminded of the results of the previous state recertification surveys when 5 out of 14 residents who attended the Resident Council meeting, (Residents 5, 33, 52, 80, and 106), did not know about the results of the previous state recertification surveys or where the binder containing the survey results was located. These failures jeopardized the right of the residents to know and examine the results of the previous state recertification surveys and the plan of corrections that the facility did for those failures. Findings: During the resident council meeting (gathering where residents of a facility come together to discuss issues) on 6/24/25 at 10:00 a.m., 5 residents, (Residents 5, 33, 52, 80, and 106), were among the attendees of the meeting. During a concurrent observation and interview with Resident 5 during the resident council meeting on 6/24/25 at 10:30 a.m., Resident 5 was seated in a wheelchair, alert, oriented and verbally responsive. Resident 5 verbalized that he was not aware of the results of the previous state recertification surveys or where the survey binder was located. Review of Resident 5's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 5 was readmitted to the facility on [DATE] with diagnoses including acute respiratory disease (a condition that affects the lungs and airways making it difficult for air exchange in the lungs), chronic pulmonary edema (the buildup of fluid in the lungs), atrial fibrillation (an irregular heart rhythm which can lead to blood clots and stroke) and muscle weakness. Resident 5's BIMS (brief interview for mental status- cognition level score of 13 to 15 points suggests that cognition is intact) score was 15. During a concurrent observation and interview of Resident 33 on 6/24/25 at 10:30 a.m., Resident 33 was seated in her wheelchair, alert, oriented, verbally responsive and participating in the resident council meeting. Resident 33 stated she was not aware of the results of the previous state recertification surveys or where the binder with the survey results was located. Review of the admission record of Resident 33 indicated, Resident 33 was readmitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation, diabetes mellitus (a condition which affects the way the body processes blood sugar), peripheral vascular disease (a blood vessel disorder that affects blood circulation), and cellulitis (a bacterial infection of the skin and tissues beneath the skin) of the left lower limb. Resident 33's BIMS score was 14. During a concurrent observation and interview with Resident 52 on 6/24/25 at 10:30 a.m., Resident 52 was alert, oriented, calm, comfortable, verbally responsive and actively participating in the resident council meeting. Resident 52 also stated that she was not aware of the results of the previous state recertification surveys or where the binder containing survey results was located. Review of the admission record of Resident 52 indicated, Resident 52 was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus, hyperlipidemia (high levels of fat particles in the blood), osteoarthritis (a condition where there's gradual wearing down of protective tissue at the ends of bones) and generalized muscle weakness. Resident 52's BIMS score was 14. During a concurrent observation and interview with Resident 80 on 6/24/25 at 10:30 a.m., Resident 80 was alert, oriented, verbally responsive and actively participating in the resident council meeting. Resident 80 stated he was not aware of the results of the previous state recertification surveys or where the survey binder was located. Review of the admission record of Resident 80 indicated, Resident 80 was readmitted to the facility on [DATE] with diagnoses including congestive heart failure (heart works less efficiently and can lead to buildup of fluid in the lungs and shortness of breath), diabetes mellitus, hemiplegia (severe muscle weakness or partial paralysis on one side of the body) affecting the right dominant side, muscle weakness and difficulty walking. Resident 80's BIMS score was 14. During a concurrent observation and interview with Resident 106 during the resident council meeting on 6/24/25 at 10:30 a.m., Resident 106 was seated in her wheelchair, alert, oriented and verbally responsive. Resident 106 verbalized not being aware of the results of the previous state recertification surveys or where the survey binder was located. Review of Resident 106's admission record indicated Resident 106 was readmitted to the facility on [DATE] with diagnoses including acute respiratory disease, hypertension (a condition in which the force of the blood against the artery walls in the heart is too high), and seizures (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity). Resident 106's BIMS score was 15. During an interview on 6/25/25 at 10:55 a.m. with the Activity Director (AD), the AD verified being employed at the facility for twenty-five years and acknowledged not knowing about the results of the previous state recertification surveys or where the survey binder for the results of the previous surveys was located. The AD then stated, It's probably in the administrator's office. During an interview with the administrator (ADM) on 6/27/25 at 11:56 p.m., the ADM verified that the AD should know where the survey binder for the results of the previous surveys was located so she could in turn inform and remind the residents about the binder location. The ADM stated that he would in-service the AD about it. During an interview on 6/27/25 at 2:04 p.m., with the Director of Nursing (DON) the DON also verified that the AD should know where the survey binder containing results of the previous surveys is located and that all staff members should know the location of the survey binder. Review of the facility's policy and procedure titled, Access to Survey Results, undated indicated, Survey results and approved plan of correction, if applicable, are available in a readable form . and are available to residents without having to ask a staff person. Survey results may be placed in a binder . Results of the most recent survey are placed readily accessible to residents in a place such as a lobby or other areas frequented by most residents, where individuals wishing to examine survey results do not have to ask to see them . Residents should be notified at least annually during Resident Council meetings of the survey results . Minutes of Resident Council meetings should reflect that survey results were communicated.

2. During the observation of Resident 7 on 6/23/25 at 12:43 p.m., Resident 7 was alert, calm, comfortable, verbally responsive and able to answer questions. Review of Resident 7's face sheet indicated, Resident 7 was readmitted to the facility on [DATE] with the primary diagnosis of unspecified paraplegia (a condition characterized by the paralysis of the lower half of the body, typically including the legs and sometimes the torso or the trunk of the human body). Review of Resident 7's physician order report from 5/24/25 to 6/24/25 indicated, Resident 7 had an order to monitor weekly weights every Saturday, at 9:00 a.m., once a day, ordered on 4/6/25. Review of Resident 7's weight records indicated that Resident 7's weights were checked on the following dates: a. 5/20/25 - 190 pounds (lbs, unit used to measure the mass); b. 5/7/25 - 195 lbs; c. 4/22/25 - 195 lbs; d. 3/19/25 - 182 lbs; e. 2/18/25 - 191 lbs and f. 1/21/25 - 200 lbs. During the concurrent review of Resident 7's clinical records and interview with nursing supervisor D (NS D) on 6/26/25 at 2:55 p.m., NS D verified that Resident 7 had an order to monitor her weight weekly every Saturday, once a day at 9:00 a.m., and they were not done. Resident 7's weight was last monitored on 5/20/25, which was 190 lbs. and there were no records that Resident 7's weights were checked weekly after that. NS D further verified that the weight monitoring order of Resident 7 was not followed. NS D then stated that she would clarify with Resident 7's physician about her weight monitoring order and would follow the order. During the interview with the director of nursing (DON) on 6/27/25 at 8:15 a.m., DON acknowledged that physician orders should be followed and Resident 7's physician order to monitor her weight weekly was not followed and would follow up on it. Review of the undated facility's policy titled, Carrying Out Physician's Orders, indicated, All physician orders must be documented, reviewed, and carried out accurately and promptly to ensure the highest standard of patient care. This policy applies to all nursing staff and healthcare providers within the facility Nursing staff: Carry out physician's orders accurately and promptly, ensuring patient safety and proper documentation Based on observation, interview and record review, the facility failed to ensure care and services were provided to meet the professional standard of practice for three of four residents (Residents 116, 30 and 7) when: 1. Two Licensed Vocational Nurses (LVN) did not wear proper Personal Protective Equipment (PPE, equipment worn to minimize exposure to a variety of hazards) when handling hazardous drugs; and 2. The weight monitoring order for Resident 7 was not followed. These failures had the potential to compromise the residents' health and safety. Findings: 1. During a medication administration observation at Station 4 with LVN J on 6/25/25 at 8:36 a.m., LVN J was observed removing a medication called Divalproex Sodium (Depakote, anticonvulsant used to treat seizures and bipolar disorders) from a blister pack (packaging used for medications) for Resident 116. LVN J confirmed the blister pack have the Hazardous Drug label and that she did not wear gloves when handling the medication. LVN J stated she should have worn gloves. During a medication administration observation at Station 5B with LVN M, on 6/25/25 at 10:32 a.m., LVN M was observed removing a medication called Divalproex Sodium from a blister pack for Resident 30. LVN M confirmed the blister pack have the Hazardous Drug label and that she was not wearing gloves. LVN M stated she should wear gloves when handling the medication. During an interview with the Director of Nursing (DON) on 6/26/25 at 2:01 p.m., the DON stated the Hazardous Drug label on medications was an indication of special instructions on how to administer the medication. The DON also stated the licensed nurses should wear gloves as protection when handling the medication. During an interview with the Consultant Pharmacist (CP) on 6/27/25 at 10:47 a.m., the CP stated the facility should follow the required precautions for medications with hazardous drug label. The CP stated the staff should wear gloves depending on the risk of exposure to the medication. Review of the facility's Hazardous Drug Handling policy and procedure (P&P), dated 1/23, indicated Scope: The facility must develop and maintain a health and safety management system which shall, at a minimum, include the following: .5. Proper use of appropriate Personal Protective Equipment (PPE) .D. Personal Protective Equipment .a. Appropriate PPE must be worn when handling HDs . Review of the facility's Hazardous Drug Handling P&P, dated 1/23, indicated H. Administering 1) The facility should provide all PPE needed and monitor use according to established policies and procedures that minimize employee and patient exposure.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) when random controlled medication use audit for seven of 12 residents (Resident 347, 28, 174, 67, 38, 65, and 226) did not reconcile when: 1. The medication was documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to Residents 65, 38, and 28 but was not signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications.), and 2. The medication was signed out of the CDR but not documented on the MAR for Residents 347, 67, 174, 65, and 226. These failures resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications. Findings: 1. The Controlled Drug Record (CDR) for 12 randomly selected residents receiving controlled medications were requested for review during the survey. A review of Resident 65's clinical record indicated he had a Physician's order for Methadone (a narcotic, used to treat moderate to severe pain) 5 milligrams (mg, unit of measurement) two tablets once a day for chronic pain, dated 6/20/25. During a concurrent interview and record review of the CDR, with Minimum Data Set Coordinator (MDSC) A, on 6/25/25 at 1:48 p.m., MDSC A confirmed three tablets were unaccounted in the CDR. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) J, on 6/25/25 at 1:50 p.m., LVN J stated she administered the medication and documented in the MAR but did not sign out in the CDR. A review of Resident 38's clinical record indicated he had a Physician order for Lorazepam (an anti-anxiety medication) 1 mg 1 tablet once a day for anxiety, dated 5/14/25. During a concurrent interview and record review of the CDR with LVN K, on 6/25/25 at 1:53 p.m., LVN K confirmed the medication was documented in the MAR but was not signed out in the CDR. A review of Resident 28's clinical record indicated he had a Physician order for Hydrocodone-Acetaminophen (Norco, used for moderate to severe pain) 5-325 mg 1 tablet three times a day. During a concurrent interview and record review of the CDR with LVN K, on 6/25/25 at 2:04 p.m., LVN K confirmed the medication was documented in the MAR but was not signed out in the CDR. 2. A review of Resident 347's clinical record indicated she had a Physician order for Oxycodone (used to treat moderate to severe pain) 5 mg 1 tablet twice a day as needed for severe pain, dated 6/22/25. During a concurrent interview and record review on 6/26/25 at 2:20 p.m., with the Director of Nursing (DON), a review of Resident 347's CDR for Oxycodone and the 6/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 6/21/25 at 11:11 a.m., but did not document the respective administration in the MAR. The DON acknowledged that the controlled medication was not accounted for in the MAR. A review of Resident 67's clinical record indicated he had a Physician order for Tramadol (used to treat moderate to severe pain) 50 mg 1 tablet every 8 hours as needed for severe pain, dated 6/23/25. During a concurrent interview and record review on 6/26/25 at 2:24 p.m., with the DON, a review of Resident 67's CDR for Tramadol and the 4/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 4/22/25 at 9:54 p.m., but did not document the respective administration in the MAR. The DON acknowledged that the controlled medication was not accounted for in the MAR. A review of Resident 174's clinical record indicated he had a Physician order for 50 mg Tramadol every 4 hours as needed for pain management, dated 6/9/24. During a concurrent interview and record review on 6/26/25 at 2:32 p.m., with the DON, a review of Resident 174's CDR for Tramadol and the 2/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 2/25/25 at 9:54 p.m. and 2/26/25 at 6:26 a.m., but did not document the respective administrations in the MAR. The DON acknowledged that the controlled medications were not accounted for in the MAR. A review of Resident 65's clinical record indicated he had a Physician order for Oxycodone 20 mg 1 tablet every 4 hours as needed for severe pain, dated 6/20/25. During a concurrent interview and record review on 6/26/25 at 2:40 p.m., with the DON, a review of Resident 65's CDR for Oxycodone and the 6/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 6/21/25 at 8:27 a.m., but did not document the respective administration in the MAR. The DON acknowledged that the controlled medication was not accounted for in the MAR. A review of Resident 226's clinical record indicated he had a Physician order for Oxycodone 5 mg 1 tablet every 4 hours as needed for moderate pain, dated 5/16/25. During a concurrent interview and record review on 6/26/25 at 2:48 p.m., with the DON, a review of Resident 226's CDR for Oxycodone and the 5/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 5/17/25 at 11:30 a.m., but did not document the respective administration in the MAR. The DON acknowledged that the controlled medication were not accounted for in the MAR. A review of the facility's Medication Administration General Guidelines policy and procedure (P&P), dated 1/24, indicated Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given . A review of the facility's Medication Administration Controlled Substances P&P, dated 1/23, indicated 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage .5. Administer the controlled medication and document dose administration on the MAR.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with facility policies when: 1. In one of six medication rooms, the were medications with different routes of administration stored in the same bin. There were also active and discontinued medications stored in this bin; 2. One opened bottle of 1,000 milliliters (ml, a unit of measurement for volume) 0.9% sodium chloride solution (known as normal saline- a common medical solution containing 0.9 grams of sodium chloride per 100 milliliters of water. It is an isotonic solution, meaning it has the same concentration of solutes as the blood and body fluids (NS) and small bottle of 0.9% (NS) was stored at Resident 65's bedside table unattended. and 3. One bottle of used 100 ml NS was stored at Resident 205's bedside table unattended. These failures had the potential to compromise the health and safety of the residents. Findings: 1. During an observation and concurrent interview with nurse supervisor H (NS H) on 6/23/25, at 8:32 a.m., one medication room was inspected. Inside the room, there was a clear plastic bin that contained face shields (personal protective equipment meant to protect the face). Upon further inspection, it was observed that this bin also contained the following: 1.) One bottle of liquid Lithium (medication used to treat psychiatric conditions) 8 milliequivalents per 5 milliliters (meq/ml, unit of dose measurement) that belonged to Resident 212; 2.) One bottle of Atorvastatin tablets (medication used to treat high cholesterol) 40 milligrams (mg, unit of dose measurement) that belonged to Resident 212; 3.) One Symbicort inhaler (medication used to treat breathing problems) 80-4.5 micrograms (mcg, unit of dose measurement) that belonged to Resident 4; 4.) One house stock (not belonging to a specific resident) bottle of normal saline (a solution that can be used for several medical purposes, including, but not limited to hydration and wound treatments); and 5.) Multiple house stock wound dressings that contained alginate (a substance added to help promote wound healing). NS H confirmed this observation and confirmed these items should not have been stored together. During an interview and concurrent record review with the director of nursing (DON) on 6/26/25, at 11:47 a.m., the DON reviewed the medical records for Resident 212 and Resident 4. The DON verified that Resident 212 had active orders for liquid Lithium 8 meq/5 ml and Atorvastatin 40 mg tablets (medications that were stored in the clear plastic bin in the medication room). She also verified that Resident 4's order for Symbicort inhaler 80-4.5 mcg had been discontinued (this medication was also stored in the clear plastic bin in the medication room). The DON confirmed active and discontinued medications should not be stored together. She also confirmed medications with different routes of administration should not be stored together. The facility's policy titled Medication Storage, dated 1/2024, indicated, Medications should be stored so that various routes of administration are separated. The policy further indicated discontinued medications are immediately removed from stock and disposed of. 2. During an initial tour of the facility on 6/23/25 at 9:55 a.m., one opened bottle of 1,000 ml of 0.9 % sodium chloride (NS) and small bottle of 0.9% (NS) were stored at Resident 65's bedside table unattended. During a concurrent observation and interview on 6/23/25 at 9:58 a.m., with the minimum Data Set Coordinator B (MDSC B), she confirmed the above observation and stated that the 0.9% NS bottles found was used for wound treatment and should have been stored inside the treatment cart. 3. During an initial tour of the facility on 6/23/25 at 10:15 a.m., one bottle of used 100 ml NS was stored at Resident 205's bedside table unattended. During a concurrent observation and interview on 6/23/25 at 10:17 a.m., with the MDSC B, she acknowledged the above observation and stated that 0.9% NS was used by a treatment nurse and should have been stored inside the treatment cart and not at the bedside table of the resident. The facility's policy titled Medication Storage, dated 1/2024, indicated, Medications and biologicals are stored properly to keep their integrity and to support safe,effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff memebers lawfully authorized to administer medications.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1.Resident 345's used and opened urinal was next to the spirometer (an apparatus for measuring the volume of air inspired and expired by the lungs- measures ventilation, the movement of air into and out of the lungs) on top of the bedside table; 1a. Resident 46's yankauer suction tube (oral suctioning tool) that was attached to suction machine was stored inside of the open clean gloves box on top of the bedside table; 1b. Resident 9's suction machine and nebulizer machine (device used to deliver medication in the form of a mist for inhalation) were covered by a used wash basin at the bedside table; 1c. Resident 128's used urinal without covering was on top of the bedside table ; 1d. Resident 330's soiled linens were on the floor; 2. Urinal full and on the floor; 3. No EBP sign on door; 3a. Treatment nurse (TN) wearing a surgical face mask below the nose during wound care for one resident and 4. Two kitchen staff were not wearing their face masks properly while preparing foods for the tray line. These failures could result in the spread of infection and cross-contamination that could affect the 238 residents who reside in the facility, staff, and visitors. Findings: 1.During an initial tour of the facility on 6/23/25 at 9:03 a.m., Resident 345's used and opened urinal was next to the spirometer on top of the bedside table. During a concurrent observation and interview on 6/23/26 at 9:04 a.m., with the assistant director of nursing (ADON), She confirmed the above observation and stated the urinal should be stored at the bedrail with cover and should not be stored next to the spirometer to prevent contamination. 1a. During an initial tour of the facility on 6/23/25 at 9:12 a.m., Resident 46's yankauer suction tube that was attached to suction machine was stored inside of the open clean gloves box on top of the bedside table. During a concurrent observation and interview on 6/23/26 at 9:14 a.m., with the ADON, she confirmed the above observation and stated that the yankauer suction tube should have been detached from the suction machine and stored in a plastic bag with label to prevent contamination. 1b. During an initial tour of the facility on 6/23/25 at 9:31 a.m., Resident 9's suction machine and nebulizer machine were covered by a used wash basin at the bedside table. During a concurrent observation and interview on 6/23/26 at 9:35 a.m., with Minimum Data Set Coordinator B (MDSC B), she confirmed the above observation and stated that the suction machine and nebulizer machine should not have been covered by the used wash basin to prevent cross contamination. 1c. During an initial tour of the facility on 6/23/25 at 9:44 a.m., Resident 128's used urinal without covering was on top of the bedside table. During a concurrent observation and interview on 6/23/26 at 9:46 a.m., with MDSC B, she confirmed the above observation and stated the urinal should be stored at the bedrail with cover to prevent contamination. During a concurrent observation and interview on 6/23/26 at 9:47 a.m., with certified nursing assistant O (CNA O), he confirmed the above observation and stated the urinal should be stored at the bedrail with cover to prevent the spread of infection contamination. 1d. During an initial tour of the facility on 6/23/25 at 10:10 a.m., Resident 330's soiled linenes was on the floor. During a concurrent observation and interview on 6/23/26 at 10:14 a.m., with the ADON, she confirmed the above observation and stated that soiled linens should not have been on the floor to prevent cross contamination. Review of the undated facility's policy titled, Linen Storage indicated prevent cross-contamination by storing soiled linen in a room or area that is separate from wash areas and clean linen storage areas Store soiled linen airtight containers Store soiled linen a manner that prevents cross- contamination. 4. During the tray line (a system of food preparation or an assembly line system where individual food trays are prepared for residents) observation and concurrent interview with cook F (COOK F) on 6/25/25 at 11:20 a.m., COOK F was not wearing his face mask properly while preparing the foods for the tray line. His face mask was not covering his nose and mouth. COOK F verified that he was not wearing his face mask properly and fixed it right away. During the interview with the dietary manager (DM) on 6/25/25 at 11:21 a.m., the DM acknowledged that COOK F should wear his face mask properly while preparing foods for the tray line and would talk to him about it. During the continued tray line observation and concurrent interview with dietary aide G (DA G) on 6/25/25 at 11:35 a.m., DA G was also not wearing her face mask properly while helping with the tray line preparation. It was only covering her mouth and her nose was still exposed. DA G verified that she was not wearing her face mask properly and fixed it right away. During the interview with the DM on 6/25/25 at 11:36 a.m., the DM also acknowledged that DA G should wear her face mask properly while helping with the tray line preparation and would also talk to her about it. During the interview with the registered dietitian (RD) on 6/25/25 at 1:15 p.m., the RD verified that kitchen staffs should wear their face masks properly, covering their nose and mouth and would remind them about it. Review of the undated facility's policy titled, COVID-19 (coronavirus disease 2019 which is a contagious disease caused by a virus called SARS-CoV-2) Using Personal Protective Equipment (PPE, equipment used to prevent or minimize exposure to hazards), indicated, Personnel working in areas with minimal to no community transmission adhere to the following infection prevention and control strategies: Employees, contracted personnel, and volunteers adhere to standard and transmission-based precautions In addition, universal use of a well-fitting face mask for source control is recommended for personnel if not otherwise wearing a respirator All personnel receive training on and demonstrate an understanding of: how to properly don, use, and doff PPE in a manner to prevent self-contamination 2. During an observation on 6/23/25, at 8:49 a.m., inside Resident 194's room, there was one full urinal, with lid closed, inside a plastic urinal holder (a plastic strap or cage that can be fastened to the resident's bed or wheelchair). There was another half-full plastic urinal, with lid closed, on the floor of Resident 194's room. During a concurrent observation and interview with certified nursing assistant N (CNA N) on 6/23/25, at 8:57 a.m., CNA N confirmed Resident 194's two urinals were not emptied, and should have been emptied. During an interview with the infection preventionist (IP) on 6/26/25 at 2:38 p.m., the IP stated urinals should be emptied to prevent the spread of infection. During a review of the facility's undated policy and procedure (P&P) titled, Bedpan or Urinal, the P&P indicated, To provide for elimination when a resident is unable to use bathroom or bedside commode. After Use of Bedpan or Urinal: 6. Empty and rinse bedpan or urinal with disinfectant . 3. Review of Resident 480's medical record indicated Resident 480 was admitted on [DATE] with diagnoses including acute cholecystitis (redness and swelling of the gallbladder [a small pear-shaped organ located under the liver in the upper right abdomen]), and viral hepatitis (infectious disease that causes liver inflammation and damage). During an observation on 6/23/25 at 8:15 a.m. in the room of Resident 480, Resident 480 was observed awake, alert and sitting on the side of the bed with a biliary drainage bag (allows the digestive fluid from the gallbladder and liver to flow out from a blocked duct) attached to a band positioned on the right leg of Resident 480. There was no enhanced barrier precaution (EBP) signage posted on the door and no personal protective equipment (PPE) outside the entrance to Resident 480's room. Review of Resident 480's Physician Order Report dated 6/13/25 indicated biliary drain on right lower abdomen: cleanse with normal saline and pat dry with dry dressing and cover it with patch dressing. Special instructions: change the dressing daily or as needed once a day. During a concurrent observation and interview on 6/23/25 at 9:36 a.m. with Licensed Vocational Nurse I (LVN I), LVN I stated there should be an EBP sign posted on the door of Resident 480's room and there should be PPE at or near the door since Resident 480 has a biliary catheter. During an interview on 6/26/25 at 2:00 p.m. with the Infection Preventionist (IP), the IP confirmed there was no EBP signage posted at the entry to Resident 480's room and no PPE. The IP stated there should be an EBP sign and PPE outside the room of Resident 480 because Resident 480 has a biliary catheter to prevent the spread of infection. Review of the facility's policy and procedure titled, Enhanced Barrier Precautions, undated indicated, EBP are indicated for residents with any of the following: .b. Wounds and/or indwelling devices even if the resident is not known to be infected . 6. For residents for whom EBP are indicated, EBP shall also be used when performing the following high-contact resident care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use, e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care, e.g., any skin opening requiring a dressing . 10 .EBP shall be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed the resident at high risk. 3a. During a concurrent observation and interview on 6/26/25 at 9:49 a.m., with the treatment nurse (TN), the TN was observed wearing a surgical face mask below the nose during wound care for Resident 35. The TN confirmed the face mask was not covering TN's nose during wound care. The TN adjusted the mask to cover the nose. The TN stated the facial surgical mask should have covered both nose and mouth for infection control. During an interview on 6/26/25 at 10:50 a.m., with the Director of Nursing (DON), the DON stated all personal protective equipment should be worn properly and the surgical face mask should be worn covering both the nose and mouth for infection prevention and control. Review of the facility's policy and procedure titled, COVID-19 Using Personal Protective Equipment (PPE), undated indicated, 1. a. Employees . adhere to standard and transmission-based precautions based on anticipated exposures and suspected or confirmed diagnoses. B. In addition, universal use of a well-fitting facemask for source control is recommended for personnel . 2. Personnel working in facilities . adhere to the following infection prevention and control strategies: c. One of the following is worn for source control while in the facility and for protection during resident care encounters: (3) A well-fitting facemask, for example: a) selection of a facemask with a nose wire to help the facemask conform to the face.

Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment when the floors in the dishwashing area of the kitchen were very wet and there was no safety sign in the area. These failures could affect the health and safety of kitchen staffs and individuals that might go inside the kitchen. Findings: During the initial kitchen tour observation with dietary manager (DM) on 6/23/25 at 8:16 a.m., the floors in the dishwashing area were very wet with water and there was no caution sign around to warn staffs and individuals that might go inside the kitchen and into the dishwashing area. During the interview with DM on 6/23/25 at 8:17 a.m., DM acknowledged that the floors in the dishwashing area were very wet with water. DM further acknowledged that he would put a warning sign right away to keep dietary staff safe. During the interview with the registered dietitian (RD) on 6//25/25 at 1:15 p.m., RD verified that kitchen areas including dishwashing areas should be kept safe at all times. RD further verified that there should be signage for wet floors to warn staffs for safety. Review of the facility's undated policy titled, Kitchen Safety, indicated, Purpose: To establish and maintain a safe working environment in the dietary department and kitchen area by ensuring adherence to sanitation, equipment use, fire safety and injury prevention practices. This protects staff, residents, and visitors from harm and complies with state and federal regulations. All dietary and kitchen staff must follow established safety guidelines at all times while in the food service area Registered Dietitian: Ensures kitchen sanitation, food service, and compliance with safety procedures during scheduled visits. Dietary Manager: Ensures staff training, implementation, and compliance with kitchen safety procedures Keep walkways clear; promptly clean spills using Wet Floor signs

Based on interview and record review, the facility failed to maintain an effective infection control training program for laundry staff regarding routine cleaning of dryer lint. The facility's documentation indicated laundry staff did not clean the dryer lint for several hours on multiple days. This failure had the potential to compromise the health and safety of the residents in the facility. Findings: During a record review on 6/26/25, at 1:08 p.m., the facility's laundry lint cleaning log was inspected. The laundry lint cleaning log was left blank from 2:00 p.m. to 8:00 p.m. on 4/11/25, 4/12/25, 4/21/25, 4/29/25, 4/30/25, 5/12/25, 5/14/25, 5/16/25, 5/17/25, 5/28/25, and 6/21/25. During an interview and concurrent record review with the housekeeping supervisor (HS) on 6/26/25, at 1:19 p.m., the HS reviewed the facility's laundry lint cleaning log and confirmed it was left blank on the above dates and times. The HS explained that the documentation on this log was proof that staff cleaned the laundry lint. During an interview with the infection preventionist (IP) on 6/27/25, at 10:48 a.m., the IP stated laundry staff needed to check the laundry lint and document on the cleaning log every hour. During a review of the facility's undated policy and procedure (P&P) titled, Laundry Area Practices, the P&P indicated, To conduct laundry operations in a clean, safe environment. Cleaning Schedule: Establish a schedule to keep the laundry area clean. Modify as necessary, to comply with Company and/or state specific requirements. CAUTION: Clean the dryer lint traps after each load! Place a checkmark in the appropriate column to establish a cleaning schedule.

Based on observation, interview and record review, the facility failed to ensure the call light button (a cord with a button used by the resident to request assistance) for one of 238 residents (Resident 25) was within reach and appropriate for her condition. This failure had the potential to result in delays of care and treatment. Findings: Review of Resident 25's medical record indicated Resident 25 was initially admitted on [DATE] and had diagnoses including Epilepsy (a neurological disorder characterized by recurring seizures [sudden , uncontrolled surges of electrical activity in the brain]), unspecified, intractable, without status epilepticus, other lack of coordination, unspecified disorder of psychological development (a condition that affects a person's cognitive, emotional, and behavioral development, often originating in childhood), and delayed milestone in childhood. During an observation on 6/23/25, at 9:36 a.m., Resident 25 was asleep, and the call light button was on the floor. During a concurrent observation and interview on 6/23/25, at 11:16 a.m., with Licensed Vocational Nurse (LVN) L, LVN L confirmed Resident 25's call light button was on the floor and verified the resident should have another device appropriate for the resident. During a review of the facility's undated policy and procedure (P&P) titled, Resident Call System, the P&P indicated, Residents are equipped with communication system, allowing them to request assistance by contacting either a staff member or a centralized workstation. 4. If a resident has a disability that prevents them from using the call system, an alternative means of communication that is usable for the residents is provided and documented in the care plan.

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability when a resident comes off Medicare Part A) for two of three residents (Residents 95 and 186). This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended. Findings: Review of Resident 95's medical record indicated she was admitted under Medicare Part A on 4/30/25. Review of the Beneficiary Notice section of the Entrance Conference Worksheet, filled out by the facility and presented to the survey team on 6/24/25, indicated Resident 95 was to be discharged from Medicare Part A services on 6/26/25 and continue living in the facility. Review of Resident 95's SNF Beneficiary Protection Notification Review, filled out by the facility and presented to the survey team on 6/25/25, indicated the facility initiated Resident 95's discharge from Medicare Part A services when benefit days were not exhausted (the resident still had Medicare Part A days remaining). The SNF Beneficiary Protection Notification Review further indicated the facility did not provide a SNF ABN to Resident 95. Review of Resident 186's medical record indicated he was admitted under Medicare Part A on 3/4/25. The medical record further indicated Resident 186 came off Medicare Part A on 5/20/25 and continued living in the facility. Review of Resident 186's SNF Beneficiary Protection Notification Review, filled out by the facility and presented to the survey team on 6/25/25, indicated the facility initiated Resident 186's discharge from Medicare Part A services when benefit days were not exhausted. The SNF Beneficiary Protection Notification Review further indicated the facility did not provide a SNF ABN to Resident 186. During an interview with the interim social services director (ISSD) on 6/25/25, at 10:41 a.m., the ISSD confirmed the facility did not provide a SNF ABN to Residents 95 and 186. The Department of Health and Human Services and Centers for Medicare & Medicaid Services Form CMS-20052, dated 2/2022, indicated the facility must provide a SNF ABN when residents are discharged from Medicare Part A services, with skilled benefit days remaining, and continue to live in the facility. According to the Centers for Medicare & Medicaid Services (CMS, https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNF-ABN-), the facility must provide a SNF ABN prior to providing custodial care.

Based on interview and record review, the facility failed to complete an annual Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 89). This failure had the potential to compromise the facility's ability to develop and implement care plan interventions. Findings: Review of Resident 89's medical record indicated she was admitted to the facility on [DATE]. The medical record indicated the facility completed an annual MDS assessment on 5/12/24. Further review of the medical record indicated the facility did not complete an annual MDS assessment for Resident 89 in May of 2025. During an interview and concurrent record review with Minimum Data Set Coordinator B (MDSC B) on 6/26/25, at 1:17 p.m., MDSC B reviewed Resident 89's medical record and stated the facility should have completed an annual MDS assessment in May of 2025. MDSC B confirmed the facility did not complete this annual MDS assessment. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2024, indicated, The Annual assessment is a comprehensive assessment for a resident that must be complete on an annual basis (at least every 366 days). The RAI manual indicated the date of the annual MDS assessment must be set within 366 days of the previous annual assessment, and must be completed no later than 14 days after the set date.

Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 36 sampled residents (Residents 164 and 192) when: 1. For Resident 164, multiple falls were not coded on the MDS; and 2. For Resident 192, tobacco use was not coded on the MDS. Failure to accurately complete the MDS had the potential to compromise the facility's ability to develop and implement care plan interventions. Findings: 1. Review of Resident 164's medical record indicated she was admitted on [DATE] and had a history of falling. Review of Resident 164's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change in a resident's condition), dated 11/16/24, indicated Resident 1 had a witnessed fall in her room. Review of Resident 164's Progress Notes, dated 11/21/24, indicated she slid down and was found on the floor in her room. During an interview and concurrent record review with Minimum Data Set Coordinator B (MDSC B) on 6/25/25, at 10:50 a.m., MDSC B reviewed Resident 164's medical record and confirmed the resident fell on [DATE] and 11/21/24. MDSC B stated these falls should have been coded on Resident 164's MDS dated [DATE]. MDSC B reviewed Resident 164's MDS, dated [DATE], and confirmed section J1800 was coded No, indicating Resident 164 did not fall during the specified time frame. MDSC B confirmed section J1800 should have been coded Yes, to indicate Resident 164 fell during the specified time frame. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2024, indicated for section J1800, Code 1, yes if the resident has fallen during the specified time frame. 2. Review of Resident 192's medical record indicated he was admitted on [DATE] with diagnoses including osteomyelitis (bone infection) of vertebra, sacral and sacrococcygeal region (bones in the spine), fracture (a break in a bone) of T7-T8 vertebra (the seventh and eight bones in the spine). Review of Resident 192's Safe Smoking Assessment Evaluation (an assessment tool), dated 3/28/25, indicated Resident 192 smoked cigarettes. During a concurrent interview and record review with MDSC A ,on 6/27/25 at 9:11 a.m., MDSC A reviewed Resident 192's medical record and confirmed the resident smoked cigarettes. MDSC A reviewed Resident 192's MDS, dated [DATE], and confirmed section J1300 Current Tobacco Use was coded No', indicating Resident 192 did not smoke cigarettes. MDSC A confirmed section J1300 should have been coded Yes, to indicated Resident 192 smoked cigarettes. The RAI Manual, dated 10/2024, indicated for section J1300, Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on observation, interview and record review, the facility failed to ensure resident-centered baseline care plans were developed within 48 hours of admission for two of thirty-six sampled residents, (Residents 337 and 380), when: 1. For Resident 337, there was no communication problem care plan that was initiated and 2. For Resident 380, there was no baseline activity care plan that was created, and she had no activity care plan at all. These deficient practices had the potential to cause delays in the continuity of care and communication which could negatively affect residents' health, safety and delivery of care. Findings: 1. Resident 337 was admitted to the facility on [DATE] with diagnosis of Cerebral infarction (necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), Aphasia (a disorder that makes it difficult to speak), abnormalities of gait and mobility, Dysphagia (difficulty swallowing). During a concurrent interview and record review on 6/26/25 at 9:52 a.m., with the assistant Director of Nursing (ADON), the ADON reviewed 337's clinical records and stated that Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/17/25 indicated Resident 337 has no speech, absence of spoken words, sometimes can make self-understood and sometimes understands others due to diagnosis of Aphasia. The ADON further stated that there was no communication problem care plan that was initiated upon admission and up to this day 6/26/25. During a concurrent interview and record review on 6/26/25 at 11:24 a.m., with Minimum Data Set Coordinator A (MDSC A), MDSC A reviewed Resident 337's MDS and Care plan confirmed the above MDS record review was accurate and there was no communication problem baseline care plan that was developed within 48 Hrs. after admission of Resident 337 on 6/10/25. Review of the undated facility's policy and procedure titled, Baseline Care Plan, indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan 2. During the observation of Resident 380 on 6/23/25 at 12:33 p.m., Resident 380 was lying in her bed and looked calm and comfortable. She was confused and could not answer questions. Review of Resident 380's face sheet (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 380 was admitted to the facility on [DATE] with the primary diagnosis of malignant neoplasm (cancerous tumor characterized by uncontrolled growth and potential spread to other parts of the body) of unspecified site of unspecified female breast. Review of Resident 380's physician order report from 5/24/25 to 6/24/25 indicated, Resident 380 may participate in activity as tolerated if not in conflict with treatment/care plan and the order was started on 6/19/25. Review of Resident 380's care plans indicated that Resident 380 did not have a resident-centered baseline activity care plan that was created and she did not have an activity care plan at all. During the concurrent review of Resident 380's clinical records and interview with the activity director (AD) on 6/27/25 at 11:48 a.m., the AD verified that Resident 380 was not assessed for her activities since she was admitted on [DATE] and there was no resident-centered baseline activity care plan that was created for her. The AD further verified that resident-centered baseline activity care plans should be created within 48 hours of admission. The AD also stated that Resident 380 was admitted on [DATE] and her baseline activity care plan should have been created and implemented already, and she did not have an activity care plan at all. Review of the undated facility's policy and procedure titled, Baseline Care Plan, indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan

Based on interview, medical record review, and facility P&P review, the facility failed to revise the comprehensive care plans to address the individual care needs for two of thirty-six sampled residents, (Residents 202 and 18), when: 1.Resident 202's care plan interventions were not revised or modified related to falls and cognitive function. 2.Resident 18's care plan for antibiotic, not resolved. This failure placed the residents at risk of not being provided appropriate, consistent, individualized care. Findings: 1.Resident 202 was admitted to the facility on [DATE] with diagnosis of Schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), Cerebral infarction cerebral infarction (necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on half of the body) , abnormalities of gait and mobility and weakness. Review of Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/16/25 indicated his cognition (mental, thought processes) and brief interview for mental status (BIMS, cognition level) score of eight is moderately impaired cognition. During a concurrent interview and record review on 6/26/25 at 2:13 p.m., with the assistant Director of Nursing (ADON), the ADON reviewed Resident 202's long term care plan dated 1/2/25 and the interventions were not revised or modified related to three falls interventions on 1/2/25, 1/7/25 and 2/26/25, and the cognitive function was not indicated. The ADON further stated that it should have been revised and modified for individualized care. Review of the facility's Comprehensive Plan of Care policy and procedure, undated, indicated Re-evaluate and modify care plans: as necessary to reflect changes in care, service and treatment; .with significant change in status assessment . 3. A review of Resident 18's Resident Face Sheet, indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (a type of stroke, caused blood to pool between the brain and skull), major contusion of left kidney (injury to the kidney), sepsis (body's extreme and potentially dangerous response to infection) . Review of Resident 18's clinical record indicated Resident 18 had a Physician order of Cefepime (antibiotic, used to treat bacterial infections) 2 grams (G, unit of measurement) every 12 hours for 7 days, dated 6/5/25. During a concurrent interview and record review with the Director of Nursing (DON), on 6/26/25 at 2:04 p.m., the DON confirmed Resident 18's antibiotic was completed on 6/12/25. The DON also confirmed the care plan for antibiotic was still active and should have been resolved. Review of the facility's Comprehensive Plan of Care policy and procedure, undated, indicated Re-evaluate and modify care plans: as necessary to reflect changes in care, service and treatment; .with significant change in status assessment .

Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for one (Resident 380), of six residents who used side rails that were investigated, when Resident 380 did not have a physician's order for her use of side rails. This failure caused the resident, to not have the proper approval from the physician for her use of side rails which could jeopardize the resident's safety. Findings: During the observation of Resident 380 on 6/23/25 at 12:33 p.m., Resident 380 was lying in bed and looked calm and comfortable. She was confused and could not answer questions. Resident 380 had bilateral (both sides) half side rails that were up. Review of Resident 380's face sheet (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 380 was admitted to the facility on [DATE] with the primary diagnosis of malignant neoplasm (cancerous tumor characterized by uncontrolled growth and potential spread to other parts of the body) of unspecified site of unspecified female breast. Review of Resident 380's physician order report or MD (Doctor of Medicine) order report from 5/24/25 to 6/24/25 indicated, there was no physician's order for Resident 380's use of side rails. During the concurrent review of Resident 380's medical records and interview with nurse supervisor D (NS D) on 6/27/25 at 3:19 p.m., NS D verified that Resident 380 had side rails but did have a physician's order for her use of side rails. NS D further stated she would notify Resident 380's physician about side rail use and then update the orders. Review of the undated facility's policy titled, Side Rails, indicated, Requirements are the same as for other physical restraints, whether or not the side rails enable mobility: Obtain MD order, including diagnosis/medical necessity for use

Based on observation, interview, and document review, the facility failed to ensure two of 36 sampled residents (Residents 106 and 195) received their lunch in accordance with scheduled meal times. This failure had the potential to result in reduced food palatability (quality of taste), which could negatively affect the residents' meal intake and nutritional status. Findings: During an interview with Resident 106 on 6/23/25, at 9:20 a.m., Resident 106 stated her food always came late and was cold most of the time. During an interview with Resident 195 on 6/23/25, at 9:54 a.m., Resident 195 also stated her food always came late and was cold most of the time. The facility's untitled document titled Meal Service Times was reviewed. The document indicated lunch was to be served to the residents between 11:40 a.m. and 1:00 p.m., depending on the area of the facility. During a dining observation on 6/23/25, the cart containing the lunch trays for Residents 106 and 195 arrived in their area of the facility at 1:32 p.m. Staff delivered the lunch trays for both residents at 1:34 p.m. During another dining observation on 6/25/25, the cart containing Resident 106's lunch tray arrived in her area of the facility at 1:43 p.m. Staff delivered the lunch tray to Resident 106 at 1:50 p.m. During an interview with the dietary manager (DM) on 6/25/25, at 2:01 p.m., the DM confirmed the last resident lunch tray should be delivered by 1:00 p.m. The facility's undated policy titled Resident Dining Program indicated, Lunch shall be served between 11:30 a.m. and 1:00 p.m.

Based on interview and record review, the facility failed to ensure the physician orders of one of three residents (Resident 1) were followed when a nurse did not perform a blood sugar check, administer insulin, and administer the correct dose of medication to Resident 1 timely. These failures had the potential to affect the health of Resident 1. Findings: Review of Resident 1's face sheet indicated the resident was admitted with diagnoses including nausea with vomiting and Type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). Review of Resident 1's Physician Order Report, from 11/16/24 - 12/9/24 indicated the resident had orders for the following: - Admelog SoloStar (insulin lispro [a short acting medication to helps to lower sugar in the blood]) 100 unit/ milliliter (mL, unit of measurement), per sliding scale for DM before meals 6:45 a.m., 11:45 a.m., 4:45 p.m., dated 12/4/24; - Myfortic (mycophenolate sodium [medication used to prevent the body from rejecting an organ transplant) tablet, delayed release, 360 mg (milligrams, unit of measurement), 3 tables, oral twice a day; 9 a.m., 9 p.m. Review of Resident 1's Diabetes Administration History, from 11/26/24 - 12/7/24 indicated on 12/3/24, insulin lispro was administered late. Review of Resident 1's Progress Note, dated 12/3/24 indicated, Writer was notified by supervisor and charge nurse that the resident missed 2 tabs of his Mycophenate [sic] medication which is supposed to be 3 tabs . Review of Resident 1's Progress Note, dated 12/4/24 indicated, Writer was informed about the late administration of blood glucose check yesterday 12/3/24 and insulin per sliding scare. LN [licensed nurse] at new station checked resident's blood glucose as soon as nurse received report that it was not done at the previous station . Review of Resident 1's Risk Meeting Notes Weekly, dated 12/4/24 indicated, MD has an order of Mycophenolate 360 mg 3 tabs BID (9am and 9pm). It was reported that charge nurse only administered 1 out of 3 tabs at 12:20PM . Charge nurse also missed checking blood sugar at 11:45AM before lunch and therefore was not given insulin on time . During an interview on 1/17/25 at 10:57 a.m., the director of nursing (DON) stated she interviewed the nurse (Registered Nurse A [RN A]). The DON stated RN A only gave one tablet of mycophenolate to Resident 1. The DON stated Resident 1 was given the other two tablets within six hours. The DON stated medications are supposed to be given one hour before or one hour after the scheduled time. The DON stated later they found out in the afternoon that RN A did not check Resident 1's blood sugar before lunch. The DON confirmed the blood sugar check and insulin administration was delayed. The DON stated the physician orders written in the chart should be followed. Review of the facility's Medication Administration General Guidelines, dated 1/23 indicated, Medications are administered in accordance with written orders of the prescriber . Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times. Based on interview and record review, the facility failed to ensure the physician orders of one of three residents (Resident 1) were followed when a nurse did not perform a blood sugar check, administer insulin, and administer the correct dose of medication to Resident 1 timely. These failures had the potential to affect the health of Resident 1. Findings: Review of Resident 1's face sheet indicated the resident was admitted with diagnoses including nausea with vomiting and Type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). Review of Resident 1's Physician Order Report, from 11/16/24 - 12/9/24 indicated the resident had orders for the following: - Admelog SoloStar (insulin lispro [a short acting medication to helps to lower sugar in the blood]) 100 unit/ milliliter (mL, unit of measurement), per sliding scale for DM before meals 6:45 a.m., 11:45 a.m., 4:45 p.m., dated 12/4/24; - Myfortic (mycophenolate sodium [medication used to prevent the body from rejecting an organ transplant) tablet, delayed release, 360 mg (milligrams, unit of measurement), 3 tables, oral twice a day; 9 a.m., 9 p.m. Review of Resident 1's Diabetes Administration History, from 11/26/24 - 12/7/24 indicated on 12/3/24, insulin lispro was administered late. Review of Resident 1's Progress Note, dated 12/3/24 indicated, Writer was notified by supervisor and charge nurse that the resident missed 2 tabs of his Mycophenate [sic] medication which is supposed to be 3 tabs . Review of Resident 1's Progress Note, dated 12/4/24 indicated, Writer was informed about the late administration of blood glucose check yesterday 12/3/24 and insulin per sliding scare. LN [licensed nurse] at new station checked resident's blood glucose as soon as nurse received report that it was not done at the previous station . Review of Resident 1's Risk Meeting Notes Weekly, dated 12/4/24 indicated, MD has an order of Mycophenolate 360 mg 3 tabs BID (9am and 9pm). It was reported that charge nurse only administered 1 out of 3 tabs at 12:20PM . Charge nurse also missed checking blood sugar at 11:45AM before lunch and therefore was not given insulin on time . During an interview on 1/17/25 at 10:57 a.m., the director of nursing (DON) stated she interviewed the nurse (Registered Nurse A [RN A]). The DON stated RN A only gave one tablet of mycophenolate to Resident 1. The DON stated Resident 1 was given the other two tablets within six hours. The DON stated medications are supposed to be given one hour before or one hour after the scheduled time. The DON stated later they found out in the afternoon that RN A did not check Resident 1's blood sugar before lunch. The DON confirmed the blood sugar check and insulin administration was delayed. The DON stated the physician orders written in the chart should be followed. Review of the facility's Medication Administration General Guidelines, dated 1/23 indicated, Medications are administered in accordance with written orders of the prescriber . Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times.

Based on observation, interview and record review, the facility failed to ensure a sanitary environment and safe food handling practices were maintained within the food service operation for 240 of 244 residents, which led to a cockroach infestation at the facility. This was evidenced by: 1. a) Live and dead cockroaches found in the kitchen under the meal tray line station and in food cooking preparation areas, confirmed by dietary staff, who reported the kitchen had a cockroach problem; Walls in the kitchen had uncovered holes with peeling baseboards, shelves had openings, and there were multiple broken kitchen appliances, which prevented adequate cleaning and sanitizing, and harbored pests; b) One of two ice machines managed by the Dietary Department had a dead baby cockroach inside on the ice curtain that covers the ice making grid water trough; c) Potentially hazardous foods (foods capable of supporting bacterial growth), also known as time control for food safety (TCS) foods, that were expired or incorrectly stored in the kitchen, which harbored pests; and d) Sanitizer solution in two red buckets were not at an effective concentration to sanitize food contact surfaces, and kitchen staff were unable to correctly demonstrate the process to test the sanitizer solution; and e) previous non-compliance of unsanitary kitchen conditions and evidence of heavy cockroach infestation at the facility identified by the County of Santa [NAME], Environmental Health Department in 2022 and 2023, per County health inspection reports; 2. Six (6) resident complaints about live and dead cockroaches in their rooms, and on their meal trays. The unsanitary kitchen practices exposed medically vulnerable residents to contaminated food that had the potential to cause widespread foodborne illnesses within this highly susceptible resident population. According to the 2022 Federal FDA (Food and Drug Administration) Food Code, .A 'Highly susceptible population' means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised (a weaker immune system); . or older adults; and (2) Obtaining food at a facility that provides services such as .health care . According to the 2022 Federal FDA Food Code, sections ,d+[DATE].11, Non-food contact surfaces, ,d+[DATE].11 Food contact surfaces, and Annex ,d+[DATE].13, indicated .equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms (tiny harmful particles like bacteria that can only be seen by a microscope), which employees may inadvertently transfer to food. If these areas are not kept clean, they may provide harborage (shelter or place providing shelter) for insects, rodents, and other pests. An immediate jeopardy (IJ) (an immediate situation where harm or potential harm could jeopardize the resident's safety) was called on [DATE] at 4:30 PM, and served to the Administrator (ADM) the due to the cockroach infestation in the kitchen, resident reports of cockroaches in meal trays, and repeated non-compliance of unsanitary dietary conditions in the kitchen which led to the extensive cockroach infestation. On [DATE] at 4:40 PM, the IJ was removed in the presence of the facility's ADM, Regional [NAME] President of Operations (RVPO), and Chief Executive Officer (CEO) after an acceptable plan of action (POA) was provided by the facility, and observations, interviews, and record reviews were conducted to validate the POA. The POA included: a) Kitchen closure by the County of Santa [NAME], Environmental Health Department on [DATE] at 5:00 PM, and thorough cleaning and sanitizing of kitchen equipment, appliances, floors, and walls. b) Resident meals were prepared at an outside skilled nursing facility, transported to the facility and served in disposable Styrofoam trays and utensils; c) Thorough cleaning and sanitizing of the entire facility including the following departments: Dietary, Nursing stations, Laundry, Rehabilitation, Maintenance, and the individual residents' rooms who had live and dead cockroaches inside the rooms; d) Kitchen staff training and in-services by the Registered Dietitian (RD) on cleaning and sanitizing food contact surfaces and safe food storage practices to prevent harboring of pests; e) During an interview on [DATE] PM at 2:56 PM with the ADM, RVPO, RD, and RD PP, the facility is not using the [NAME] menus (a corporate nutrition company who create menus and recipes) as previously decided but are using the emergency menu approved by the facility's RDs; f) Daily Pest control services in the kitchen and in the resident's rooms with live and dead cockroaches; g) Nursing staff in-services by the Director of Staff Development (DSD) on infection control practices, sanitation, and pest sightings in the facility; h) Kitchen and Facility staff monitoring and logging of pests and cockroach sightings in 'Pest Binders' located in the kitchen area, nurse's stations, laundry department, rehabilitation department, and other common areas; i) The facility's Environmental Services Director (ESD)/Designee (Administrator) will review the pest control schedule weekly or as necessary based on the results of the program. Any issues identified will be reviewed with the Administrator for resolution. All trends from these observations will be reported to the facility's Quality Assurance Performance Improvement (QAPI) committee daily x 60 days, weekly x 60, then reevaluated until compliance is sustained. The facility's QAPI committee will provide further recommendations when indicated to confirm that the facility follows protocols and regulations. The facility's QAPI committee meetings will return to monthly after full compliance is achieved. j) Approval by OSHPD (Office of Statewide Healthcare Planning and Development/HCAI (Healthcare Access and Information) to install new kitchen appliance equipment for food preparation, food storage, and food production to replace damaged, inoperable, unclean kitchen equipment which provided an entry access to cockroaches. In addition, the plan included daily routine monitoring of pests in the kitchen, an updated dietary staff cleaning schedule; and daily pest control services increased to weekly to ensure a safe, clean, and sanitary kitchen is maintained, in accordance with Federal Food & Drug Administration (FDA) Food Code, county, state, federal and OSHPD/HCAI requirements. Findings: 1. Unsanitary Foodservice Practices (a) Ice machine: According to a manufacturer (name of company), A single cockroach sighted during the day can indicate that there is a significant infestation. Cockroaches, also known as 'roaches,' are nocturnal and prefer to live and breed in dark shelters near food and moisture. But if a harborage site is overpopulated, they can be forced out in daylight, often in search of food ., to get to the food they can tread across the floor and through garbage in search of food, then crawl across the food-contact surfaces . (http://www.(name of company).com/pages/the-dangers-cockroaches-bring-to-food-safety) During a concurrent observation of the ice machine at station 4 on [DATE] at 3:17 PM, a dead baby cockroach was found inside the ice machine cover facing the ice curtain. The RD and Dietary Services Manager (DSM) confirmed the finding of the dead baby cockroach inside the ice machine cover, and the DSM stated, Oh wow. The RD and DSM stated they did not know the last time the ice machine was cleaned and sanitized. During an observation on [DATE] at 3:23 PM of the ice machine at nursing station 4 (NS 4) and interview with the facility's Regional Maintenance Director (FMD), the FMD acknowledged the black residue and brown crusty buildup inside the ice machine curtain, chute, and tiny black residue in the ice bin. The FMS stated the ice machine should be always clean, without the residue. The RD, DSM and the FMD acknowledged the dirty thick black and brown buildup and residue. The FMD further stated the ice machine should be cleaned every month using the manufacturer's guidelines. During an interview with the ADM on [DATE] at 4:01 PM, the ADM stated the maintenance supervisor probably just cleaned the inside of the ice machine and the dietary staff cleaned the outside of the ice machine. According to the 2022 Federal FDA Food Code, section ,d+[DATE].17, titled Ice Units, Separation of Drains, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice . the potential for mold .growth in this area is very likely due to the high moisture environment. Molds . that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. During a review of the facility's undated policy and procedure (P&P) titled Ice Machines, the P&P indicated .Follow the manufacturer's guidelines for cleaning .Cleaning 1. Disinfect the drop opening of the ice machine once a week with an appropriate disinfectant or use ,d+[DATE] cc's (cubic centimeters which equals milliliters of volume) of bleach to 1,000 cc's of warm water . (b) Kitchen Cockroach Infestation: During the initial kitchen tour on [DATE] at 8:58 AM, an observation of the back walls in the kitchen with shelves, a metal food prep counter and food prep sink had uncovered holes and pealing baseboards. Additionally, there were multiple broken and non-operation kitchen appliances, including a large reach-in refrigerator, a walk-in refrigerator, and condensation build-up on the ceiling of the walk-in freezer. The kitchen floor had food crumbs, debris, plastic strips, food wrappers, and other trash scattered all throughout the entire kitchen floor. Additionally, unsanitary practices including dirty dishes stored as clean dishes, light brown food crumbs and stains inside the two large reach-in refrigerators inside the DSM's office. One of three refrigerator door gaskets was ripped hanging off the inside of the door with a dark brown sticky substance on it. And a fire sprinkler was inside the walk-in freezer ceiling protruding from a large open hole. These physical environment conditions prevented adequate cleaning and sanitizing that allowed for and contributed to the harborage of pests. On [DATE] at 11:31 AM, during a kitchen observation, a dead roach was found on the floor in the food prep area. The DSM acknowledged the dead cockroach and stated not ok. Three more dead cockroaches were spotted in the corner on the floor near the steamer in the food prep area. A live cockroach was spotted on the floor crawling from the food prep counter adjacent to the tray line station. The DSM verified the three dead cockroaches and the live cockroach and then stepped on the live cockroach to kill it. On [DATE] at 12:26 PM, during a subsequent observation and interview in the kitchen, a dead cockroach was found on an electrical outlet under the food prep sink area and acknowledged by the DSM. Review of an outside company pest control reports dated [DATE], [DATE], [DATE], and [DATE] indicated, .Heavy roach infestation in kitchen .recommending roach clean out services .treated kitchen .12 refrigerators .pulled out due to German cockroaches being spotted on them . Further review of the outside company's pest control reports from [DATE] to [DATE] indicated treated kitchen and under food carts and repeated comments of treated food cart storage room . According to the Food and Drug Administration, Insects and rodents carry disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. The presence of insects and rodents is minimized by protecting outer openings to the food establishment. (FDA 2022 Annex 3 - Public Health Reasons/Administrative Guidelines, ,d+[DATE].15 Outer Openings, Protected) According to the Centers for Disease Control and Prevention (CDC), the German cockroach is a known vector for diseases including: Salmonellosis - Salmonella food poisoning causes diarrhea, fever, and abdominal cramps within 12 to 72 hours. Symptoms are generally mild, but can be severe, especially for those with a compromised immune system. Staphylococcus infections - This gastrointestinal [stomach and intestines] illness develops soon after food is eaten and usually last about a day. The toxins are heat resistant so are not destroyed by cooking. Escherichia coli (E. coli) bacteria normally lives in the intestines of people and animals and some types can cause illness with diarrhea. Typhoid fever - This life-threatening illness is caused by Salmonella Typhi. When a contaminated food is consumed, the bacteria multiply and spread into the bloodstream. Gastroenteritis - inflammation of the stomach and small and large intestines, generally leading to vomiting or diarrhea. General diarrhea. People may become infected with any of these by eating or drinking a contaminated food or beverage . https://www.cdc.gov/healthypets/pets/wildlife/rodent-control.html During a review of the recent County of Santa [NAME], Department Environmental Health Inspection report dated [DATE], the report indicated .Major Violations .3 live adult cockroaches and 2 live juvenile cockroaches found behind equipment at cookline. 3 juvenile cockroaches found on the wall at the dish station. One live adult cockroach laying an egg sack found on wall at dish station. Moderate amount of dead cockroaches found throughout the kitchen (behind tape) .The premises of each food facility shall be kept free of vermin (pests). A food facility shall not operate when there is a vermin infestation that has resulted in the contamination of food contact surfaces, food packaging, utensils, food equipment, or adulteration of food(s). The food facility shall cease operation of the food facility immediately. The food facility shall remain closed until there is no longer evidence of a vermin infestation; all contaminated surfaces have been cleaned and sanitized; and contributing factors such as cleaning, repairs, and the elimination of harborages have been resolved. Review of the County of Santa [NAME], Department of Environmental Health Inspection dated [DATE], the inspection indicated .Observed some uncovered holes in the kitchen walls behind storage shelves .to prevent rodent/insect infestation, seal all possible holes leading to the kitchen area . Review of the County of Santa [NAME], Department of Environmental Health Inspection dated [DATE] indicated, .Many dead cockroaches and one live cockroach was observed on cockroach traps located inside the (Dietary) office which is also used for food storage; .Major Violations .Multiple dead cockroaches were observed below the cooking, preparation, washing, storage tables in the kitchen area. Many live cockroaches were observed below these structures .The dead cockroaches must be cleaned, and the floor area properly sanitized immediately . During a review of the facility's undated policy and procedure (P&P) titled Pest Control, the P&P indicated .2. Train employees on preventive measures, unsanitary conditions .4. Keep all food storage and preparation areas clean .This includes walls, floors, shelving, cabinet tops, sinks, and equipment 7. Keep facility grounds free of trash . (c) Expired, Mold-like substances, and Exposed food: During the recertification survey initial kitchen tour on [DATE] at 8:55 AM, the kitchen was overall had food crumbs, debris, plastic strips, food wrappers, and other trash scattered all throughout the entire kitchen floor. Additionally, unsanitary practices including dirty dishes stored as clean dishes, light brown food crumbs and stains inside the two large reach-in refrigerators inside the DSM's office. One of three refrigerator door gaskets was ripped hanging off the inside of the door with a dark brown sticky substance on it. And a fire sprinkler was inside the walk-in freezer ceiling protruding from a large open hole. On [DATE] at 9:14 AM, an observation and interview were conducted in the Dietary Manager's office. A large Ziploc bag labeled puree kit dated [DATE] was found in the larger reach-in refrigerator with other nourishments. The Ziploc bag had a container of cooked cream of wheat and a bowl of soup. The DSM acknowledged the expired food items and stated they should have been thrown out. On [DATE] at 9:31 AM, a concurrent observation and interview were conducted with the DSM. There was a large clear plastic bin found in an open space underneath a food prep counter with a bag of 32 yellow onions, and 23 had multiple dark black, gray, and brown spots resembling mold, and soft to touch. The DSM acknowledged the 'mold-like' colored areas on the onions and stated the onions should have been rejected when they were delivered. On [DATE] at 9:59 AM, a concurrent observation and interview were conducted with the DSM. There was a scooper left inside a box of diced carrots in the walk-in freezer. The DSM acknowledged the scooper and stated, it should not be left there. The DSM did not know how long the scooper was left inside the case of carrots. During a review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control, dated 2023, the P&P indicated .All perishable food items .will be stored properly .8. Fresh .vegetables should be stored in designated bins or containers in a designated area of the refrigerator . During a review of the facility's policy and procedure (P&P) titled Food Purchasing, Receiving and Production dated 2023, the P&P indicated .All food will be of good quality and obtained from sources approved or considered satisfactory .3. All fresh .vegetables will be of good quality and freshness. Fresh produce should be purchased ,d+[DATE] times per week to ensure freshness and maximum nutritional value . (d) Sanitizer solution: During a kitchen observation on [DATE] at 10:03 AM and interview with a dishwasher Diet Aide (DA) J and the DSM, DA J stated the dish machine wash temperature should be 110 degrees F, and he thinks the sanitizer should be at 200 ppm (parts per million). DA J tested the sanitizer with a test strip from a chlorine test strip container and dipped it into the sanitizer solution from the dish machine for 13 seconds. DA J then compared the result against the test strip container results and shook his head. DA J took another test strip and redipped it for 10 seconds in the dish machine solution, then redipped the same strip for 8 more seconds and stated he is looking for a different result than what he's getting. DA J stated the sanitizer solution was not hot enough, that is why he did not get the desired result on the test strip because the color was gray, which was close to 200 ppm but not at 200 ppm. DA J stated he got trained on testing the sanitizer level in 2016 when he was hired and then again last week, but he doesn't remember the training. On [DATE] at 10:17 AM, the DSM acknowledged DA J's sanitizer test demonstration and stated he should know how to test this correctly. The DSM then placed a stainless-steel container upside down and ran it through the dish machine. She dipped a test strip from the chlorine test strip container on top of the stainless-steel container. The test strip was medium gray, which read ,d+[DATE] ppm (parts per million). The DSM stated, this is the correct level, it should be between ,d+[DATE] ppm. During an observation on [DATE] at 10:18 AM and interview with DA CC, DA CC tested the sanitizer solution by dipping the test strip in the red bucket for 15 seconds then compared the result with the test strip container and it was mostly orange with dark green on the tip. DA CC stated the strip should be at 400 ppm, which is acceptable and dark green because that is a good level. The DSM acknowledged the incorrect sanitizer test demonstration by DA CC. The DSM stated, the sanitizer in the red bucket should be between 200 ppm, and DA CC should know the correct process. During a review of the manufacturer's label on the sanitizer bottle for the sanitizer used in the red buckets, the effective concentration to sanitize should be at ,d+[DATE] PPM. The chem test strips from the vial that the facility used provided a color-coded graph in increments of 100 PPM, 200 PPM, 300 PPM, 400 PPM, and 500 PPM. There was no measurement on the chem strip vial available to determine 150 PPM. According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section ,d+[DATE].14, titled Sanitizing Solutions, Testing Devices, A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided. During a review of the facility's undated policy and procedure (P&P) titled Dietary Cleaning, the P&P indicated .Proper cleaning and sanitation of equipment ensures removal of residual food, chemicals, and bacteria .More sanitizer is not better; too much sanitizer can cause chemical poisoning. Use test strips to determine the proper strength of sanitizer .4.Removable parts can be washed, rinsed, and sanitized manually .Non-removable parts will be washed, rinsed, air dried, and sprayed with sanitizing solution . 2. Residents cockroach complaints a) During an interview with Resident 223 on [DATE] at 10:20 a.m., Resident 223 stated he saw a cockroach in his room on the wall last week. b) During a review of Resident 8's minimum data set (MDS, an assessment tool), dated [DATE] indicated her brief interview for mental status (BIMS) score was 15 (a score 13 to 15 indicates the resident is cognitively intact). During an interview on [DATE] at 1:30 p.m. with Resident 8, the resident stated she had seen one baby cockroach crawling on the plastic top of her juice cup. Resident 8 further stated that there was another dead cockroach on her meal tray not too long ago. c) Review of Resident 218's face sheet (a document that contains a summary of a patient's personal and demographic information) indicated, Resident 218 was admitted to the facility with diagnoses including severe sepsis (the body's extreme response to an infection), depression (loss of pleasure or interest in activities for long periods of time), and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days). Review of Resident 218's MDS, Quarterly assessment, dated [DATE], indicated, Resident 218 had a brief interview for mental status (BIMS, an assessment used in nursing homes and other long-term care facilities to monitor cognition) score of 15 (cognition is intact). During a concurrent observation and interview with Resident 218 on [DATE] at 9:05 a.m., inside his room, Resident 218 was lying on bed and stated there were some cockroaches in their room in the past and could not remember the date. d) Review of Resident 176's MDS Annual assessment dated [DATE], indicated Resident 176 had a BIMS score of 15. During an interview with Resident 176 on [DATE] at 10:51 a.m., Resident 176 stated there were small cockroaches found inside the food cart. Resident 176 further stated the Surveyors needed to check the kitchen because there were small cockroaches found on the plate's lid. During a subsequent interview with Resident 176 on [DATE] at 1:20 p.m., Resident 176 stated he found a cockroach under his bed at night on [DATE] and has seen cockroaches crawling under his bed in the past. Resident 176 felt upset knowing that there were cockroaches under his bed. e) Review of Resident 213's MDS, dated [DATE] indicated her BIMS score was 15 (score 13 to 15 indicates the resident is cognitively intact). During an interview on [DATE] at 10:29 a.m., Resident 213 stated she had a concern about roaches coming on her bed. She stated she told the facility about the roaches. Resident 213 stated the facility said they would move her out of the room and clean the room. She stated her room has not been cleaned yet. Resident 213 stated there was a roach problem ever since she was admitted to the facility in [DATE]. Resident 213 also stated she bought her own traps to deal with the roach problem. f) Review of Resident 168's MDS, dated [DATE] indicated his BIMS score was 15. During an interview on [DATE] 1:37 pm, Resident 168 stated his room was treated by a pest control company in [DATE] after weeks of asking. During the time when the pest control company did the pest treatment in his room, he claimed the cockroaches were crawling on him at night and waking him up. Resident 168 stated he also saw a cockroach in his lunch tray one time. He stated he went to the kitchen the next day to tell them about the cockroach, and the kitchen staff told him the cockroach was not from the kitchen. During a review of the County of Santa [NAME], Department of Environmental Health Inspection report dated [DATE], indicated .2. This routine inspection is conducted because of a complaint reported by residents about the cleanliness of the kitchen . During an interview with the Administrator (ADM) on [DATE] at 11:30 AM, the ADM indicated a Pest Control company treated the kitchen and the six residents' rooms. Per interview with the ADM and the Regional [NAME] President of Operations (RVPO), the pest control company will continue the pest treatment for the entire building in the following days/weeks. Review of a pest control company invoice dated [DATE] indicated .Full kitchen clean out for German cockroaches' infestation: performed crack and crevice treatment in the kitchen using several methods. 1) open up all electrical sockets drilled holes in the walls and treated .2) .did a baseboard treatment under and behind all equipment .strongly recommend weekly services along with daily follow ups, and placing out monitors to evaluate activity . During an observation of the kitchen to monitor cockroach activity on [DATE] at 8:50 AM, there was one (1) live cockroach and ,d+[DATE] dying cockroaches at the various areas in the kitchen. The kitchen was not under a sanitary condition for use and remained closed. During an observation and interview on [DATE] at 12:20 PM of the kitchen with the ADM and RD, the kitchen was moderately cleaned but still had food particles in drawers under the metal food prep counter. Per the ADM, the kitchen area was deep cleaned by a company on Saturday [DATE] and pest control sprayed on Friday, [DATE]. New kitchen equipment including a new combi oven and 2 free standing industrial refrigerators were purchased for installation because the facility felt they could not clean and sanitize the old equipment effectively. During an observation and interview with the Housekeeper (HK) QQ, RD, and RD BB on [DATE] at 12:50 PM in the kitchen. HK QQ stated she cleaned the kitchen floor this morning at 8:30 AM and did not see any live or dead cockroaches. There were no bait traps observed in the kitchen. RD and RD PP also validated the absence of bait traps in the kitchen. On [DATE] at 1:30 PM, during an observation and interview with the director of staff development (DSD), the DSD acknowledged resident rooms were deep cleaned as part of the Plan of Action (POA), however she had not done any training to staff of the importance of keeping the traps in place to monitor activity prior to surveyor identification that they were missing. There were no entries documented for cockroach activity observed in the binders for the previous 24 hours. The DSD acknowledged the blank entries in the Pest binder. During a concurrent observation and interview on [DATE] at 8:37 AM of the kitchen with the RD, the RD confirmed there was a total of 37 dead carcasses found in five of eight monitors and on the floor of the kitchen. During an observation on [DATE] at 9:08 AM of the kitchen, there was a total of six dead carcasses of roaches found in one of 13 monitors and on the floor of the kitchen near the three-compartment sink. During an observation on [DATE] at 3:27 p.m., in room [ROOM NUMBER] to 220, each of the rooms had a cockroach trap but no cockroach activity was seen. During an observation and concurrent interview on [DATE] at 3:32 PM with Certified Nursing Assistant (CNA) S, there was a pest control logbook binder available in the nurses' station. The log dated [DATE] indicated during the afternoon shift, there was one cockroach seen in resident room at nursing station 2 (NS 2). During an observation on [DATE] at 8:24 AM of the breakfast tray line, the therapeutic emergency menu was followed to feed residents. During a concurrent observation and interview on [DATE] at 9:15 AM in the kitchen, with Administrator in Training (AIT) and ADM, one dead carcass was found in one of 20 monitors. AIT confirmed the finding. During this kitchen observation and inspection on [DATE] at 9:15 AM, kitchen inspection with the ADM and AIT, the 20 traps were observed. Two (2) traps had 1 roach each on them. Facility was instructed to clean and sanitize the kitchen prior to installing the new equipment. During an interview with DA DD on [DATE] at 11:12 AM, DA DD stated in-services were done either yesterday or the day before for kitchen staff on how to check for the roach traps, any signs of roaches on the traps, they need to inform the DSM. If she is not there, then write it in the maintenance log that was in the kitchen. During an interview on [DATE] at 11:21 AM with the RD and RD PP, both RDs stated they conducted kitchen staff trainings and in-services, including the DSM on basic handwashing, labeling of food for food storage, fire extinguisher use, 3-compartment sink use, test strip sanitizer solution testing 200 ppm for testing quat (ammonia), and clean and sanitize kitchen areas. 44583 48590

Based on observations, interviews, and record reviews the facility failed to ensure the Food and Nutrition Services Department, the kitchen, and resident rooms were free from cockroaches, with an effective pest control program maintained. This failure caused 244 residents to be exposed to potential food contaminants that could cause food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). Cross reference 812, 908 Findings: 1) Cockroaches in Dietary Department According to a manufacturer (name of company), A single cockroach sighted during the day can indicate that there is a significant infestation. Cockroaches, also known as 'roaches,' are nocturnal and prefer to live and breed in dark shelters near food and moisture. But if a harborage site is overpopulated, they can be forced out in daylight, often in search of food ., to get to the food they can tread across the floor and through garbage in search of food, then crawl across the food-contact surfaces . (http://www.(name of company).com/pages/the-dangers-cockroaches-bring-to-food-safety) According to the Food and Drug Administration, Insects and rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. The presence of insects and rodents is minimized by protecting outer openings to the food establishment. (FDA 2022 Annex 3 - Public Health Reasons/Administrative Guidelines, 6-202.15 Outer Openings, Protected.) During the initial kitchen tour on 1/22/24 at 8:58 AM, an observation of the back walls in the kitchen with shelves, a metal food prep counter and food prep sink had uncovered holes and pealing baseboards. Additionally, there were multiple broken and non-operation kitchen appliances, including a large reach-in refrigerator, a walk-in refrigerator, and condensation build-up on the ceiling of the walk-in freezer. The kitchen floor had food crumbs, debris, plastic strips, food wrappers, and other trash scattered all throughout the entire kitchen floor. Additionally, unsanitary practices including dirty dishes stored as clean dishes, light brown food crumbs and stains inside the two large reach-in refrigerators inside the DSM's office. One of three refrigerator door gaskets was ripped hanging off the inside of the door with a dark brown sticky substance on it. And a fire sprinkler was inside the walk-in freezer ceiling protruding from a large open hole. These physical environment conditions prevented adequate cleaning and sanitizing that allowed for and contributed to the harborage of pests. During an observation of the ice machine at station 4 and interview with the DSM and RD on 1/22/24 at 3:17 PM, a dead baby cockroach was found inside the ice machine cover facing the ice curtain. RD and DSM confirmed the finding of the dead baby cockroach inside the ice machine cover, and the DSM stated, Oh wow. RD and DSM stated they did not know the last time the ice machine was cleaned and sanitized. During an observation on 1/22/24 at 3:23 PM of the ice machine at station 4 and interview with the facility's Regional Maintenance Director (FMD), the FMD acknowledged the black residue and brown buildup inside the ice machine curtain, chute, baffle, and tiny amounts in the bin and stated the ice machine should be always clean, without the residue. RD, DSM and FMD acknowledged the dirty thick black and brown buildup and residue. The FMD further stated the ice machine should be cleaned every month using the manufacturer's guidelines. During an interview with the Administrator (ADM) on 1/22/24 at 4:01 PM, the Administrator (ADM) stated the maintenance supervisor probably just cleans the inside of the ice machine and the dietary staff cleans the outside of the ice machine. During a review of the facility's undated policy and procedure (P&P) titled Ice Machines, the P&P indicated .Follow the manufacturer's guidelines for cleaning .Cleaning 1. Disinfect the drop opening of the ice machine once a week with an appropriate disinfectant or use 10-20 cc's (cubic centimeters which equals milliliters of volume) of bleach to 1,000 cc's of warm water . During a kitchen observation on 1/23/24 at 11:31 AM with the DSM, there was a dead roach was found on the floor in the food prep area. The DSM acknowledged the dead cockroach and stated, not ok. Three more dead cockroaches were spotted in the corner on the floor near the steamer in the food prep area. Then a live cockroach was spotted on the floor crawling from the food prep counter adjacent to the trayline station. The DSM verified the three dead cockroaches and the live cockroach and then stepped on the live cockroach to kill it. During a kitchen observation on 1/23/24 at 12:26 PM with the DSM, a dead cockroach was found on an electrical outlet under the food prep sink area and confirmed by the DSM. On 1/23/24 at 12:58 PM, an interview was conducted with the facility's Pest Control company. The Pest Company stated they've instructed the kitchen staff about overall sanitation, and ensuring the building is free of clutter with card boxes to prevent pests including cockroaches. The Pest company further stated they have treated the staff breakrooms, janitorial closets, dining rooms and resident rooms for pests and cockroaches but the focus has been in the kitchen. During an interview with the RD on 1/23/24 at 2:15 PM, the RD stated cockroaches were identified in the kitchen for several months, but the pest control company came out to spray the kitchen to monitor the cockroaches. Review of the monthly kitchen inspection reports titled Quality Assessment for Performance Improvement dated 2/5/23, 3/3/23, 4/5/23, 5/5/23, 6/3/23, 7/5/23, 8/7/23, 9/5/23, 10/20/23, 11/6/23, 12/5/23, and 1/5/24 completed by the RD was conducted. The 12/5/23 and 1/5/24 inspection reports indicated .PROBLEM: Broken oven handle, broken middle refrigerator, broken steamer, broken plate warmer, ceiling leaking, fan in walk-in fridge broken, gasket in fridge broken .Notified maintenance .SANITATION .cockroaches in kitchen . During an interview with the ADM on 1/23/24 at 2:30 PM about the pest control services at the facility, the ADM stated the pest control company the facility used from January 2023- April 2023, was not effective so the facility switched to a different pest control company. The ADM acknowledged the cockroaches found in the kitchen and further stated they have been a problem for a while. During a review of the recent County of Santa [NAME], Department Environmental Health Inspection report dated 1/23/24, the report indicated .Major Violations .3 live adult cockroaches and 2 live juvenile cockroaches found behind equipment at cookline. 3 juvenile cockroaches found on the wall at the dish station. One live adult cockroach laying an egg sack found on wall at dish station. Moderate amount of dead cockroaches found throughout the kitchen (behind tape). [CA] The premises of each food facility shall be kept free of vermin. A food facility shall not operate when there is a vermin infestation that has resulted in the contamination of food contact surfaces, food packaging, utensils, food equipment, or adulteration of food(s). The food facility shall cease operation of the food facility immediately. The food facility shall remain closed until there is no longer evidence of a vermin infestation; all contaminated surfaces have been cleaned and sanitized; and contributing factors such as cleaning, repairs, and the elimination of harborages have been resolved. Review of an outside company pest control report dated 7/20/23 indicated .Heavy roach infestation in kitchen .recommending roach clean out services . Review of an outside company pest control report dated 10/19/23 indicated .treated kitchen .12 refrigerators that (DSM name) pulled out due to German cockroaches being spotted on them . Further review of pest control reports dated from 5/2/23 to 1/18/24 indicated treated kitchen and under food carts and repeated comments of treated food cart storage room . According to the Centers for Disease Control and Prevention (CDC), the German cockroach is a known vector for diseases including: Salmonellosis - Salmonella food poisoning causes diarrhea, fever, and abdominal cramps within 12 to 72 hours. Symptoms are generally mild, but can be severe, especially for those with a compromised immune system. Staphylococcus infections - This gastrointestinal [stomach and intestines] illness develops soon after food is eaten and usually last about a day. The toxins are heat resistant so are not destroyed by cooking. Escherichia coli (E. coli) bacteria normally lives in the intestines of people and animals and some types can cause illness with diarrhea. Typhoid fever - This life-threatening illness is caused by Salmonella Typhi. When a contaminated food is consumed, the bacteria multiply and spread into the bloodstream. Gastroenteritis - inflammation of the stomach and small and large intestines, generally leading to vomiting or diarrhea. General diarrhea. People may become infected with any of these by eating or drinking a contaminated food or beverage . https://www.cdc.gov/healthypets/pets/wildlife/rodent-control.html During a review of the County of Santa [NAME], Department of Environmental Health Inspection reports dated 4/15/22 and 5/3/23, the reports indicated .Many dead cockroaches and one live cockroach was observed on cockroach traps located inside the (Dietary) office which is also used for food storage .Major Violations .Multiple dead cockroaches were observed below the cooking, preparation, washing, storage tables in the kitchen area. Many live cockroaches were observed below these structures .The dead cockroaches must be cleaned, and the floor area properly sanitized immediately . 2) Cockroaches in Resident rooms and Care areas: a) During an interview with Resident 223 on 1/22/24 at 10:20 a.m., Resident 223 stated he saw a cockroach in his room on the wall last week. b) During a review of Resident 8's minimum data set (MDS- an assessment tool), dated 12/20/23 indicated her brief interview for mental status (BIMS, measure of cognition level) was 15 (score 13 to 15 indicates the resident is cognitively intact). During an interview on 1/23/23 at 1:30 p.m. with Resident 8, the resident stated she had seen one baby cockroach crawling on the plastic top of her juice cup. Resident 8 further stated that there was another dead cockroach on her meal tray not too long ago. c) Review of Resident 218's face sheet (a document that contains a summary of a patient's personal and demographic information) indicated, Resident 218 was admitted to the facility with diagnoses including severe sepsis (the body's extreme response to an infection), depression (loss of pleasure or interest in activities for long periods of time), and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days). Review of Resident 218's MDS dated [DATE], indicated, Resident 218 had a brief interview for mental status (BIMS, an assessment used in nursing homes and other long-term care facilities to monitor cognition) score of 15 (cognition is intact). During a concurrent observation and interview with Resident 218 on 1/22/2024 at 9:05 a.m., inside his room, Resident 218 was lying on bed and stated there were some cockroaches in their room in the past and could not remember the date. d) Review of Resident 176's MDS Annual assessment dated [DATE], indicated Resident 176 had a BIMS score of 15. During an interview with Resident 176 on 1/22/2024 at 10:51 a.m., Resident 176 stated there were small cockroaches found inside the food cart. Resident 176 further stated the Surveyors needed to check the kitchen because there were small cockroaches found on the plate's lid. During a subsequent interview with Resident 176 on 1/23/2024 at 1:20 p.m., Resident 176 stated he found a cockroach under his bed at night on 1/22/2024 and has seen cockroaches crawling under his bed in the past. Resident 176 felt upset knowing that there were cockroaches under his bed. e) Review of Resident 213's MDS, dated [DATE] indicated her BIMS score was 15 (score 13 to 15 indicates the resident is cognitively intact). During an interview on 1/22/24 at 10:29 a.m., Resident 213 stated she had a concern about roaches coming on her bed. She stated she told the facility about the roaches. Resident 213 stated the facility said they would move her out of the room and clean the room. She stated her room has not been cleaned yet. Resident 213 stated there was a roach problem ever since she was admitted to the facility in April 2023. Resident 213 also stated she bought her own traps to deal with the roach problem. f) During an interview on 1/23/24 at 12:59 p.m. with licensed vocational nurse (LVN) C, LVN C stated, approximately one week ago during the evening shift, she saw three (3) small cockroaches crawling out of a drawer in nursing station A (NS A). She said, I killed one [cockroach] .housekeeping sprayed [insecticide] right away. g) During an interview on 1/23/24 at 1:02 p.m. with Certified Nursing Assistant (CNA) D, CNA D stated, one resident complained about cockroaches two weeks ago. She could not recall the name of the resident. h) During an interview on 1/23/24 at 1:03 p.m. with Registered Nurse (RN) E, RN E stated, she could recall two recent cockroach incidents. RN E stated the most recent incident was 11/2023 when Resident 35's family member saw a cockroach alive in the resident's room and complained to her. RN E said, Resident 35 was moved .janitor sprayed the room .48 hours later the resident was moved back .[Resident 35] currently still in the facility. RN E stated, the second cockroach incident occurred in 8/2023 when Resident 192 saw a cockroach and called the nursing station. RN E stated, she went to the room, saw the cockroach alive, moved the resident to another room, and a janitor sprayed a pest control spray. RN E stated, a facility janitor sprayed the cockroach at that time, and added, not a pest control company. When asked to describe the process for reporting cockroach incidents, RN E stated, both times the administrator was informed, and she added, If we see cockroaches we spray and tell [the] infection control manager. During a review of the County of Santa [NAME], Department of Environmental Health Inspection report dated 5/3/23, indicated .2. This routine inspection is conducted because of a complaint reported by residents about the cleanliness of the kitchen . During a review of the facility's undated policy and procedure (P&P) titled Pest Control, the P&P indicated .2. Train employees on preventive measures, unsanitary conditions .4. Keep all food storage and preparation areas clean .This includes walls, floors, shelving, cabinet tops, sinks, and equipment 7. Keep facility grounds free of trash . 48590

Based on observation, interview and record review, the facility failed to provide supervision to prevent one of 14 residents (Resident 27) who were at risk for elopement from leaving the facility without staff's knowledge and permission when: 1. Staff did not provide Resident 27 with supervision and one staff physical assistance for locomotion on unit (how resident moves between locations in her room and adjacent corridor in the same floor), and locomotion off unit (how resident moves to and returns from off-unit locations [i.e., hallways, dining, or how resident moves to and from distant areas on the floor]). 2. Four out of five charge nurses (licensed vocational nurse B [LVN B], LVN C, LVN F, and registered nurse G [RN G]) did not know how to check the functionality of the wander guard (a device applied to the resident's body that triggers an alarm if the resident tries to exit the facility); and 3. Licensed Nurse did not complete the quarterly Elopement Risk Assessment and did not develop an elopement risk care plan in a timely manner. These failures compromised Resident 27's health and safety, as she was found by paramedics (persons trained to give emergency medical care to people who are injured or ill) on the street eating dirt and rocks. Resident 27 sustained scrapes and scratches on the bridge of her nose and on both knees. She was admitted to the acute hospital for treatment and evaluation. Findings: 1. Review of Resident 27's medical record indicated she was admitted to the facility on [DATE] with diagnoses of dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes) with behavioral disturbance, generalized muscle weakness, difficulty walking, [CONDITION(S)] (severe mental disorder that causes abnormal thinking and perceptions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and hypertension (abnormally high blood pressure). Review of Resident 27's Minimum Data Set (MDS, an assessment tool) dated 6/16/22, indicated she had short-term and long-term memory problems, with severely impaired daily decision making. The MDS indicated Resident 27 rarely or never understood others and was rarely or never able to make herself understood. The MDS further indicated Resident 27 required supervision (oversight, encouragement, or cueing) and one staff physical assistance for eating, transfers, walking in room and corridor, and locomotion on and off unit. Review of Resident 27's Elopement Risk Assessment, dated 7/15/22, indicated she was at risk for elopement, was ambulatory (able to walk), had behaviors of wandering without purpose, and had a substance abuse/psychiatric history. Review of Resident 27's care plan titled Risk for elopement and wandering out of the facility, dated 7/15/22, indicated the resident was to have a wander guard bracelet and staff was to check the alarm for functioning. During an observation and concurrent interview with certified nursing assistant A (CNA A) on 7/13/22 at 2:28 p.m., Resident 27 was ambulating (walking) independently in the hallway near her room. CNA A stated Resident 27 was confused, wandered around, and walked independently. During an interview with CNA D on 7/14/22 at 8:54 a.m., CNA D stated Resident 27 walks around all the time. CNA D stated staff need to watch and supervise her, sometimes she wants to go out and wanted go home, we need to follow her around. CNA D also stated, If busy, the supervisor needs to follow her when she's up because she could go out. On 7/15/22 at 2:41 p.m., two surveyors (Pharmacy Consultant and a nurse surveyor) reported having heard the facility's exit door alarm sound off and witnessed Resident 27 trying to get out of the facility at 1:17 p.m. The facility's consultant/Vice President ran after Resident 27 and brought her back inside. Review of Resident 27's SBAR (Situation, Background, Assessment, Recommendation; a communication tool), dated 7/16/22 indicated, Writer received a call from paramedics that resident was found outside the facility on Forest Avenue near the corner stop light and when assessed by the paramedics resident noted with an elevated temperature and [CONDITION(S)] (fast heart rate over 100 beats a minute) Resident 27 was sent to the emergency room for further evaluation and treatment. During an interview and concurrent record review with RN R on 7/18/22 at 10:23 a.m., RN R stated she was the nurse supervisor on duty when Resident 27 eloped on 7/16/22. RN R confirmed having received a call from the paramedics that Resident 27 was found near the stoplight on Forest Avenue (about a two-minute walk from the facility). RN R stated Resident 27 was wearing a wander guard bracelet and she had no idea how the resident got out of the facility. RN R also stated she interviewed the receptionist on duty at the time of incident, who claimed the door did not alarm or sound off when Resident 27 got out of the facility. RN R also reviewed Resident 27's physician's order, dated 3/14/22, that indicated wander guard to prevent elopement RN R stated charge nurses were responsible for checking the functionality of the wander guard alarm. During an interview with the receptionist staff (RS) on 7/18/22 at 12:46 p.m., he confirmed he worked as receptionist on 7/16/22 from 7:00 a.m. to 4:00 p.m. The RS confirmed he received a call from the paramedics, then transferred the call to the nurse supervisor on duty. The RS confirmed he and the facility staff were aware that Resident 27 was an elopement risk. The RS also stated Resident 27 had a history of pulling out doors and trying to get out. The RS stated the main door and other exit doors did not sound off and he did not know how Resident 27 was able to get out of the facility without the alarm sounding off. Review of Resident 27's History and Physical from the acute hospital, dated 7/17/22, indicated she was brought in by ambulance on 7/16/22 after bystanders noted the resident to be face down in a planter attempting to eat rocks, and the facility did not know she left the facility. Resident 27 presented to the ED (emergency department) after being found by EMS [emergency medical services] altered [physical and/or mental condition were not normal]. The ED notes also indicated, found by EMS altered, on the floor by a street trying to eat rocks and dirt. Patient was found to be a conserved [under the protection of a guardian or custodian] resident of and they were unaware she was missing. Patient was brought to the ED and work up for fall and infection was done. Resident 27 was admitted to the hospital's emergency roiagnom on [DATE]. On physical examination it indicated the resident was disheveled [untidy, messy or unkempt], dirt all over face. Patient presenting with PMH [previous medical history] for dementia, major neurocognitive disorder with behavioral and [CONDITION(S)], depression, and anxiety, being admitted for AMS [altered mental status]. In the ED, Resident 27 had a heart rate of 134 beats per minute (normal heart rate is 60 to 100 beats per minute). On admission she appeared disheveled, had dry mucous membranes, and had scrapes and scratches on the bridge of her nose and both knees. She presented in the ED with lactic acidosis (lactic acid build up in the bloodstream caused by impaired/decreased tissue oxygenation; a potential medical emergency). She was administered 3 L (liters, unit of measurement) of IV (intravenous- given by vein) fluids, and IV [MEDICATION(S)] and [MEDICATION(S)] (antibiotics, medications to treat infection). 2. Review of resident 27's physician's order, dated 3/14/22 indicated, Wander guard to prevent elopement twice a day at 0900 A.M., 0500 P.M During an interview with LVN B on 7/18/22 at 10:50 a.m., LVN B confirmed having been assigned to Resident 27 and another resident who had a wander guard. LVN B admitted he had never used any device to check if his residents' wander guards were functioning properly. He stated, Never used it before, and does not have the machine. During an interview with LVN C on 7/18/22 at 10:52 a.m., LVN C stated she had been assigned in Station 3 before. LVN C admitted she was not taught or instructed on how to check the functionality of the wander guard. During an interview with housekeeping/maintenance (HKM) and housekeeping maintenance staff (HKS) on 7/18/22 at 11:02 a.m., both staff stated they had not checked any wander guards used by residents. During an interview with LVN E on 7/18/22 at 11:08 a.m., LVN E stated the machine to check the functionality of the wander guards was kept in Station 4. During an observation and concurrent interview with LVN F on 7/18/22 at 11:15 a.m., LVN F and RN R both searched for the wander guard checking device from the Station 4 medication cart but could not find it. LVN F claimed nobody oriented her on how to check the functionality of the wander guard and she did not know how to use such device. LVN F also stated she would have the director of staff development (DSD) teach her. RN R heard and confirmed LVN F's claim. During an interview and concurrent record review with the DSD on 7/18/22 11:30 a.m., the DSD confirmed she had not done any in-service (training) with the registry nurses (nurses from a staffing agency who come to work temporarily in the facility) and other nurses on how to check the functionality of the wander guard. The DSD, upon review of her in-service log with her assistant, confirmed the Elopement In-service conducted did not include the procedure on how to check the wander guard. During an interview with RN G on 7/18/22 at 11:40 a.m., RN G stated, I don't know how to check, don't' know how to use the device. 3. During a record review and concurrent interview with the minimum data set coordinator (MDSC) on 7/15/22 at 2:02 p.m., the MDSC stated the Elopement Risk Assessment should be completed every quarter. The MDSC confirmed she knew Resident 27 because she is the one wandering around and she was at risk for elopement. During the concurrent record review, the MDSC confirmed Resident 27's Elopement Risk Assessment was done only upon admission on 3/9/22 and was not completed in June 2022. The MDSC also confirmed the elopement risk care plan was not developed. The facility completed the Elopement Risk Assessment and developed the elopement risk care plan on 7/15/22, after this record review and concurrent interview. Review of the facility's 12/1/2005 policy and procedure, Elopement, indicated Elopement Risk Form will be completed for all patients upon admission, readmission, quarterly, and with significant changes. Patients showing to be at Risk for Elopement will have a wander guard placed if applicable to the facility.

Based on interview and record review, the facility failed to assess Resident 1's elopement risk based on his past medical history. This failure resulted in Resident 1's elopement incident in the facility and returned to the facility with swollen left upper lip with bluish discoloration, redness on right knee, multiple skin tears on left knee, and a lump on right upper thigh. Findings: Review of Resident 1's admission records dated 11/26/18, indicated following [DIAGNOSES REDACTED]. in walking) and mobility (ability to move). Review of Resident 1's acute hospital progress notes dated 11/26/18, indicated documented [MEDICAL CONDITIONS] presents after being found confused wandering around the hospital admitted for placement. It further stated that Resident 1's girlfriend's daughter stated that Resident 1 has dementia and often wanders away from home. Review of Resident 1's Elopement Risk Review dated 11/26/18, indicated he was not at risk for elopement. Review of Resident 1's nurse's notes dated 12/6/18 at 5:10 p.m., indicated Resident 1 cannot be found in the facility. Review of Resident 1's nurse's notes dated 12/6/18 at 7:32 p.m., indicated facility staff reported to police department that Resident 1 was missing. Review of Resident 1's clinical records dated 12/7/18 at 10:50 a.m., indicated the director of nursing (DON) received a call around 8:48 a.m. from Resident 1's friend stating that police dropped off Resident 1 at their home and requested for the facility to pick up Resident 1. At 10:50 a.m., Resident 1 returned to facility accompanied by a staff member. Review of Resident 1's physical assessment dated [DATE] at 10:50 a.m., indicated swollen left upper lip with bluish discoloration, redness on right knee, multiple skin tears on left knee, and a lump on right upper thigh. During an interview with receptionist A (RECEP A) on 12/7/18 at 1:00 p.m., he confirmed Resident 1 had no evidence of elopement risk identification form kept in the elopement risk binder they keep in reception desk. During an interview with the DON on 12/7/18 at 1:45 p.m., she stated based on the history that the acute hospital provided, Resident 1 was at risk for elopement. She also confirmed Resident 1 was assessed for elopement incorrectly and should have had a Wander Guard band (a type of bracelet that a resident wear to prevent person at risk from leaving a facility unless they are accompanied). Review of the facility policy, Elopement dated 12/1/2017, indicated 2. Patient showing to be at Risk for Elopement will have a Wander Guard band placed if applicable for facility. 3. Patient showing to be at Risk for Elopement will have completed the Elopement Identification Form with attached Photo. 4. Elopement Risk Identification Forms will be in an Elopement Binder and maintained at the Reception Desk.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received adequate supervision to prevent falls and injury. Resident 1 had a history of [REDACTED]. The staff failed to follow their care plan to ensure Resident 1 was checked frequently, and to ensure equipment (patio chair) was safe for use. Resident 1 was not supervised when he walked to the dining/patio area and fell , sustained a broken hip, and required surgical repair. This failure caused pain and suffering to the resident. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His Minimum Data Set (MDS, an assessment tool) dated 2/9/17, indicated he had short and long term memory problems, made poor decisions, required cues (prompting) and supervision for activities of daily living (ADL). Review of Resident 1's Fall Risk Data Collection form indicated he scored 22 on 9/30/16 and 20 on 2/4/17. The form indicated a total score of 10 or above represented a high falls risk. Review of Resident 1's Non-Compliant care plan, dated 4/12/16, indicated the resident had problem behaviors including refusing care, and was difficult to redirect by nursing staff as he became verbally and physically aggressive. Review of Resident 1's at risk for falls/injury care plan, dated 2/12/16, indicated he had a history of [REDACTED]. The interventions (approaches) to prevent falls included to identify type of assistance the resident needed, provide assistance as identified with transfer and mobility, and to provide frequent visual checks. Review of Resident 1's At Risk for Wandering Out of the Facility care plan, dated 2/12/16, indicated he had interventions of having a WanderGuard (device placed on a person's extremity that would alarm when entering a designated area), and to check the resident's whereabouts. Review of Resident 1's clinical record indicated he fell seven times between 9/8/16 and 2/24/17. The 9/8/16, 9/17/16, and 11/6/16 falls occurred in the dining room. The 9/30/16, 1/9/17, and 2/24/17 falls occurred on the patio next to the dining room. Review of the physical therapy progress and discharge notes, with the end of care date of 9/29/16, indicated the physical therapist recommended the resident was not safe to ambulate (walk) with staff. Review of the facility floor plan indicated there was an elevator in Station 2 and a dining room was next to the elevator. The dining room led to a patio area. During an observation on 3/23/17 at 3:15 p.m., the dining room located near Station 2 led to a patio. The patio had two glass sliding doors, concrete flooring and was not locked. There were residents seated in dining room chairs and no staff in attendance. During an interview at the time of the observation on 3/23/17 at 3:15 p.m., licensed vocational nurse (LVN) A stated she found Resident 1 on the patio floor off the dining room near Station 2 on 2/24/17 before 7 a.m., and the patio door was not kept locked. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem) form, dated 9/30/16 at 2:40 p.m., indicated the resident fell on the patio when a leg of the chair suddenly broke. Review of the Witnessed Fall care plan, revised on 9/30/16, had preventative measures of visual checks, monitor whereabouts of the resident and have maintenance staff check the patio chair for safety. During an interview with the Maintenance/Housekeeping Supervisor, who reviewed the maintenance log on 3/27/17 at 9:40 a.m., he stated he had no knowledge and no maintenance request of a broken patio chair. During an interview, on 3/27/17 at 9:40 a.m., certified nurse assistant (CNA) B stated Resident 1 smoked on the patio, that his walk was wobbly, he sometimes lost his balance, and he walked around the facility without supervision. During an interview on 3/27/17 at 11:15 a.m., the nursing supervisor (NS) stated Resident 1 walked around the facility independently without an assistive device (cane or walker) and would often get physically combative when staff tried to redirect him. The NS said that staff were afraid of Resident 1 and did not know where he was going when he walked. The NS stated frequent visual checks indicated to observe a resident every one to two hours. During an interview on 3/29/17 at 7:10 a.m., the charge nurse (CN) C stated that during the night shift there were a maximum of 43 residents on Station 2 with one licensed nurse and two CNAs on duty. CN C stated the two CNAs worked together as a team and had several duties including making rounds, passing water pitchers, and providing incontinence care. The CN said that residents who were awake at night were grouped together in a hallway where one CNA watched them, and Resident 1, when awake at night, walked to the kitchen and elevator and he could not be closely watched. During an interview on 3/29/17 at 7:25 a.m., the CN D stated Resident 1 ambulated around the hall by himself unsupervised and was able to open the patio door. CN D recalled she was passing medications on 2/24/17 at 6:50 a.m. when an alarm sounded at the elevator. CNA D stated CNAs maybe checked on Resident 1, who triggered the alarm, and later left him in the dining room. CN D stated she was informed by a CNA at 7 a.m. about Resident 1 having fallen on the patio. The WanderGuard only triggered the alarm when residents passed by the elevator. During an interview on 3/29/17 at 8:50 a.m., LVN E described Resident 1 as physically and verbally aggressive to staff, able to open the patio door, did not want to be redirected and had a history of [REDACTED]. LVN E stated that Resident 1 walked, he called for CNAs to assist and watch, and the resident would became angry when he was watched or followed by staff. LVN E stated frequent checks indicated checking on the resident every 30 minutes to one hour. During an interview on 3/29/17 at 11:10 a.m., CNA F described Resident 1 as hard to approach, that he would suddenly become angry and aggressive, and she was afraid to be physically hurt by him. The CNA stated on the morning he fell (2/24/17), Resident 1 slept in late. She said an alarm sounded at 6:50 a.m. when Resident 1 passed by the Station 2 elevator. She said she and another CNA checked on Resident 1 and left him in the dining room. CNA F stated she and another CNA were in a hurry to change Resident 1's bedsheet because CNAs had to sign out by 6:53 a.m. She said when she returned to work that night, she learned Resident 1 had fallen. During an interview on 3/29/17 at 11 a.m., the director of nurses (DON) confirmed there was no specific policy for supervision and presented a form, EVERY 30 MINUTES SAFETY WATCH, which was to be completed for frequent visual checks. The monitoring forms were requested for Resident 1 on the days of his falls. The DON stated the forms were not part of the medical records and were not provided. Review of the Fall Prevention policy, dated 11/17/18, did not address a process in place as to how residents were frequently checked or supervised. Review of the acute care hospital Inpatient Medicine Discharge Summary, dated 2/28/17, indicated Resident 1 was brought in for an unwitnessed fall and found to have a left intertrochanteric fx (hip fracture) and was taken for urgent left hip surgery.

Based on interview and record review, the facility failed to adequately prevent an accident and injury for one of three sampled residents (Resident 1). Resident 1's fall risk assessment was done inaccurately on readmission and a sensor pad alarm was discontinued because of the inaccurate fall risk assessment. Resident 1's bowel and bladder training (B&B training, a form of behavior therapy to treat or reduce urinary incontinence (a loss of control of the bladder)) was not implemented as care planned as one of the interventions to prevent a fall, and the resident was not provided assistance in a timely manner for toileting. These failures resulted in Resident 1's fall, hip fracture (broken hip), surgery, and anger. Findings: Resident 1's clinical record was reviewed. The resident was admitted to the facility on [DATE] with a history of falls. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 5/11/16, indicated the resident was cognitively intact and had no memory problem. Resident 1 required extensive assistance (the resident involved in activity and staff provide weight-bearing support) of one person for toileting. It indicated the resident had unsteady balance while moving on and off the toilet and was only able to stabilize with staff assistance. It further indicated she had occasional incontinence of bladder. Review of Resident 1's SBAR (situation, background, assessment, and recommendation, a communication and assessment tool used by nurses for a resident's change of condition) dated 3/20/16, indicated the resident attempted to use a bedside commode, lost her balance, and fell . Review of Resident 1's Fall Care Plan dated 3/20/2016, indicated to apply a sensor pad alarm (when a resident is about to get up from a bed, staff hear an alert and can quickly go to the resident to prevent a fall) to the resident's bed and perform B&B training to prevent another fall. There was no documented evidence the B&B training was performed. Resident 1's Incontinence Care Plan dated 5/11/16, indicated Resident 1 refused to get up to use a bathroom on schedule. There was no other documentation indicating Resident 1 was assessed for an appropriate toileting program utilizing B&B assessment tools which were required per the facility's policy. Review of Resident 1's clinical record indicated the resident was discharged on [DATE], readmitted to the facility on [DATE], and the resident's fall risk was reassessed. Review of Resident 1's Fall Risk Data Collection dated 8/12/16, indicated the total score for fall risk was 8 which meant the resident was not at high risk for falls (the total score of 10 or above represents high risk for falls). The assessment included level of consciousness, history of falls, mobility with elimination, gait, balance, medications, and predisposing disease. Review of Resident 1's Fall Care Plan initiated 2/10/16 and revised on 8/12/16, indicated the resident's sensor pad alarm in her bed was discontinued on 8/12/16. Review of Resident 1's SBAR dated 8/15/16, indicated the resident had an unwitnessed fall. Review of Resident 1's History and Physical from an acute care hospital dated 8/16/16, indicated the resident was transferred to the acute care hospital after her fall on 8/15/16, and sustained a right hip fracture. Review of Resident 1's discharge summary from an acute care hospital dated 8/19/16, indicated the resident underwent [REDACTED]. During an interview with nursing supervisor A (NS A) on 8/29/16 at 9 a.m., she stated Resident 1's fall risk assessment was inaccurate and the score should be 12, instead of 8. She acknowledged Resident 1 was at high risk for falls. During an interview with certified nursing assistant B (CNA B) on 8/29/16 at 11:40 a.m., she stated Resident 1 needed assistance to use a bedside commode. She stated Resident 1 should have had a bed alarm to alert staff when she tried to get up from her bed. During an interview with nursing supervisor C (NS C) on 8/29/16 at 1:15 p.m., she stated Resident 1's sensor pad alarm was removed when the resident was readmitted to the facility because of the inaccurate fall risk assessment. NS C stated the alarm would prevent Resident 1 from falling by alerting the staff when Resident 1 tried to get up from her bed. During an interview with Resident 1 on 8/29/16 at 2 p.m., she stated on 8/15/16 at night, she pushed a call light to ask for assistance to use her bedside commode but no one came to help her. The resident stated she could not hold her bladder, she decided to use a bedside commode on her own, and when she stood up she slid from her bed to the floor. She stated every time she called for help, she waited for 15 minutes for the staff to come and assist her. She stated she was angry for what had happened to her regarding her fall, the fracture requiring surgery, and not getting assistance on time for toileting. During a concurrent interview with Resident 1's responsible party (RP, a person empowered to make medical decisions for the resident), she stated on 8/15/16, she was in the facility until 9:45 p.m. and Resident 1 pressed a call light around 9:15 p.m. to ask for assistance to use a bedside commode. RP stated no staff came to help Resident 1. At 9:30 p.m., RP went to a nurse's station to ask assistance to toilet Resident 1. At 9:45 p.m., she left the facility and up until that time, no staff came to help Resident 1. At 10:15 p.m., when she was at home, a nurse called her and reported Resident 1 tried to use her bedside commode by herself and fell . During an interview with the director of nursing (DON) on 8/29/16 at 2:30 p.m., she acknowledged Resident 1's fall risk assessment on readmission was inaccurate. She stated the sensor pad alarm was discontinued because of the inaccurate fall risk assessment. DON stated Bowel and Bladder Training Form, Bladder Continence Assessment Form, and Bowel and Bladder Pattern Record were not completed to assess and initiate Resident 1's B&B training. DON stated Resident 1's B&B training was not done as care planned. Review of the facility's policy Bowel and Bladder Assessment dated 11/2008 and revised 1/2009, indicated B&B training is to identify causes of incontinence, to reduce the number of incontinent episodes, assist a resident in becoming continent and independent in toileting, and to promote self-esteem and dignity. The procedures included to complete Bowel and Bladder Training Form, Bladder Continence Assessment Form, and Bowel and Bladder Pattern Record. Review of the facility's policy Fall Prevention dated 12/1/05, indicated a fall prevention program will be developed for each resident that will provide resident care staff with creative functional strategies to prevent falls and undue injuries from such incidents, while recognizing the residents' rights and their need to maintain their highest level of functioning.

Based on observation, interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided adequate supervision when implemented interventions were not consistent with Resident 1's assessed needs. Resident 1 was not provided with two person assistance when transferred during a shower as per the facility policy. This failure resulted in Resident 1 sustaining a left shoulder fracture and chest contusion. Findings: Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 5/7/14 indicated Resident 1 was not oriented and with memory problems. Review of Resident 1's MDS dated [DATE] under Section G-Functional Status indicated Resident 1 was totally dependent and needed a "2+ persons physical assist" during transfers. Resident 1's "Kardex" (an abbreviated care plan used by certified nurse assistants as an aid to identify resident care needs) indicated Resident 1 was a total care for transfers and should be "2 people transferring not 1". Review of Resident 1's Initial Nurse's Progress Notes dated 8/2/14 at 5:00 a.m., indicated Resident 1 complained of pain to her left shoulder and arm. Licensed vocational nurse E (LVN E) indicated she saw Resident 1's weak left side including the left arm and shoulder with "some swelling" and beginning bluish discolorations on the left upper breast and left upper inner arm. Resident 1 stated she had an afternoon shower on 8/1/14. LVN E notified the attending physician and the resident's family who was the responsible party. Review of Resident 1's "Weekly non-pressure Ulcer Records" (a skin assessment form) dated 8/3/14 indicated the following entries: a) discolorations extended "to the left breast" and towards the back of the arm pit with measurements of 14 centimeters (cm) x 27 cm b) greenish discolorations on the left clavicle (collar bone) with measurements of 4 cm x 4 cm c) left upper arm had multiple greenish discs with no measurements d) left upper back had greenish disc like discolorations with measurements of 5 cm x 2 cm e) right breast had a greenish disc discoloration with measurements of 8 cm x 22 cm Review of Resident 1's "Physician's Progress Notes" dated 8/2/14 at 7:30 a.m. indicated Resident 1's attending physician (MD D) received a telephone call at 6:00 a.m. regarding Resident 1's left shoulder bruising and pain and noted Resident 1's bruising and pain of her left shoulder. MD D ordered an X-ray of the left shoulder. Review of Resident 1's X-ray results dated 8/2/14 of the left shoulder indicated "acute shoulder fracture." Review of the general acute care hospital discharge instructions dated 8/2/14 indicated Resident 1 had a fractured left shoulder and chest contusion. The instructions included notifying Resident 1 to use a shoulder immobilizer. Review of Resident 1's "Physician's Progress Notes" dated 8/12/14 written by orthopedic (doctor specializing in bone disorders) physician G (MD G) indicated Resident 1 had a fractured left shoulder and was to continue to wear the shoulder immobilizer. During an interview on 8/12/14 at 2:30 p.m., physical therapist H (PT H) stated rehabilitation director B (RD B) "told me (Resident 1) was always a total two person assist." During a telephone interview on 8/13/14 at 10:26 a.m., certified nurse assistant C (CNA C) stated he gave Resident 1 a shower on 8/1/14 on the afternoon shift. He stated he transferred Resident 1 from her bed to the shower chair by himself. During a telephone interview on 8/13/14 at 10:38 a.m., physician D (MD D) stated he saw Resident 1 on 8/2/14 after staff reported the incident to him. MD D stated Resident 1 had bruises on her chest and left arm. MD D stated he referred Resident 1 to an orthopedic physician (MD G) for treatment because Resident 1 had an acute left shoulder fracture. During a telephone interview on 8/13/14 at 2:03 p.m., LVN E stated she was responsible for providing Resident 1 care on 8/2/14 during the night shift. LVN E stated Resident 1 complained of pain at 1:00 a.m. and she gave Resident 1 some Tylenol, who fell asleep and stated at about 5:00 a.m., Resident 1 complained of pain again so LVN E assessed Resident 1's left shoulder at that time. LVN E stated the left shoulder area was swollen and tender, Resident 1's right breast, left under arm, left breast and shoulder were just "starting (to develop) discolorations (bruising) and turning red." During an interview on 8/15/14 at 3:24 p.m., shift supervisor F (RN F) stated she assessed Resident 1 with LVN E the night Resident 1 complained of pain. RN F stated Resident 1's left shoulder and breast area had some swelling and the beginnings of a bruise. Review of the facility's policy "Resident Transfer: From Bed to Chair" dated 8/15/12 indicated a transfer with two person assist mandates the use of two persons for moving a resident safely between surfaces.