Every finding on record at Spring Valley Post Acute LLC

Based on interview and record review, the facility failed to ensure they followed state laws when one of three Certified Nursing Assistants (CNA 1) did not receive a health examination within the required specific period. This failure had the potential to jeopardize the health and safety for 107 highly vulnerable residents.During a review of the Employee Health Exam, for the three sampled Certified Nursing Assistants (CNA) on August 5, 2026 at 11:34 AM, of Employee Health Exam, there was no documented evidence to indicate CNA 1 had an employee health examination which included TB test (Tuberculosis test-a screening method to check if a resident has been infected with bacteria that causes Tuberculosis, which is a contagious bacterial infection).During a concurrent phone interview and record review on September 3, 2026 at 1:54 PM with the Administrator (Admin), the Admin reviewed the Employee Health Exam, and confirmed CNA 1 had no record of employee health examination which included TB test prior to working to and while working at the facility. The Admin stated, We do not have her [CNA 1's] record, probably she promised that she will submit her health examination but she never did.During a concurrent phone interview and record review on September 8, 2026 at 2:15 PM with the Admin, the undated facility policy titled, Hiring, was reviewed. The P&P indicated, This policy outlines one the criteria for determining whether an applicant is qualified for a specific job position which states, a. Ability to perform the essential functions of the job (with or without reasonable accommodations; The admin stated this policy was not followed.During a concurrent phone interview and record review on September 8, 2026 at 2:17 PM with the Admin, the federal regulation was reviewed. The regulation indicated, The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The Admin stated this was not followed.During a concurrent phone interview and record review on September 8, 2026, at 2:20 PM, with the Admin, Title 22 under S72535 Employees' Health Examination and Health Records, was reviewed. The regulation indicated, a. All employees working in the facility, including the licensee, shall have a health examination within 90 days prior to employment or within seven days after employment and at least annually thereafter by a person lawfully authorized to perform such a procedure. Each such examination shall include a medical history and physical evaluation. The report signed by the examiner shall indicate that the person is sufficiently free of disease to perform assigned duties and does not have any health condition that would create a hazard for himself, fellow employees, or patients or visitors . The Admin stated this regulation was not followed.

Based on interview and record review, the facility failed to ensure that Discharge Minimum Data Set (MDS- computerized assessment instrument) assessments were initiated, completed and submitted within the required 14 day timeframe following resident discharge, in accordance with Centers for Medicare & Medicaid Services (CMS) requirements, for three of three sampled residents reviewed for resident assessments (Residents 35, 78, and 104).This failure had the potential to result in incomplete resident assessment discharge status information, which may affect continuity of care, follow up services, and compliance with federal reporting requirements.Findings:1. During a review of Resident 35's admission Record (a document that contains demographic and clinical information), Resident 35 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a group of airway diseases that restrict breathing).A review of Resident 35's physician's order, dated October 6, 2025, indicated, May D/C [discharge] home on [DATE] [October 9, 2025].A review of Resident 35's MDS was conducted on March 4, 2026, and it indicated Resident 35's Discharge MDS assessment had not been initiated, completed and submitted for four months and 24 days. 2. During a review of Resident 78's admission Record, Resident 78 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease stage 3A (mild-to-moderate loss of function).A review of Resident 78's physician's order, dated September19, 2025, indicated, May go to [Named of hospital].A review of Resident 78's MDS was conducted on March 4, 2026, and it indicated Resident 78's Discharge MDS assessment had not been initiated, completed and submitted for five months and 14 days. 3. During a review of Resident 104's admission Record, Resident 104 was admitted to the facility October 4, 2025, with diagnoses which included COPD.A review of Resident 104's physician's order for Resident 104, dated December 12, 2025, indicated, D/C [discharged ] to acute [hospital].A review of Resident 104's MDS was conducted on March 4, 2026, and it indicated Resident 104's Discharge MDS assessment had not been initiated, completed and submitted for two months and 21 days.During an interview on March 4, 2026, at 2:40 PM, with the MDS Nurse, the MDS Nurse confirmed Residents 35, 78, and 104's Discharge MDS assessments had not been completed. The MDS Nurse stated that the assessments should have been completed but was unsure of the required timeframe.During an interview on March 5, 2026, at 3:00 PM, with the Director of Nursing (DON), the DON stated that the facility follows the CMS RAI manual (Resident Assessment Instrument- provides guidelines and definitions for completing MDS assessment) that the required Discharge MDS assessment should have been completed within 14 days after Residents 35, 78 and 104's discharge from the facility.During a concurrent interview and record review on March 5, 2026, at 3:10 PM, with MDS Nurse and the DON, the MDS Nurse and the DON reviewed the facility's policy and procedures titled Resident Assessment, revised November 2019, which indicated, Policy Statement A comprehensive assessment of every resident's needs is made at intervals designated by OBRA [is a federal law that establishes regulations for nursing facilities] . Policy Interpretation and Implementation. 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility: . (5) Discharge Assessment - Conducted when a resident is discharged from the facility. The Interdisciplinary Team uses the MDS form currently mandated by Federal and State regulation to conduct the resident assessment . The DON stated that the facility did not follow the policy.During a review of CMS RAI manual dated October 2025, it indicated, . 09. Discharge Assessment-Return Not Anticipated (A0310F = 10) Must be completed when the resident is discharged from the facility . Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days).

Based on observation, record review, and interview, the facility failed to ensure that pressure injury (the type wound [open sore on the skin] caused by sitting or lying in one position too long) treatment and services were consistent with the residents' current wound conditions and with the facility's own treatment protocol for one out of three sampled residents (Resident 3) reviewed for pressure injury care. This failure resulted in delays in appropriate treatment, slowed the healing process, and increased the risk of further deterioration of Resident 3's right ischium (the lower, back part of the hip bone) pressure injury. Findings:During a review of Resident 3's admission Record (a document that contains demographic and clinical information), Resident 3 was admitted to the facility on initially on December 12, 2010, with diagnoses including hemiplegia and hemiparesis following cerebral infraction effected right dominant side (a condition means that a stroke (brain attack) has damaged the left side of the brain, that controls the right side of the body) , anemia (low levels of healthy red blood cells), and hypertension (blood pressure that is higher than normal).A review of Resident 3's physician's order, dated February 23, 2026, indicated RT [right] ischium Stage 2 Pressure Injury [a stage that the top layer of skin (epidermis) has broken, and the second layer (dermis) is exposed] : Cleanse with NS [sterile solution]., Pat Dry, Cover with foam dressing [ a medical dressing that super-fast absorbent] Q [every] D [day] and PRN [as needed] .During a wound care observation on March 4, 2026, at 9:48 AM, with the Treatment Nurse (TN), the TN performed wound care to Resident 3. The TN applied treatment to the resident's right ischium pressure injury, full thickness tissue loss in which contained yellow slough (soft tissue) and dark brown eschar (dead tissue) that covered the wound bed and prevented visualization of the base, demonstrating characteristics consistent with an unstageable pressure injury. The TN continued to apply interventions ordered for a Stage 2 pressure injury and did not reassess or modify the treatment based on Resident 3's right ischium pressure injury condition at the time of the observation.During an interview on March 5, 2026, at 1:40 PM, with the TN, the TN asked to describe Resident 3's current right ischium wound condition. The TN stated the wound had some part slough and some part eschar covering the wound bed, making it difficult to see the base of the wound. The TN further stated that when slough or/and eschar is present and still covering the base, therefore the true depth, and stage cannot be determined (unstageable).During a follow up interview on March 5, 2026, at 1:50 PM, with the TN, the TN referred to the wound staging poster kept on the unit and compared the wound's appearance to the pictures on the poster. The TN stated the wound characteristics were consistent with an unstageable pressure injury. The TN further stated she reported that she had notified the wound physician but was unable to provide documentation to show that any notification occurred.During a concurrent record review and interview on March 5, 2026, at 5:20 PM, Resident 3's clinical record was reviewed with the Director of Nurses (DON) which showed that Stage 2 treatment continued through March 5, 2026, with no documented reassessment, no notification to the provider of the change in wound condition, and no updated treatment orders reflecting the unstageable status. The DON stated when wound care is performed, the wound should be assessed at the same times and follow the treatment according to facility's wound protocol.During a concurrent interview and record review on March 5, 2026, at 5:30 PM, with TN and DON, TN and DON reviewed the facility policy and procedures titled Policy and Procedure on Pressure Ulcers dated October 2010, indicated The facility shall ensure that a resident who enters the facility with pressure ulcer and/or develops unavoidable pressure ulcers while being in the facility, must receive treatment and services necessary to promote healing, prevent infection, and prevent new ulcers from developing. Procedures: Licensed charge nurse or treatment nurse shall conduct basic assessment and data collection on the following.progress towards healing (slow response or delayed healing, healing well). 2. Assessment of pressure ulcers shall be done at least once every week or as wound condition changes.3. Document general findings in the weekly skin and wound progress report. The DON stated that staff should have reassessed Resident 3's right ischium pressure injury when the wound condition changed and updated the treatment orders to reflect the wound's Unstageable status to ensure the resident receive appropriate care to promote healing and prevent further decline. The DON further stated that the facility did not follow the policy.During a concurrent record review and interview on March 5, 2026, at 5:55 PM of the facility's pressure injury treatment protocol with the Administrator and DON titled PRESSURE ULCER GUIDELINES revised February 7, 2012, indicated . STAGE II, WITHOUT INFECTION: _________ (area) Stage II Pressure Ulcer - Cleanse w/ [with] NS to surrounding skin, cover w/ Hydrocolloid Dressing [medical dressing for surface open wounds] Q 3 Days & PRN soiling/ displacement until healed; then D/C [discontinue] . UNSTAGEABLE. Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. _________ ,(area) Unstageable Pressure Ulcer -Cleanse well w/ NS, generously apply Santyl Ointment [a prescription topical medication used to debride (remove) dead tissue from the wound] , . Q Day & PRN, soiling/displacement; until fully debrided, then reevaluate. The DON acknowledged that the treatment provided for Resident 3's right ischium did not follow the correct protocol for either the initial staging (stage 2) or the actual wound condition (unstageable). The DON stated Resident 3's right ischium pressure injury should have been identified as Unstageable and initiated the treatment according to the facility's pressure ulcer guidelines, but the facility protocol was not followed.

Based on observation, interview, and record review, the facility failed to implement its smoking safety policy for one of three sampled residents reviewed for smoking safety (Resident 47), when Resident 47 was found to have smoking materials in his possession on March 4, 2026.This failure had the potential to place the residents and others at risk for fire-related injury or other smoking-related accidents.Findings: During a review of Resident 47's admission Record (a document that contains demographic and clinical information), Resident 47 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a group of airway diseases that restrict breathing).A review of Resident 47's clinical record of Resident Smoking Assessment dated January 22, 2026, indicated , . A. Does the Resident Smoke? . [marked] 2. Yes. Proceed with assessment .During an observation and concurrent interview on March 3, 2026, at 11:00 AM, in Resident 47's room, Resident 47 removed a pack of cigarettes and a lighter from a jacket pocket. Resident 47 stated I keep these [cigarette and lighter] with me because I am an independent smoker.During a concurrent observation and interview on March 4, 2026, at 2:00 PM, in Resident 47's room, with the Activity Director (AD), Resident 74 pulled a cigarette from his pants' pocket, with a lighter stored inside the cigarette box. The AD verified the finding and stated that an independent smoker may keep their cigarettes but should not keep a lighter.During a concurrent interview and record review on March 5, 2026, at 2:05 PM, with the Administrator (Admin), the Admin reviewed the facility's policy and procedures titled Resident Supervised Smoking Policy effective January 16, 2026, which indicated Policy: It is the policy of the facility to allow residents to exercise their right to smoke in a manner that does not jeopardize other residents, facility property, staff and the resident exercising that right. All resident smoking must be supervised and materials secured. Procedure: . 7. Residents are not permitted to keep smoking materials, lighters, matches or any related materials in their possession. Smoking materials will be labeled with the resident's name and secured in a designated location. Responsible party and/or family members will be asked not to provide smoking materials directly to residents. Smoking materials brought into the facility should be presented to Social Services staff or charge nurses. 8. This facility may check periodically to determine if residents have any smoking articles in violation of this policy. The Administrator stated it was his responsibility to ensure staff were educated on the updated smoking policy. The Administrator acknowledged that according to the updated policy, residents should not keep any smoking materials, including cigarettes or lighters, regardless of smoking independence status, to reduce fire and safety risks. The Admin further stated that the facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to follow their dialysis policy for one resident (Resident 130) when staff did not monitor and complete Resident 130's Post Access Site Assessment (checking the dialysis access site after treatment to make sure it is safe and there are no problems like bleeding, swelling, infection). This failure had potential to cause complications at the access site for Resident 130. Findings: During a review of Resident 130's admission Record (contains patient demographics), the admission Record indicated Resident 130 was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus with hyperglycemia (a condition where body cannot produce enough insulin), dependence of renal dialysis (a person with permanent kidney failure requires regular, life-sustaining, artificial blood filtration (dialysis- to remove waste and excess fluids), and dysphagia (difficult swallowing). During a review of Resident 130's Orders Summary Report (active physician orders), dated March 3, 2026, it indicated Dialysis Days: T-TH- S (Tuesday, Thursday, Saturday) Observe/monitor bruit (abnormal rushing or whooshing sound heard via stethoscope indicating turbulent blood flow)/thrill (palpable, buzzing vibration felt over the same area indicating turbulent blood flow) for (0)absence and (1) =presence. During a concurrent observation and interview on March 3, 2026, at 2:45 PM, in Resident 130's room, Resident 130 was awake in her bed. She had a fistula (connection surgically made that's used for dialysis access) on her left arm. Resident 130 stated she has dialysis on Tuesdays, Thursdays, and Saturdays. During a concurrent interview and record review on March 4, 2026, at 1:30 PM, with the Director of Nursing (DON), the DON reviewed Resident 130's Dialysis Communication Record Post Dialysis Assessment for January 29, 2026, February 7, 2026, February 11, 2026, February 14, 2026, and acknowledged there were no documented evidence to indicate the Post Access Site Assessment were conducted for those days. The DON stated nurses were to monitor and to document after each post dialysis. During a concurrent interview and record review on March 5, 2026, at 8:20 AM, with the DON, the facility's policy and procedures (P&P) titled Dialysis Care revised in October 2019 was reviewed. The P&P indicated, Policy. It is this facility policy to provide standards of care to residents receiving dialysis care.2. After each dialysis treatment, licensed nurse shall evaluate resident and notify physician immediately of any apparent complication from dialysis procedures.5. Licensed nurse shall monitor and document on pre and post dialysis observations such as vital signs, change of condition, bruits, thrill, and dialysis access site for redness, swelling, and drainage . The DON stated her expectation was for nurses to assess the resident and document the assessment after each dialysis.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with the physician's orders and policy for one of six residents reviewed for Medication Administration (Resident 103) when a Licensed Vocational Nurse (LVN 1) administered an anti-hypertensive (used to treat high blood pressure) to Resident 103. This failure had the potential to result in poor blood pressure control and increased risk of hypertension-related complications. Findings: During a record review of Resident 103's admission Record (contains demographic and medical information), it indicated Resident 103 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia (clear signs of such as memory loss, confusion, and behavioral changes), hyperlipidemia (high level of fats) and secondary hypertension (high blood pressure). During review of Resident 103's Order Summary (active physician orders for a resident's care), it indicated Resident 103 had an order to receive Metoprolol Tartrate (used to treat high blood pressure) 25 mg (milligram (used to measure medication dosages)). Give 1 tablet by mouth two times a day for HTN (hypertension) Hold if SBP (top number in a blood pressure reading (maximum force of blood pushing against artery walls when the heart beats and contracts)) < (less than) 110 or HR)( Heart Rate (the number of times your heart beats per minute)) < 60. During a medication administration observation and concurrent interview, with LVN 1, on March 4, 2026, at 8:43 AM, LVN 1 was inside Resident 103's room to check Resident 103's blood pressure and heart rate. The blood pressure reading was 124 /80, while the heart rate was 61. LVN 1 then went to the Medication Cart to prepare Resident 103's due medications, which included Metoprolol Tartrate. LVN 1 searched the Medication Cart and the e-kit (emergency kits (sealed, secured, and regularly audited supply of essential medications and emergency supplies)) but was unable to find Resident 103's Metoprolol Tartrate. LVN 1 stated that a supervisor reached out to the pharmacy and had the medication delivered as soon as possible. During a concurrent interview and record review on March 4, 2026, at 10:45 AM, with the Director of Nursing (DON) and the Administrator, the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019 was reviewed. The P&P indicated .4. Medications are administered in accordance with prescriber orders, including any required time frame. The DON and the Administrator stated the policy was not followed. The DON further stated that the medication should have been given in a timely manner.

Based on observation, interview, and record review, the facility failed to maintain a sanitary and safe environment for one of five residents reviewed for infection control when a License Vocational Nurse (LVN 2) entered Resident 130's room, which was a contact isolation precautions resident room ( prevent the spread of infections transmitted through direct or indirect contact with a patient or their environment), without wearing personal protection equipment (PPE-such as gloves and gown). This failure had the potential for cross contamination and infection (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) which can jeopardize the health and safety of residents and staff. Findings: During a review of Resident 130's admission Record (contains patient demographics), the admission Record indicated Resident was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus with hyperglycemia (a condition where body cannot produce enough insulin), dependence of renal dialysis(a person with permanent kidney failure requires regular, life-sustaining, artificial blood filtration (dialysis) to remove waste and excess fluids, and dysphagia (difficult swallowing). During a review of Resident 130's Orders Summary Report (active physician orders), dated March 3, 2026, it indicated Resident 130 was placed on Contact isolation precautions for ESBL (Extended-Spectrum Beta-Lactamase- bacterial infection resistant to common antibiotics).During a concurrent observation and interview on March 3, 2026, at 10:35 AM, with LVN 2, in Resident 130's room, there was a sign posted at the door that indicated Resident 130 was on Contact isolation precautions for ESBL. LVN 2 was inside the room talking to Resident 130 and family. She was not wearing a gown. LVN 2 verified the finding and stated she was not sure about the difference between EBL (Enhanced Barrier precautions-an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) and contact isolation. During a concurrent interview and record review with Infection Preventionist (IP), on March 3, 2026, at 11:23 AM, the facility's policy and procedure (P&P) titled, Infection Control-Transmission-based Precautions, revised in October 2019 was reviewed. The P&P indicated Contact Precautions, Contact precautions are intended to prevent transmission of infections that are spread by direct(person-to-person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves upon entering the resident's room or cubicle. The PPE should be removed, and hand hygiene performed before leaving the resident's room or cubicle. The IP stated when contact isolation precautions sign is posted at the door, staff need to wear appropriate PPE and wash hands. The IP stated LVN 2 did not follow the policy. During a concurrent interview and record review with the Director of Nursing (DON), on March 5, 2026, at 8:05 AM, the DON reviewed and acknowledged the facility's policy and procedure (P&P) titled, Infection Control-Transmission-based Precautions, revised in October 2019, which indicated Contact precautions are intended to prevent transmission of infections that are spread by direct (person-to-person) or indirect contact with the resident or environment, and require the use of appropriate PPE, including a gown and gloves upon entering the resident's room or cubicle. The PPE should be removed, and hand hygiene performed before leaving the resident's room or cubicle The DON stated her expectation was for the staff to wear appropriate PPE.

Based on observation, interview, and record review, the facility failed to follow its own policy and procedure concerning the use of physical restraints when three of three Justice-Involved Residents (residents under the care of law enforcement, community supervision, in custody, held involuntarily through operation of law enforcement authorities [Residents 1, 2, and 3]) did not receive respectful and dignified treatment. This includes the right to be free from physical restraints, which was not necessary to address residents' medical conditions. The facility, instead, placed sole responsibility on the correctional officers for the application, removal, and monitoring of potential complications associated with the use of restraints.These failures had the potential to place clinically compromised residents (Resident 1, 2, and 3) at risk of serious physical injuries, including skin damage, pressure ulcers, nerve damage, and prolonged immobility. Additionally, it can also lead to serious psychological effects, such as loss of dignity, which may lead to anxiety, depression, and suicidal thoughts resulting from lack of monitoring by a trained staff, physician order, care plan, nursing assessments, and proper documentation related to the use of restraints.Findings:During an observation in Resident 1's room on September 24, 2025, at 12:10 PM, Resident 1 was observed lying on bed, restrained with metal shackles on both ankles, which were attached to the end of the bed frame. Resident 1 appeared alert and calm during the observation. The skin around the shackles was assessed and found to be intact, with no evidence of redness, blistering, discoloration, or any other skin issues that possibly are associated with the use of shackles. During this observation, two correctional officers were present at the bedside, monitoring Resident 1. During a review of Resident 1's admission Record (general demographics) on September 24, 2025, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis ( partial paralysis on one side of the body), heart failure (heart is not pumping blood as well as it should), and hypotension ( low blood pressure).During an observation in Resident 2's room on September 24, 2025, at 12:15 PM, Resident 2 was observed on bed in the same room as Resident 1. Resident 2 was restrained with metal shackles on both ankles, which were attached to the end of the bed frame. Additionally, a metal shackle was observed on his left wrist and was attached to one of the side rails of the bed, while two correctional officers were on bedside monitoring Resident 1 and 2.During a review of Resident 2's admission Record (general demographics) on September 24, 2025, the admission Record indicated Resident 2 was admitted on [DATE], with a diagnoses that included peripheral autonomic neuropathy (condition that affects the nerves that control involuntary body functions, such as heart rate, blood pressure, and sweating), acute kidney failure ( kidney suddenly stops working properly), and fracture of the left hand (break in one or more bones in the left hand).During an observation in Resident 3's room on September 24, 2025, at 12:26 PM, Resident 3 was observed on bed, restrained with metal shackles on both ankles that were attached to the end of the bed frame. Additionally, a metal shackle was also observed on his left wrist and was attached to one of the side rails of the bed, while two correctional officers were watching him.During a review of Resident 3's admission Record (general demographics) on September 24, 2025, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with a diagnoses that included cellulitis ( bacterial infection that gets into the deeper layer of the skin) of the right lower limb, neuropathy (damaged nerves), and hypertension (high blood pressure).During an interview on September 24, 2025, at 1:20 PM, with a Certified Nursing Assistant (CNA 1), CNA 1 stated, the shackles were removed when the patients [residents] are taken to the restrooms and receive a bath. When asked how she repositions the residents while they are in shackles, she stated, I request the correctional officer to remove the shackles. however, she noted the shackles are not usually removed because there is enough slack for the residents to move their legs around.During an interview on September 24, 2025, at 1: 31 PM, with Certified Nursing Assistant (CNA) 2. CNA 2 confirmed that she is assigned to the three residents who are in shackles. CNA 2 stated she requested the correctional officers to remove the shackles for Resident 1 and Resident 2 when they went to the toilet and when they took a shower. For Resident 3, CNA 2 stated she did not release the shackles throughout her shift, as he had not gone to the bathroom yet. When CNA 2 was asked if she had checked the wrists and ankles of Resident 1, Resident 2, and Resident 3 for bruises, CNA 2 mentioned she only observed briefly while she performed activities of daily living (ADL - basic tasks that residents perform to maintain their personal care).During an interview on September 24, 2025, at 1:50 PM, with the Activity Director (Director), Director stated, .The inmates do not participate with the activities of other residents, they are only given magazines, reading materials about people, nature or any topics they are interested in. The director confirmed the residents never leave their rooms except for showers and physical therapy sessions.During an interview on September 24, 2025, at 1:59 PM, with Licensed Vocational Nurse (LVN), LVN stated, the only time these shackles are removed is when the inmates go to the toilet or bathroom. The facility is a non- restraint facility, and the staff are not trained in the use of restraints. Furthermore, the staff indicated he does not visually check the resident's wrists and ankles. He also stated that the facility does not classify shackles as a means of restraint, and there is no official order for restraint as it is not part of the physician's orders.During a concurrent interview and record review on September 24, 2025, at 2:15 PM, with the Registered Nurse supervisor (RN supervisor), the medical records for Residents 1, 2, and 3 have no documentation of the following:a. no physician's order for the use of restraints.b. no care plan in place for restraints.c. no assessment conducted regarding the use of restraints; nor restraint was coded on Minimum Data Set (MDS-a standardized assessment tool used collect information about residents' health, functional abilities, and psychosocial status).d. no nursing progress notes documenting the placement and removal of the restraint; ande. no assessment of skin integrity associated with the use of restraints.These findings were verified by the RN supervisor, who stated that the facility is a no-restraint facility. The three residents, under the supervision of correctional officers admitted to the facility in shackles; however, the facility does not consider those shackles to be restraints.During an interview on September 24, 2025, at 2:59 PM, with the Director of Staff Developer (DSD), the DSD stated, This is a no restraint facility, we don't have residents on restraints, federal guards are the ones releasing the shackles when the staff requested during patient [resident] care like when they go to shower. The DSD further stated the staff are not trained in the use of restraints.During an interview on September 24, 2025, at 3:10 PM, with Resident 3, he stated, I do not go out, they only give me magazines to read. The resident stated his shackles are only released when he goes to the bathroom and toilet and when he does physical therapy training in the evening at least once a day.During an interview on September 24, 2025, at 3:39 PM, Resident 1 confirmed he does not participate in any activity, and his shackles are only released during toileting, showers, and physical therapy training. Resident 1 also stated that PT training is conducted in his room in the evening at least once a day.During an interview on September 24, 2025, at 3:44 PM, Resident 2 confirmed his shackles are only released when he goes to the bathroom, showers and does physical therapy training at least once a day, for a few minutes in the evening. Resident 2 also stated he does not participate in any activities. During a concurrent interview and record review on September 24, 2025, at 4:45 PM, with the administrator and the DSD, the facility's policy and procedure (P&P) titled, Use of Restraints, dated October 2022, was reviewed. The P&P defined physical restraints, . as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. The P&P also states, Prior to placing a resident in restraints, there shall be a pre-restraining assessment, . The P&P further states, Restraints shall only be used upon the written order of a physician. Also, the P&P mandates, A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel, When asked if this P&P was being followed, the administrator responded, The residents came with restraints, citing that they are inmates under the custody of correctional officers.During an interview on September 24, 2025, at 3:48 PM, with the Correction Officer (Officer), the Officer stated, inmates does not go out from their rooms, and the staff does not released shackles. Officer confirmed that they are with the residents twenty-four (24) hours a day, and they have to be on shackles per their policy.On September 24, 2025, at 5:00 PM, an immediate jeopardy (IJ- a situation that has threatened or was likely to threaten the health and safety of a resident) situation was called in the presence of the Administrator and the DSD for noncompliance related to the use of physical restraints, resulting in Residents 1, 2, and 3 being denied the right to be treated with respect and dignity. The Administrator and the DSD were verbally notified of the IJ situation.A corrective action plan (CAP) was requested following the implementation of IJ.On September 26, 2025, at 1:30 PM, an IJ Removal Plan was provided by the facility, which included:Upon notification, the facility initiated the following actions:1. What corrective action will be accomplished for those patients found to have been affected by the deficient practice?- Residents identified as affected by the deficient practice involving the use of physical restraints were discharged in coordination with the Federal Correctional Complex (FCC) Victorville and attending physician and transferred to [NAME] Valley Global Medical Center. The attending physician declined to issue orders for the continued use of restraints.- Residents affected by the deficient practice will be discharged in coordination with FCC as follows:o. Room # 9A Resident 1 on 9/25/25 to [Name of the hospital].o. Room # 9C Resident 2 on 9/25/25 to [Name of the hospital].o. Room # 16C Resident 3 on 9/25/25 to [Name of the hospital]. 2. How will the facility identify other patients having the potential to be affected by the same deficient practice?- A comprehensive review of records for 107 residents was completed. In addition, direct observations were conducted across all shifts by charge nurses and Registered Nurses. Alert residents were interviewed by staff. No additional residents were found to be affected by the deficient practice.- On 09/24/25 around 5:00 PM on-going in-service training was provided by Director of Staff Development with an emphasis on the distinction between medical and correctional restraints.3. What measures will be put into place or what systemic changes will be made to ensure the deficient practice does not recur?- To prevent recurrence of the deficient practice related to physical restraints, the facility has implemented the following systemic changes:o Resident's requiring physical restraints will be observed for 72 hours, during which non-pharmacological interventions will be attempted in collaboration with Activities, Social Services, Nursing, and Rehab.o Physicians and family members will be notified, and nursing staff will follow up on all physician orders.o Social Services, in coordination with the interdisciplinary team (IDT), will provide information regarding the resident's behavior and the effectiveness of the treatment plan to the resident and, as appropriate, to the family or responsible party.o Licensed nurses will conduct weekly skin integrity checks and document daily progress notes. Any concerns will be escalated to the Primary Care Provider (PCP) and family.o Residents will be repositioned per facility protocol. 9/26/2026 Monthly psychosocial-emotional assessments will be conducted by Social Services, with documentation of observations, interviews, and reviews involving residents, families, and staff.4. How will the facility monitor its corrective actions to ensure ongoing compliance?Recapitulation of findings will be presented and reported by the Director of Nursing (DON) or designee to the Quality Assessment and Assurance Committee on a monthly basis for three months, or until 100% compliance has been sustained. The Committee will review the findings and take action as indicated.The facility will not admit justice-involved individuals until it has confirmed substantial compliance with all applicable statutes and regulations governing the care of justice-involved individuals. This includes alignment with the authorities outlined in F604.The safety and security of all residents remain the facility's highest priority. This corrective action plan directly addresses the Immediate Jeopardy finding by implementing the immediate measures outlined above.The IJ was removed on September 26, 2025, at 3:44 PM, in the presence of the Administrator and Meridian Management Representative after onsite observation, interview, and record review verified the facility's implementation of the corrective action plan.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free of any significant medication errors (administration of medications which was not in accordance with accepted professional standards and principles), when Resident 1 was given medications that belongs to another resident. These failures had the potential to jeopardize the health and well-being of medically compromised Resident 1. Findings: During a phone interview on March 12, 2025, with Resident 1, Resident 1 reported that at 8:47 AM on February 26, 2025, a nurse gave her a medication cup labeled 52 B containing 6 different types of medication. She claimed that she did not take the medication because she is aware that it is not hers. A review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated, Resident 1 was admitted on [DATE], with a diagnosis that included Chronic Obstructive Pulmonary Disease (COPD - is a group of lung diseases that make it hard to breath). During a review of Resident 1 ' s Minimum Data Set (facility assessment tool), dated October 19, 2024, under Section C, it indicated her Brief Interview for Mental Status (BIMS) score was 15. (A BIMS score of 13 to 15 suggests the patient is cognitively intact). A review of Resident 1 ' s Medication Administration Record (MAR) for the Month of February 2025, indicated on February 26, 2025, resident 1 received the following medications: Lidoderm Patch 5%, Gabapentin capsule 300 mg, Allopurinol oral table 300 mg, Ergo Cal oral capsule 1.25 mg, Folic Acid tablet 1 mg, Isosorbide Mononitrate Oral Tablet 20 mg, Levothyroxine Sodium oral table 125 mcg, Apixaban oral tablet 5 mg, Magnesium oral table 200 mg, Nifedipine ER oral tablet 60 mg, Pantoprazole sodium tablet 40 mg. During an interview on March 13, 2025, at 11:14 AM with the Director of Nursing (DON 1), the DON 1 stated on February 28, 2025, a Registered Nurse (RN 1) notified her that Resident 1 claimed a Licensed Vocational Nurse (LVN 1) provided her with 5 tablets of medication in a cup labeled 52B. Resident 1 asserted she did not consume it because she identified it was not hers. The RN recorded a photo of the medication and communicated it with her. She indicated that she verifies it with the pharmacy consultant, and it was concluded that the medications were: Levetiracetam oral tablet 1000mg, Montelukast Sodium oral tablet 10 mg, Zoloft oral tablet 50 mg, Finasteride oral tablet 5 mg. She noted that none of those medications were linked to Resident 1. She also mentioned that upon reviewing the medications, the four pills that Resident 1 identified belonged to Resident 5, but because Resident 5 had been admitted to the hospital on February 26, 2025, it remains uncertain how Resident 1 acquired the medication. During concurrent record review and interview on March 13, 2025, at 11:23 AM with the DON 1, incident report dated February 28, 2025, was reviewed. DON acknowledged that Incident report indicated the incident of medication error took place however, unable to identify which Nursing staff member committed the error, the exact date and time it happened was unknown. During an interview on March 13, 2025, at 12:04 PM with the Administrator (Admin 1), the admin 1 stated that he thinks if the nursing staff are doing the job properly it shouldn ' t happen. During an interview on March 13, 2025, at 12:10 PM with LVN 1, LVN1 stated that the incorrect medications are those given in the morning, and since she is the night nurse, it was not her who administered the medication. A review of the facility policy and procedure (P&P) titled, Medication and Treatment Administration dated October 2014, indicated, .9. Residents shall be identified before administration of a drug or treatment .

Based on record review, interview, and facility policy review, the facility failed to ensure the accuracy of a preadmission screening and resident review (PASARR) for 2 (Resident #34 and Resident #74) of 3 sampled residents reviewed for PASARRs. Findings included: A facility policy titled, Pre-admission Screening and Resident Review (PASARR), revised 12/2006, indicated All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review process. Policy Interpretation and Implementation 1. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD, unless the individual was admitted directly to the facility from a hospital where he or she received acute impatient care and a Level I PASARR had already been completed and submitted. 1. An Admission Record indicated the facility admitted Resident #74 on 11/04/2024. According to the Admission Record, the resident had a medical history that included diagnoses of schizophrenia, unspecified psychosis due to a known substance or physiological condition, impulse disorder, mood disorder due to known physiological condition, depressive episodes, and anxiety disorder Resident #74's Resident Care Plan, titled Psychosis revealed the resident had behavioral episodes of verbal outburst and a long history of psychosis and dementia with psychotic features. Resident #74's Preadmission Screening and Resident Review Level I Screening dated 11/04/2024, revealed the resident did not have a serious diagnoses mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance. During an interview on 11/20/2024 at 10:49 AM, the Minimum Data Set/Resident Coordinator stated the Director of Nursing Services (DNS) reviewed a resident's PASARR for accuracy. During an interview on 11/21/2024 at 8:51 AM, the DNS stated Resident #74 had a diagnosis of schizophrenia and the resident's diagnosis should have been listed on the PASARR. During an interview on 11/21/2024 at 11:18 AM, the Administrator stated Resident #74's PASARR should have been checked for accuracy. 37683 2. An Admission Record revealed the facility admitted Resident #34 on 09/11/2024. According to the Admission Record, the resident had a medical history that included diagnoses of mood disorder and psychosis not due to a substance or known physiological condition. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include psychotic disorder. Resident #34's Resident Care Plan titled Psychosis included a problem/concern area, dated 09/22/2024, that indicated the resident was at risk for increasing confusion and disordered thoughts secondary to a diagnosis of psychosis. Resident #34's Order Summary Report, which contained active orders as of 11/20/2024, revealed an order dated 09/11/2024, for Seroquel oral tablet 100 milligrams, give one tablet by mouth one time a day for psychosis. Resident #34's Preadmission Screening and Resident Review Level I Screening dated 09/11/2024, revealed the resident did not have a serious diagnoses mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance. During an interview on 11/20/2024 at 10:50 AM, the MDS/Resident Coordinator stated she was not responsible for ensuring the accuracy of a resident's PASARR. The MDS/Resident Coordinator stated she did not know why Resident #34's diagnosis of psychosis was not captured on the PASARR Level I Screening dated 09/11/2024.

Based on interview and facility policy review, the facility failed to update their abuse policy and procedure related to 1 of the 7 components of abuse prohibition. Specifically, the facility policy did not reflect the reporting of all allegations of abuse within the mandated timeframe of immediately, but not later than 2 hours after the allegation was made. Findings included: A facility policy titled, Policy and Procedure on Patient Abuse and Prevention, with an effective date of 10/2014, indicated, VII. Reporting, Facility shall ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required, and to take all necessary corrective actions based on the results of the investigation. a) Facility administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. b) Facility shall report the incident by calling the DHS within 24 hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. This letter shall be maintained in a separate file and made available to the Department upon request. c) The Administrator and Director of Nurses, in the order written shall report incidents of suspected abuse to the following agencies within twenty-four (24) hours of occurrence: - Department of Health-Licensing and Certification - LTC [long-term care] Ombudsman or designee or - Local enforcement agency or Police Department - Managing Physician for treatment orders as required - Family Members/Responsible Parties or Guardians. During an interview on 11/21/2024 at 3:36 PM, the Administrator stated the abuse policy was the one the facility had when he became the administrator in 07/2023. The Administrator stated that according to the facility abuse policy, the facility had 24 hours to report any allegation of abuse unless it involved serious bodily injury.

Based on interview, record review, and facility policy review, the facility failed to timely report an allegation of abuse to the state survey agency for 1 (Resident #27) of 1 sampled resident reviewed for abuse. Findings included: A facility policy titled, Policy and Procedure on Patient Abuse and Prevention, with an effective date of 10/2014, indicated, 2. Verbal Abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The policy specified, VII. Reporting, Facility shall ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required, and to take all necessary corrective actions based on the results of the investigation. a) Facility administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. b) Facility shall report the incident by calling the DHS within 24 hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. This letter shall be maintained in a separate file and made available to the Department upon request. c) The Administrator and Director of Nurses, in the order written shall report incidents of suspected abuse to the following agencies within twenty-four (24) hours of occurrence: - Department of Health-Licensing and Certification - LTC [long-term care] Ombudsman or designee or - Local enforcement agency or Police Department - Managing Physician for treatment orders as required - Family Members/Responsible Parties or Guardians. According to the policy, VII. Abuse Prevention Coordinator. The facility Administrator is the duly appointed Abuse Prevention Coordinator. In the absence of the Administrator, the designated alternate or Assistance Administrator, if any, will take over the responsibilities. An Admission Record indicated the facility admitted Resident #27 on 12/07/2018. According to the Admission Record, the resident had a medical history that included diagnoses of morbid obesity, chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, muscle weakness, and chronic combined systolic and diastolic heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2024, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an interview on 11/18/2024 at 9:20 AM, Resident #27 stated the certified nursing assistants (CNAs) did not provider them a shower because of their weight. According to Resident #27, CNA #8 told them that staff could not do their shower because the staff had lives and homes to get back to, that their weight placed the staff in danger, and if the staff gave them a shower and got hurt, the CNAs could sue them Resident #27 reported CNA #8 had not worked with them lately and they had been getting their showers recently. On 11/18/2024 at 9:40 AM, the surveyor reported the allegation of abuse to the Administrator and the Director of Nursing Services. During an interview on 11/21/2024 at 3:03 PM, the Administrator stated he reported the allegation of abuse to the state agency on 11/18/2024 at 4:00 PM. The Administrator stated since there was no physical harm, the allegation only needed to be reported within 24 hours and not 2 hours.

Based on observation, interview, record review, facility policy review, the facility failed to develop a care plan to address a resident's right hand contracture for 1 (Resident #185) of 1 sampled resident reviewed for limited range of motion. Findings included: A facility policy titled Care Plan with the effective date of 10/2014 revealed, Policy. Consistent with the facility's policy of providing appropriate care & services to residents admitted to the facility, the facility shall ensure development of a comprehensive care plan for each resident to meet his/her medical, nursing, and mental and psychological needs as identified in the comprehensive assessment. 2. Goals for plan of care should be measurable, achievable/attainable and resident centered. The policy specified, 7. Care Plan should be oriented to prevention of avoidable declines in functioning or functioning levels. An Admission Record revealed the facility admitted Resident #185 on 10/21/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominate side. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2024, revealed Resident #185 had a Staff Assessment for Mental Status (SAMS), that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS revealed the resident had a range of motion limitation on side in both their upper and lower extremities. Resident #185's medical record revealed no evidence to indicate a care plan had been developed to address the resident's right hand contracture. During an observation on 11/18/2024 at 11:21 AM, Resident #185 was noted to have a right hand contracture. During an observation on 11/19/2024 at 12:37 PM, Resident #185 was noted to have a right hand contracture. During an interview on 11/20/2024 at 10:52 AM, Licensed Vocational Nurse #25 stated Resident #185 had a contracture of their right hand. During an interview on 11/21/2024 at 3:03 PM, the MDS/Resident Coordinator stated she completed residents' care plans with Director of Nursing Services. The MDS/Resident Coordinator confirmed Resident #185 did not have a care plan to address their right hand contracture. During an interview on 11/21/2024 at 3:11 PM, the Administrator stated a resident's care plan should include the resident's limited range of motion.

Based on observation, interview, record review, and facility policy review, the facility failed to implement services for the treatment of a right hand contracture for 1 (Resident #185) of 1 sampled resident reviewed for limited range of motion. Findings included: A facility policy titled, Range of Motion, dated 10/2015, revealed, Residents need movement in order to prevent decreased functioning. Hence, it is vital that nursing assistances recognize the role they play in aiding the resident to maintain an or achieve as much movement as is possible relative to physical & medical conditions. An Admission Record revealed the facility admitted Resident #185 on 10/21/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominate side. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/01/2024, revealed Resident #185 had a Staff Assessment for Mental Status (SAMS), that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS revealed the resident had a range of motion limitation on side in both their upper and lower extremities. Resident #185's medical record revealed no evidence to indicate a care plan had been developed to address the resident's right hand contracture. During an observation on 11/18/2024 at 11:21 AM, Resident #185 was noted to have a right hand contracture and no use of a splint or hand towel was present. During an observation on 11/19/2024 at 12:37 PM, Resident #185 was noted to have a right hand contracture. During an observation on 11/20/2024 at 7:51 AM, Resident #185 was observed in bed. The resident was noted to have a right hand contracture and no splint or hand towel was present. During an interview on 11/20/2024 at 10:42 AM, Registered Nurse #24 stated there was a not a splint or hand roll in place that she knew of for Resident #185. During an interview on 11/02/2024 at 11:01 AM, Certified Nursing Assistant (CNA) #26 stated Resident #185's right hand was contracted and usually there was towel placed between the resident's fingers and hand. CNA #26 confirmed the hand roll or towel was not in place for the resident on 11/02/2024. During an interview on 11/21/2024 at 11:48 AM, the Administrator stated the expectation was that range of motion be provided based on the resident's assessment. Per the Administrator, a hand roll would be a measure to prevent infection and contractures.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff donned personal protective equipment (PPE) before they entered the room of a resident who was on contact isolation and failed to ensure staff cleaned a multi-use glucometer after use before it was placed back on the medication cart for 1 (Resident #75) of 3 sampled residents reviewed for infection control. Findings included: A facility policy titled, Infection Control- Transmission- Based Precautions, revised 10/2019, indicated Contact precautions are intended to prevent transmission of infections that are spread by direct (person-to-person) or indirect contact with the resident, or environment, and require the use of appropriate PPE including a gown and gloves upon entering the resident's room or cubicle. The PPE should be removed, and hand hygiene performed before leaving the residents room or cubicle. A facility policy titled, Blood Glucose Meter Calibration and Care, effective 10/2014, indicated Glucometer shall be sanitized in between patient use with any sterilizer per manufacturer's recommendation. The User Instruction Manual for the blood glucose monitoring system (glucometer) revealed, We suggest cleaning and disinfecting the meter between patient [resident] use. The manual specified, Cleaning and disinfecting can be completed by using a commercially available EPA [Environmental Protection Agency]-registered disinfectant detergent or germicide wipe. An Admission Record indicated the facility admitted Resident #75 on 07/07/2021. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with foot ulcer and acute osteomyelitis of the right ankle and foot. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2024, revealed Resident #75 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had a surgical wound and received insulin injections. On 11/19/2024 at 11;35 AM, Licensed Vocational Nurse (LVN) #6 entered the room of Resident #75 to check the resident's blood sugar. A sign posted on the resident's door indicated the resident was on contact isolation and those who entered the room must wear a gown and gloves. LVN #6 entered the room without application of a gown or gloves. LVN #6 stated he did not need to wear PPE because he was not going to touch the resident. Once LVN #6 pricked the finger of Resident #75 to obtain blood with a multi-use glucometer, LVN #6 placed the glucometer in the top drawer of the medication cart, without sanitizing the glucometer. During an interview on 11/19/2024 at 11:51 AM, LVN #6 stated he was taught to sanitize the glucometer after use. LVN #6 acknowledged the glucometer used was a multi-use glucometer. LVN #6 stated he did not clean the glucometer after it was used because he did not have any disinfectant wipes on the medication cart. LVN #6 commented that if he was at a safe distance from the resident and did not provide physical contact, he did not need to apply PPE to enter the resident's room, even if the resident was on contact isolation. During an interview on 11/19/2024 at 1:36 PM, the Infection Preventionist (IP) stated staff were to always wear a gown and gloves when they entered a room of resident on contact precautions. During a follow-up interview on 11/21/2024 at 8:18 AM, the IP stated Resident #75 was on contact precautions for methicillin resistant staphylococcus aureus (MRSA), and all staff were to wear a gown and gloves when they entered the resident's room, regardless of the activity to be completed. The IP stated glucometers were to be cleaned after each use. During an interview on 11/21/2024 at 8:51 AM, the Director of Nursing Services (DNS) stated Resident #75 was on contact precautions for MRSA in a wound, and staff were to put on a gown and gloves when they entered the resident's room. The DNS stated LVN #6 should clean the glucometer after use. During an interview on 11/21/2024 at 11:18 AM, the Administrator staff were expected staff to wear a gown and gloves when they entered Resident #75's side of the room, and blood glucose meters were to be cleaned after each use.

Based on observation, interviews, and record review, the facility failed to protect the resident ' s right to be free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish), for one of five sampled residents (Residents 1), when a Certified Nursing Assistant (CNA 1) was witnessed using profanity towards Resident 1, on November 6, 2024. This failure had the potential for Resident 1 to experience psychosocial harm. Findings: During a review of Resident ' s 1 Admission Record (document containing clinical and demographic data), it indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis which included anxiety disorder unspecified (feeling of fear, dread, or uneasiness that can range from mild to severe). During a review of Resident 1's clinical records, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated November 7, 2024, indicated, Resident 1 ' s score was a 15 which indicated Resident 1 ' s cognition (the mental process of thinking, learning, remembering, and being aware of surroundings) is intact. During an interview on November 7, 2024, at 2:02 p.m., with Certified Nursing Assistant ( CNA 2), CNA 2 stated she was standing in the hallway with another staff member, when she overheard Resident 1 and CNA 1 engaged in a heated argument. CNA 2 stated Resident 1 was very upset and shouting regarding CNA 1 had gotten in his face and demanding him to Sit the hell down. During an interview on November 7, 2024, at 2:13 p.m., with Resident 1, Resident 1 stated, on November 6, 2024, he had asked CNA 1 for some ice, CNA 1 grabbed the water pitcher and left the room to grab some gloves. Resident 1 stated he mentioned I guess I am not getting ice, because he though he did something wrong. Resident 1 further stated CNA 1 returned to the room right away and approached Resident 1 in a confrontational manner and got very close to his face. During an interview on November 7, 2024, at 3:18 p.m., with Resident 1 ' s roommate (Resident 2), Resident 2 stated he heard a verbal altercation between his roommate and a staff member on November 6, 2024. Resident 2 indicated that while he could hear the exchange, he was unable to observe it directly due to a curtain that separates their beds. During a telephone interview on November 7, 2024, at 4:11 p.m., with the Administrator, (ADM 1), ADM 1 stated CNA 1 ' s actions involved in the verbal altercation constituted a verbal abuse. During a telephone interview on November 13, 2024, at 3:21 p.m., with ADM 1, ADM 1 clarified detail regarding the facility ' s summary of investigation. ADM 1 stated Resident 1 asked a staff member for some ice, the staff member asked CNA 1 to bring ice for Resident 1. AMD stated, while in the room, CNA 1 realized he did not have the correct size of gloves, when CNA 1 walked out of the room to get some gloves without informing Resident 1, Resident 1 mistakenly thought he had done something wrong an exclaimed, Oh, f**k me. ADM 1 further stated CNA 1 returned to the room immediately upon hearing Resident 1 and told him If you don ' t sit your ass down, I will make you. During a review of the facility ' s policy and procedure (P&P) titled, Policy and Procedure on Patient abuse and Prevention, dated October, 2014, the P&P indicated, The facility shall uphold resident ' s right to be free from any form of verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Based on interview, and record review, the facility failed to notify the resident's designated responsible party for one of three sampled resident (Resident 1) when Resident 1's change of condition when Resident 1 developed redness, irritation to right side of throat and right ear with pain and itching. This failure prohibited Resident 1's representative to be actively involved in participating with Resident 1's comprehensive Plan of care. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was re- admitted to the facility on [DATE].2024, with diagnoses to include: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), peripheral autonomic neuropathy ( a disorder that damages the nerves that control your internal organs), hypertensive heart disease ( condition that develops over many years in people with high blood pressure which occurs when the heart muscle does not pump properly), type 2 diabetes mellitus (condition in which the body has trouble controlling blood sugar), and dementia (loss of thinking, remembering, and reasoning). During a concurrent interview and record review of Change of Condition notification (COC) with LVN 1 on June 18,2024 at 10:30 am. LVN 1 stated that on April 30,2024 at 10:30 am, she did not notify Resident 1's Responsible Party (RP) of redness, irritation to right side of throat and right ear with pain and itching. LVN1 stated that Resident 1 is self-responsible per documentation on Admission Record. During a record review of Resident 1's History and Physical (H&P) with LVN1, Resident 1's Primary Physician (MD), indicated that Resident 1does not have the capacity to understand and make decisions. When LVN1 was asked if she reviewed the H&P that was written by Resident 1's MD on April 8, 2024, LVN 1 denies reviewing the H&P. She stated that she only read the admission record. During a concurrent record review and interview on June 18,2024 at 11:05 am with Director of Nursing (DON), DON stated that Resident 1's RP on COC form indicated that RP was not notified on April 23,2024 and April 30,2024. DON stated that Resident 1's Admission Record should have been updated to reflect MD's H&P written on April 8, 2024, indicating that Resident 1 does not have the capacity to understand and make decisions. During a review of the facility's policy titled, Change of Condition , revised in December,2014, the policy indicated: It is the policy of this facility, except in medical emergencies, to notify the resident, his/her attending physician, and any interested family member or legal representative, of changes in the resident's condition and /or status.

Based on interview, and record review, the facility failed to follow their policy and procedure (P&P) when it did not administer regular insulin (a medication that helps your body use sugar for energy) that was readily available in their emergency kit (e-kit- small quantity of medications that can be dispensed when pharmacy services are not available) and instead used the insulin brought to the facility by resident's family. This had the potential to administer a medication that could have been tampered, contaminated or unsafe for use for one of three sampled residents (Resident 1). Findings: During an interview on October 9, 2023 at 10:53 AM with Resident 1 inside his room, Resident 1 stated he was admitted on [DATE] and did not receive his insulin dose when he first came in. A review of Resident 1's Admission Record , indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (DM- commonly referred as diabetes, a health condition that affects how your body turns food into energy) among others. A review of Resident 1's History and Physical (a brief documentation of a resident's medical condition) , dated October 2, 2023, indicated Resident 1 has the capacity to understand and make decisions. During a concurrent interview and record review on October 9, 2023 at 11:53 AM with the Director Of Nursing (DON), Resident 1's SBAR/COC Assessment Form (SBAR- a written communication tool that helps provide essential, concise information, usually during a change of condition [COC]), dated September 30,2023, at 2:30 PM was reviewed. The DON stated that per SBAR/COC, Resident 1 had a blood sugar (concentration of sugar in the blood, with normal range of 70 to 100 milligram per deciliter [mg/dl- a unit of measurement]) of 506 mg/dl. Further review of the associated Licensed Progress Notes indicated Resident 1's doctor was made aware with order for 20 units of insulin. During an interview on October 12, 2023 at 2:08 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was helping out LVN 1 in taking care of Resident 1 on September 30, 2023. LVN 2 stated she checked Resident 1's blood sugar at 506 mg/dl and notified the doctor. LVN 2 stated she also notified the doctor that Resident 1's medications hasn't been delivered yet by pharmacy, and that Resident 1's wife was insisting on administering Resident 1's regular insulin brought in from home by Resident 1's wife. LVN 2 stated there was regular insulin in the facility e-kit, but she administered the regular insulin brought in by Resident 1's wife after getting approval from the doctor and the DON. LVN 2 stated she should have given the regular insulin from the e-kit. During a concurrent interview and record review on October 12, 2023, at 2:49 PM with the DON, Resident 1's Physician's Telephone Orders , dated September 30, 2023, at 2:30 PM was reviewed. The order indicated, Give 20 units regular insulin x 1 dose . The DON stated there was nothing in the order that indicated the regular insulin could be taken from the home medication brought in by Resident 1's wife. The DON further stated the regular insulin administered to Resident 1 should have been taken from the e-kit. During a concurrent interview and record review on October 16, 2023 at 9:12 AM, with the DON, the facility's P&P titled, Medications Brought to the Facility by the Resident/Family , effective October 2015 was reviewed. The P&P indicated, .The facility shall ordinarily not permit residents and families to bring medications into the facility .2. The facility discourages the use of medications brought in from outside, and will inform residents and families of that policy as well as applicable laws and regulations .3. If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services/RN Supervisor shall check to ensure that: a. State law and regulations allow such use; b. The medications have been ordered by the resident's Attending Physician, and documented on the physician's order sheet; c. The contents of each container are labeled in accordance with established policies . The DON stated the physician's order dated September 30, 2023 at 2:30 PM did not indicate that the insulin can be taken from home meds brought in by Resident 1's wife. The DON stated the regular insulin was available and should have been taken from the facility e-kit. The DON further stated the facility did not follow their policy and procedure.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) when there were missing documentation for bowel and bladder elimination for one of three sampled residents (Resident 1). These failures had the potential to cause unsafe conditions and poor quality of life for Resident 1. Findings: During a review of Resident 1's clinical record, the Admission Record (contains demographic and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes (high sugar level), and a fracture (a partial or complete break) of the right femur ( a long bone that runs the length of your upper leg or thigh). During a concurrent interview and record review on September 26, 2023, at 12:10 PM, with the Director of Nursing (DON), Resident 1's Bladder Elimination, dated September 1, 2023, through September 26, 2023, had missing documentation for the following dates and times: A. September 21, 2023, night shift (10:00 PM to 6:00 AM- the next day). B. September 23, 2023, night shift. C. September 25, 2023, evening shift (2:00 PM to 10:00 PM). During a subsequent interview and record review on September 26, 2023, at 12:12 PM, with the DON, Resident 1's Bowel Elimination, dated September 1, 2023, through September 26, 2023, had missing documentation for the following dates and times: A. September 21, 2023, night shift. B. September 25, evening shift. The DON acknowledged the missing bladder elimination and bowel elimination dates and times and stated it is understood that staff must chart every shift for the bowel and bladder elimination, and if it is not charted then we do not know if it was done. During a concurrent interview and record review on September 26,2023, at 12:33 PM, with the DON, the facility's P&P titled, Activities of Daily Living (ADLs- personal care such as bathing, toileting, eating), Supporting, dated October 2014, indicated, .Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . The DON stated the policy was not followed and should have been.

Based on interview, and record review, the facility failed to ensure one of three residents (Resident 1) received the appropriate safeguards to ensure Resident 1 did not fall while a certified nursing assistant was providing care (CNA 1). This failure placed Resident 1 at high risk for injury to her back after surgery. Findings: An abbreviated survey was conducted on August 9, 2023 at 10:56 AM to investigate a complaint related to quality of care. A review of Resident 1's face sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included: dementia with mood disturbances (mood changes, such as depression or anxiety) and heart failure. During a review of Resident 1's clinical record, the Physician's Admission Order, dated April 4, 2023, indicated Resident 1 was status post laminectomy lumbar [operation to remove the back of one or more vertebrae (back bones)] for back bones one through four. Resident one is to wear a back brace. During a record review of the Fall risk assessment dated [DATE], indicated Resident 1's total score was 12. Scores over 10 indicated the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately . During a record review of Resident 1's weekly weight record dated April 4, 2023, indicated Resident 1's admission height was 5 feet 10 inches and a recorded weight of 199 pounds. During a record review of Residents 1's Change of Condition Form dated April 7, 2023, indicated Resident 1 had a fall during brief changes. CNA1 (certified nursing assistant) was present at time of the fall. CNA 1 stated that due to the resident being on a air mattress, the air shifted to where the resident leaned. Resident 1 leaved to far to the opposite side and fell to the floor. The nursing assistant taking care of Resident 1 at the time of this fall was CNA 1. During an interview with Certified Nursing Assistant (CNA 1), on August 23, 2023, at 2:07 PM, CNA 1 stated, It was a fall. I was changing Resident 1. Resident 1 rolled over and the mattress sunk in because she rolled to far to the side. Usually in that situation there's two people. It should have been two people. I was frustrated because I could not find anyone to help. I went out to find someone but I could not find anyone. CNA 1 stated further, That second person is to help support the weight and to help roll the resident over. I had counseling after the fall. They said we need to make sure we have two people for care. of Resident 1. During an interview and concurrent record review of Resident 1's records with the Director of Staff Development (DSD), on August 23, 2023, at 2:40 PM, DSD stated, We need two people for care if the resident is status post laminectomy. After reviewing Resident 1's records, DSD stated, Resident 1 would need extra assistance. You should have a extra person while providing care to Resident 1. During an interview with the Director of Nursing (DON), on August 23, 2023, at 4:02 PM, DON stated, If I'm a CNA and I feel like it's not safe. I would wait. CNA 1 should have waited until someone came. DON stated further, He should have used proper technique. The fall should have been prevented. It should not have happened. DON confirmed the fall was preventable and should not have happened while Resident 1 was in CNA 1's care. The facility policy and procedure titled Safety and Supervision of Residents dated July 2017, indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities .4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify accidents, hazards and try to prevent avoidable accidents .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Ice machine was not kept in sanitary condition and put residents at risk for foodborne illness (stomach illness acquired from ingesting contaminated food). 2. The handwashing sink in dish washing area was not providing enough hot water pressure to wash hands effectively, which had the potential to cause foodborne illness. 3. The microwave was not kept in sanitary condition which could transfer to residents' foods during reheating. This had the potential to contaminate the food and cause foodborne illness. 4. The floor under the stainless-steel counters and center island had food crumbs and trashes that had the potential to attract pests. 5. The floor under the shelves in the dry storage had food crumbs and three dead roaches that had the potential to attract pests. 6. The inside of a cabinet on the steamtable had black grime and food crumbs that had the potential to attract pests and harbor bacteria growth. 7. The can opener in the kitchen was not kept in sanitary condition which could transfer to residents' foods. This had the potential to cause foodborne illness. 8. The storage space on the stove had food crumbs and black grime that had the potential to attract pests and harbor bacteria growth. 9. The shelves in dry storage room, across from the family room, were not smooth and easily cleanable that had the potential to attract pests. 10. The three compartment sinks (three sinks used for washing dishes, one for washing, one for rinsing and one for sanitizing dishes) that was also used for food preparation did not have an air gap (an air gap refers to a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevents drain water from backing up into the sink and possibly contaminating the area used for washing food. An air gap is a way to make certain wastewater and contaminants never re-enter the clean water supply), which had the potential for back flow from the drain to contaminate the sink. This had the potential to cause foodborne illness. 11. The dish machine wash temperature was not reaching the appropriate temperature per the manufacturer guidelines. This had the potential for dishes to not be washed properly and potentially cause food borne illness. 12. There were three boxes of food that were open and the food was not sealed. Having the food exposed to the air in the freezer could potentially cause freezer burn and affect the quality of the food. The facility's failures to ensure a safe and sanitary condition resulted in the likelihood of microorganisms that harbor foodborne pathogens to come in contact with residents' food which would cause food-borne illness to a population of 91 of 92 residents who received food from the kitchen and are medically compromised. Findings: 1. During a concurrent observation and interview with Maintenance Supervisor (MS) on February 1, 2022, at 10:19 AM, there was black and red slime buildup on the ice chute inside ice machine storage bin. Surveyor used a white paper towel to remove a chunk (spoonful) of the black and red slime from around the rim of the ice chute, where ice drops and enters the ice storage bin. Verified black and red slime with MS. MS stated he cleaned the inside top part of the ice machine, where ice was made monthly. When he cleaned the top part of the ice machine, he had housekeeping clean the ice storage bin. MS stated the housekeeping may need to adjust deep cleaning twice per month instead of once per month to prevent the buildup of slime. He stated that he thinks that housekeeping may have missed that area where the buildup was found because it is hard to reach. During an interview on February 1, 2022, at 12:31 PM, with Housekeeping 1 (HK1) and the MS, in front of ice machine. HK 1 stated she just cleaned the ice machine storage bin with bleach and water mixture. After she cleaned the ice machine storage bin, she needed to write down the date in the ice machine sanitation log located next to ice machine. But today she forgot to write the date. HK 1 showed the sanitation log to surveyors and stated her coworker just cleaned the ice machine yesterday on January 31, 2022. Surveyor used white napkin to wipe the ice chute inside the ice storage bin. There still was black slime buildup. Verified finding with HK 1 and MS. HK 1 stated she had no idea why after she cleaned the internal ice machine storage bin with bleach, the black slime was still there. During an interview on February 1, 2022, at 4:27 PM, with ice machine Service Technician (ST) from company name, ST stated he provided services for the facility's ice machine many years. There was an area where the gasket (rubber piece that lined the top of the ice bin where the ice maker sat on top) was damaged in the ice machine. He stated that dirt could enter there, had that was how the slime buildup developed. ST recommended they replace the gasket of the ice machine and use bleach to sanitize ice machine ice storage bin to remove slime. During a record review of the FDA Federal Food Code 2017,, it indicates that (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch and food-contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free from sharp internal angles, corners, and crevices, finished to have smooth welds and joints . The Food Code states that the purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. During a record review of the Federal FDA 2017 Food Code 4-204.17, indicated The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form . are difficult to remove and present a risk of contamination to the ice stored in the bin. During a record review of the Ice machine Cleaner and Sanitizer Usage titled, [Company name], undated, provided by MS indicated, Cleaning the Ice Bin and Drop Zone. Ice is held in ice bins and dispensers until it's ready to be used. As this is where ice spends the majority of its time, it's imperative to clean the ice bin thoroughly. Mold, slime, and algae can grow in an ice bin, feeding off dust and yeast from the air and enjoying relative privacy in the dark, moist bin environment. Get a bead on these contaminants and wipe them out during deep cleaning .Descale Your Ice Bin 2. Remove any visible grime or debris by wiping the interior . with warm water and a cloth . During a record review of the facility's policy titled, Sanitation, Revised 2017, indicated, 2. All . equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams, cracks and chipped areas . During a record review of the Food and Nutrition Monthly Kitchen Audit Checklist/Report, dated November 30, 2021, December 28, 2021, and January 25, 2022, the RD 1 put a check mark met on the box 40 that indicated The interior and exterior of the ice Machine is clean and operable, free of rust. Ice scoop is covered when not in use. Passes white paper towel test. Record Review of the facility document titled Diet Order Listing Report. dated February 1, 2022, indicated there were 91 residents on PO (by mouth) diet. Review of the facility document titled Diet Order Listing Report, dated February 1, 2022, indicated there was one resident on NPO (nothing by mouth) means not receiving food by mouth. An immediate jeopardy (IJ) was called on 483.60(i)(2) - Store, prepare, distribute, and serve food in accordance with professional standards for food service safety, on February 1, 2022, at 3:00 PM, the survey team verbally notified the facility Administrator, Director of Nursing, and Maintenance Supervisor of the IJ due to the ice machines not being kept in sanitary condition. Failure to maintain sanitary ice machines had the potential to cause food-borne illness to the highly susceptible residents who received ice from the ice machines. The Corrective Action Plan (CAP) included the following: 1. Turned off the ice machine for servicing and sanitizing, until the issue(s) have been resolved. 2. Contacted a third party licensed vendor for immediate servicing and cleaning ice machine. 3. Provided in service training to maintenance staff, and dietary staff by the third party licensed vendor. 4. Purchased ice from the store while the ice machine was being serviced. 5. Based on the third party licensed vendor's recommendations, the ice storage bin gasket was replaced. 6. The ice machine bin will be cleaned twice a month and as needed. 7. The maintenance Supervisor will inspect the ice machine and document in the cleaning log every 2 weeks and as needed. Action plan completed on February 2, 2022. 1. Third party licensed ice machine service vendor was contacted, and ice machine service technician was in the facility on February 1, 2022. Service Technician recommended replace the bin gasket of the ice machine. Service Technician also provided in service on cleaning and sanitizing ice machine and ice storage bin with Maintenance Supervisor and Interim Dietary Manager. 2. The ice machine gasket replaced on February 1, 2022. 3. The Maintenance Supervisor received training on cleaning and sanitizing ice machine and ice storage bin. 4. The Interim Dietary Manager received training on cleaning and sanitizing ice machine and ice storage bin. During an interview on February 2, 2022, at 11:31 AM, with MS and Interim Dietary Manager (IDM), in front of ice machine. MS stated he replaced old gasket of ice machine per ST recommendation. In future, dietary and maintenance will clean and disinfect ice machine biweekly, housekeeping clean and disinfect exterior ice machine daily. Verified with IDM, he stated he is going to clean internal ice machine biweekly. When cleaning internal ice machine, he would remove ice from ice storage bin. Then he cleaned the ice storage bin with sanitizer solution including ice chute. Any build up and any color slime should not be in ice machine storage bin. During an interview on February 2, 2022, at 3:18 PM, with Registered Dietitian 1 (RD 1) and Interim Dietary Manager (IDM), at Sun patio dining room. RD 1 stated she only checked ice machine sanitation log; checked that there was no ice scoop inside internal ice machine storage bin; She used a white paper tower to check the cover of the ice bin. She stated she does not check the ice chute for cleanliness. During an interview on February 3, 2022, at 9:45 AM, with IDM. IDM stated ice from the ice machine is for everyone (residents, employee) in this building and also used for food preparation in the kitchen. During an interview on February 3, 2022, 12:40 PM, with HK 1. HK 1 stated when she clean ice machine on February 1, 2022, she only used bleach and water. There was a little slime (look like Jell-O) come out from ice storage bin. HK 1 admitted she may miss the ice chute because it hard to reach. During an interview on February 4, 2022, at 10:08 AM, with MS, MS stated the manufacturer guidelines for the ice machine indicated that the ice machine needed to be cleaned every six months and did not provide instruction on how to clean or scrub the interior of the ice storage bin, so he developed a cleaning protocol. He stated despite using the cleaning protocol, he thought that housekeeping probably did not reach into the ice storage bin and look up into ice chute to clean it. That is why surveyor found the slime build up. During an observation on February 2, 2022, at 11:01 AM, ice machine was clean, no slime buildup. During a review of facility invoice for ice machine service vendor [Company name], dated February 1, 2022, indicated Start time: 3:40. Time finish: 4:40. Service Performed: Give instructions on cleaning and sanitizing ice machine and bin with maintenance supervisor and Dietary supervisor. Replacement of bin gasket should be done. During a review of facility's receipt [Company name], dated February 1, 2022, at 6:41 PM provided by MS, indicated purchasing of ice machine gasket. During a review of facility document titled, In-service on how to properly clean the ice machine, dated February 1, 2022, at 4:30 PM indicated Maintenance Supervisor and Interim Dietary manager completed the competency training on February 1, 2022. The Immediate Jeopardy was abated on February 2, 2022, at 3:11 PM, in the presence of the Administrator, at the Administrator office, after an acceptable corrective action plan was provided and verified to be implemented by observation, interviews, and document review. 2. During a record review of the FDA Federal Food Code 2017, 6-103.12, indicated, Water under pressure shall be provided to all fixtures, equipment, and nonfood equipment that are required to use water and inadequate water pressure could lead to situations that place the public health at risk. For example, inadequate pressure could result in improper handwashing. During a record review of the FDA Federal Food Code 2017, 5-202.12, indicated, A handwashing sink shall be equipped to provide water at a temperature of at least 38° C (100°F) through a mixing valve or combination faucet, and Warm water is more effective than cold water in removing the fatty soils encountered in kitchens. An adequate flow of warm water will cause soap to lather and aid in flushing soil quickly from the hands. ASTM Standards for testing the efficacy of handwashing formulations specify a water temperature of 40°C ± 2°C (100 to 108°F). During an observation on February 1, 2022, at 11:12 AM, the handwashing sink located in the dish washing area, was not providing enough hot water pressure. When cold water was used to increase the water pressure, it caused water to came out from faucet cold. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. IDM stated he had brought up to maintenance that the hand washing sink located in dish washing area had inadequate water pressure, but maintenance claimed they could not fix it because of the location. RD 1 stated she expected the handwashing sink to meet adequate temperature and pressure to meet the Food Code. 3. The Federal Code 2017 indicates food contacted surface and utensils are to be clean to sight and touch and utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to scratching, and decomposition. During an observation on February 1, 2022, at 9:42 AM, the microwave was dirty with food crumbs and yellow grime on the top inside where food is placed to be warmed. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated the microwave should be cleaned weekly. RD 1 expected microwave should have a weekly deep clean and kept clean with wipe down after meal service. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner .2. All .equipment shall be kept clean. 3. All equipment, food contact surfaces .shall be washed to remove or completely loosen soils. 4. During a concurrent observation and interview with the IDM, on February 1, 2022, at 9:21 AM, the floor under the stainless-steel counters, between juice machine and coffee maker, had a build-up of dust, trash and black grime. The floor under the center islands had food trash, debris, and used gloves. The IDM stated it should not be like that. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated the floor should be cleaned four times per day. Cleaned after each meal trayline and 4th time cleaned was end of the day. She stated after New year, this facility had hired lot of new employees. Possibly there was some job responsibility confusion. Will continue to do in-service and request Dietary Assistant supervisor do spot check. During a record review of the FDA Federal Food Code 2017, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. During a record review of the FDA Federal Food Code 2017, it indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. During a review of the facility policy's titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 1. All kitchen, Kitchen areas and dining area shall be kept clean, free from litter and rubbish .15. Kitchen .not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 5. During a record review of the FDA Federal Food Code 2017, Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests. During a concurrent observation and interview with the IDM, on February 1, 2022, at 9:32 AM, at dry food storage. The floor under dry food storage shelves had a build-up of food crumbs, cheerios. Three dead roaches were found on the floor underneath a black crate. IDM stated Dietary staff had not done cleaning under shelves in dry food storage. Dietary staff sweep and mop dry food storage room twice per week. Every two-week, dietary staff clean the storage room underneath shelves. Once per month dietary staff do the deep cleaning at dry food storage room. There is no cleaning log for food dry storage room done bi-weekly. I do not notice any pests in the kitchen. If there is pest issue, I will inform Maintenance Supervisor. Maintenance Supervisor will contact pest control vendor. IDM admitted it is not enough cleaning in dry food storage room since there was build up food crumbs and dead roaches. During an interview on February 1, 2020, at 10:51 AM, with MS, MS stated that pest control company come one per month at the beginning of the month. The pests contract company came out and sprays for free if they have to call between the one-month time frame. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated the floor needed to be swept regularly, there should not be food crumbs, cheerios, and roaches. Dietary would notify maintenance if there was pest issue. During a record review of the FDA Federal Food Code 2017, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 1. All kitchen, Kitchen areas and dining area shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. During a review of the facility's policy titled Food Receiving and Storage, Revised October 2017, indicated Foods shall received and stored in a manner that complies with safe food handling practices. 1. Food Services, or other designated staff. Will maintain clean food storage area all times. 6. During a record review of the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. During an observation on February 1, 2022, at 9:26 AM, there was black grime and food crumbs inside cabinet of the steamtable. Cabinet was not used for storage, but it was a potential area to attract pests. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. IDM stated the cabinet of the steamtable had not been cleaned in a long time. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 15. Kitchen .not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 7. During a record review of the FDA Federal Code 2017, indicates food contact surface and utensils are to be clean to sight and touch and utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to scratching, and decomposition. During an observation on February 1, 2022, at 9:43 AM, there was black grime at the base of can opener and sticky residue on blade. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. IDM stated he expected can opener should be clean after each used. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 2. All .equipment shall be kept clean. 3. All equipment, food contact surfaces .shall be washed to remove or completely loosen soils . 8. During a record review of the FDA Federal Food Code 2017, .(C) Non-food contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue, and other debris. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents and other pests. During an observation on February 1, 2022, at 9:29 AM, the storage space on stove had food crumbs, and was dirty and dusty. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated the storage space on stove should be kept clean. During a review of the facility's policy titled, Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner.15. Kitchen .not in contact with food shall be cleaned . 9. During a record review of the FDA Food Code 2017, Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. During a concurrent observation and interview with DM (Dietary Manager) and IDM on February 2, 2022, at 9:09 AM, dry food storage room located across from the family room, observed tears in the linoleum shelves covering. Interviewed DM who works in sister facility come to this facility helping. DM stated It is not acceptable to have tears in the linoleum shelves coverings, they need to remodel the shelves. Debris that gets caught under the torn linoleum will attract pests. Interviewed IDM, IDM stated Maintenance aware the tear and torn shelves, pending approval to get shelves fix. IDM admitted it is not acceptable to have tear and torn shelves in dry food storage. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated shelves in the dry food storage cannot be sanitized correctly because the linoleum was peeling on the shelves. IDM stated maintenance will take out the shelves and replaced new shelves. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner. 2. All ., shelves shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams and chipped areas that may affect their use or proper cleaning. 10. During a record review of the FDA Federal Food Code 2017, indicates A plumbing system shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the food establishment, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under 5-202.12. 5-202.13 indicated An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. In addition, During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Providing an air gap between the water supply outlet and the flood level rim of the plumbing fixture or equipment prevents contamination that may be caused by backflow. During a concurrent observation and interview on February 2, 2022, at 9:42 AM, with the MS, the three compartment sinks that was also used for food preparations did not have air gap. MS stated that a plumbing company recently come to fix the pipes because they were backing up. He stated they did a drain clean out. 11. During an observation on February 2, 2022, at 10:10 AM, the dish machine wash water temperature gauge was observed at 100 degrees Fahrenheit (Fahrenheit unit of measurement °F). Verified dish machine wash temperature with DA 2, she stated it was 102 °F. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. RD 1 stated will request dish machine [company name] come in checked the inadequate dish machine wash water temperature. During a review of the facility's policy titled Sanitization, Revised July 2017, indicated The food service area shall be maintained in a clean and sanitary manner . 8. Dishwashing machines must be operated using the following specifications: Low Temperature Dishwasher (Chemical sanitization). a. Wash temperature (120 °F). 12. During a concurrent observation and interview on February 2, 2022, at 9:22 AM, with IDM, reach in freeze, observed a box of 20-pound opened bread stick exposed to the air. Another box of opened 20.5-pound Ranch style roll exposed to the air. Walk in freeze had a box of opened Cinnamon French toast exposed to the air. Interviewed IDM. IDM stated, opened foods items need to be seal. During an interview on February 2, 2022, at 3:18 PM, with RD 1 and IDM, at Sun patio dining room. IDM 1 stated he needed to do in service opened food items need to be seal. During a review of the facility policy statement Food Receiving and Storage, Revised October 2017, indicated Foods shall received and stored in a manner that complies with safe food handling practices. 8. All foods stored in the refrigerator and freeze will be covered .

Based on observation, interview, and record review the facility failed to ensure for one of nine residents (Resident 1) with a diagnosis of dementia and periods of forgetfulness was being properly monitored and supervised when the following occurred: 1. The facility failed to implement 1:1 monitoring and supervision of care after Resident 1 left the building on February 1, 2021, without staff's knowledge. 2. Staff failed to monitor and properly supervise Resident 1 on June 26, 2021, when he eloped (leaving building without permission from the physician) and was hit by a car causing his death. These failures resulted in Resident 1 not being monitored or supervised resulting in Resident 1 eloping on February 1, 2021, and June 26, 2021. Resident 1 was hit by a motor vehicle resulting in Resident 1's death after the June 26, 2021, elopement. Findings: 1. An unannounced visit to the facility was made on July 2, 2021, at 11:35 AM, to investigate a complaint that Resident 1 had eloped from the facility under the category of death. During a review of the face sheet (contains demographic and diagnosis) of Resident 1, it indicated Resident 1 was admitted on [DATE], with diagnosis (DX) that included anxiety disorder, confusion, major depressive disorder, and dementia (group of condition characterized by impairment of at least two brain function) without behavioral disturbance. During a concurrent interview and record review with the DON on June 30, 2021, at 5:51 PM, Resident's 1 BIMS (Brief Interview for Mental Status) score was indicating different score of 5 and 14 during the same assessment period. Then on May 7, 2021, indicated BIMS score of 15. The DON further stated she spoke to the Minimum Data Set Nurse (MDS-clinical assessment of all residents) nurse, and she admitted having accurate assessments are important. Having an inaccurate assessment can negatively impact the care Resident 1 would have received. During a review of resident 1's baseline care plan dated August 13, 2020, indicated a need for observation, assessment, and medical management for Dementia, Altered level of consciousness (ALOC), and confusion. Interventions were as follows: Observe and review Resident 1 for any change of condition, complete assessment for elopement and identify risk factors and plan of accordingly. During a review of Wander-Elopement Risk Evaluation dated August 13, 2020, indicated Resident 1 had a risk factor of being cognitively impaired and a diagnosis of Dementia. During a review of Resident 1's history and physical dated November 1, 2020, indicated a DX of dementia, anxiety and difficulty walking. During a review of the License Progress Notes dated February 1, 2021, at 5:45 AM, indicated Certified Nurse's Assistant 1 (CNA 1) noted Resident 1 not in the room. At 6:15 AM, Resident 1's brother called the facility to inform Resident 1 made a call and was outside of the facility and wanted to go home. Law enforcement was notified. At 6:30 AM CNA 1 located Resident 1 wandering outside the facility and trying to go home. During a review of the Social Services Notes dated February 1, 2021, for Resident 1 indicated Resident 1 wandered outside the facility and called his brother. Resident 1's brother called to inform the facility and they found Resident 1 outside off facility grounds. During a review of the 72-Hour RN RE-Assessment for Resident 1 dated February 1, 2021, indicated the following: Type of Incident: Resident 1 wandering out of the facility: Resident 1 verbalized with intention to go back home. Resident 1 stated, I do not want a sitter at my bedside but, I still know I might faultier. Please remind me if I am leaving the facility, I need to notify the nurse. During a review of Resident's 1 physician order's dated February 1, 2021, indicated, May have 1:1 monitoring and discontinue if no episodes or verbalization of wandering. During a review of Resident 1's clinical record dated February 4, 2021, indicated no documentation for 72-hour monitoring was found. During a review of License progress notes dated February 16, 2021, at 8:00 AM, indicated increased forgetfulness and diagnosis of Dementia. Physician was notified. During a review of Nurse Notes dated February 17, 2021, at 5:00 AM, indicated Resident 1, Wants to go out to the post office and check his mail. During a review Psychiatry notes for Resident 1 dated February 20, 2021, indicated Resident 1 reported wanting to elope. During an interview on July 6, 2021, at 3:50 PM with Resident 2, Resident 2 stated, Resident 1 was my roommate during the month of February 2021, and he would wander around talking about wanting to go home. During a record review on July 2, 2021, at 3:57 PM, care plan was initiated on February 1, 2021. The care plan indicated to Start one to one (a staff is assigned to be with the resident at all times) for 72 hours, and update Wander-Elopement Risk Evaluation form. The Wander-Elopement Risk Evaluation form was updated on February 4, 2021 (four days after Resident 1 had wandered out of the facility with-out staff's knowledge) indicated Resident 1 was not at risk for wandering/elopement. During a concurrent interview on July 2, 2021, at 3:57 PM with the MDS coordinator, the MDS coordinator stated, I do not know why the Wander-Elopement Risk Evaluation form indicated Resident 1 was not at risk for Eloping. The MDS coordinator stated after Resident 1's incident of wandering on February 1, 2021, Resident 1 should have been placed on 1:1 monitoring x 72 hours and updated as at risk for wandering. During an interview on January 26, 2022, at 11:19 AM with the Director of Nurses (DON), the DON stated there is no documentation required when conducting 1:1 monitoring for the residents. The DON Confirmed physician order for 1:1 monitoring for Resident 1 was not implemented. During a telephone interview on January 26, 2022, at 11:22 AM with the DON, the DON stated no care plan was initiated for 1:1 monitoring for Resident 1. When ask the DON if Resident 1 had exit seeking behaviors the DON stated, He did not have any exit seeking behaviors. The DON stated, When a resident continuously states they want to go home, that is not exit seeking behavior. During a telephone interview on January 26, 2022, at 11:36 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated, When there is an order for 1:1 monitoring it should be documented every hour and a care plan should be initiated. 2. During an interview on June 29, 2021, at 2:55 PM with CNA 1, CNA 1 stated Resident 1 tried to leave the facility a few times to get food or to see his daughter. CNA 1 stated, On June 26, 2021, at 10 PM, I was on Station 1 and LVN 1 said she could not find Resident 1. We both notified the Charge Nurse (CN). CNA 1 stated she went outside to the parking lot, could not find Resident 1, and informed the CN. CNA 2 drove around the area to look for Resident 1 and did not could-not find him. During an interview on June 29, 2021, at 3:42 PM with Housekeeping (HK), HK stated, I saw Resident 1 on June 26, 2021, playing the piano and there is a door close to that area where families, CNAs', and housekeeping use the door and the alarms do not work. During an interview on June 30, 2021, at 3:59 PM with LVN 2, LVN 2 stated, If the resident has DX of Dementia, behavioral issues, and history of elopement, then the resident is considered at risk for eloping or wandering During an interview on June 30, 2021, at 4:19 pm with CNA 2, CNA 2 confirmed Resident 1 has episodes of confusion. CNA 2 further stated he last saw Resident 1 on June 26, 2021, at 8:15 PM in resident's room. CNA 2 stated there is only one exit door in the hallway where no one can enter but, anyone can exit that door. CNA 2 further stated, Resident 1 could have also left using the front door. CNA 2 believe the front lobby door didn't have an alarm. During an interview on June 30, 2021, at 5:21 PM with the Registered Nurse Supervisor 1 (RNS 1), RN'S 1 stated, Resident 1 had periods of confusion and was at risk for elopement. During a telephone interview on July 2, 2021, at 8:15 AM with Resident's 1 daughter, Resident 1's daughter stated, On June 26, 2021, my father left the facility without staff knowing and was involved in a motor vehicle accident which resulted in his death. Resident 1's daughter further stated he had left the facility without staffs' knowledge back in February as well and had informed the facility Resident 1 had dementia and forgetfulness and needed to be monitored. During an interview on July 2, 2021, at 11:50 AM with the Receptionist, the Receptionist confirmed there should be someone at the main entrance door 24 hours a day. The Receptionist further stated, Staff cannot view the entrance of the facility unless they are physically present at the door to screen everyone. During an interview on July 2, 2021, at 2:28 PM with Social Service 1 (SS 1), SS 1 confirmed if a resident is at risk for wandering, staff should monitor them, alarms on the doors, and not does not feel putting alarms on the residents or their wheelchair works. During an interview on July 6, 2021, at 11:45 AM with Assistant Maintenance Director (AMD), AMD stated There are three doors that alarms will not be triggered when opened. He stated if a resident goes out that door and no one hears the alarms, the resident can't get back in. During an interview on July 6, 2021, at 1:26 PM with RN 2, RN 2 stated the facility does not have any residents at risk for elopement. RN 2 further stated, We have a risk for wandering elopement form, it is completed by the RN'S and reviewed periodically but, not sure who reviews it. During an interview on July 6, 2021, at 3:19 PM with CNA 3, CNA 3 stated, The last time I saw Resident 1 was on June 26, 2021, around 8:15 PM. CNA 3 said at 10:30 PM on June 26, 2021, he was going to do vital signs (checking temperature, respirations, pulse, blood pressure and pain) Resident 1 was not in the room. I believe Resident 1 went out the front door because the door in the front lobby did not have an alarm. During several observations on July 2, 2021, of the facility were as follows: a. At 11:25 AM observed exit door near room 34 opened did not alarm close to parking lot facing main street with sign stating alarm on door. b. At 11:42 AM observed exit door near room 51 opened and it did not alarm. During a review of the license progress notes dated June 26, 2021, at 10:40 PM, indicated as follows: Went and checked on Resident 1 and noticed he was missing. LVN 1 checked the facility inside, outside called the DON, police, and emergency contact. During a review of SBAR (Situation, Background, Assessment, and Recommendation) /COC (Change of condition) Assessment Form dated June 26, 2021, at 10:50 PM indicated Resident 1 was missing from his room. During a review of Licensed progress notes dated June 26, 2021, at 11:20 PM indicated Resident 1 was missing and immediate search was done. The DON arrived at the facility and instructed staff to do a head count and Resident 1 was not accounted for. A review of Coroner's autopsy report dated July 1, 2021, indicated the cause of death, Multiple [MEDICATION(S)] force injuries, instantaneous. During a concurrent interview and record review with the DON on July 6, 2021, at 2:45 PM, facility's policy and procedure titled, Policy and Procedure on Elopement dated October 14, 2019, the DON stated it was her expectation that staff should do monitoring and checks every 1-2 hours. It is everyone's responsibility to make sure the residents are checked and safe. The DON stated the policy was if they identify a resident that is at risk for wandering, they offer a one-to-one staff monitoring and the Social Worker will try to find placement. A review of the facility's Policy and Procedure titled Policy and Procedure on Elopement, dated October 14, 2019, indicated . Residents will be assessed and elevated for risk for wandering/elopement upon admission, quarterly, and change of condition. Residents who are assessed and evaluated to be at high risk for wandering/elopement will be provided 1:1 monitoring, and Social Services Designee will evaluate resident within 72 hours for appropriate placement. Each resident will be provided with a safe place or residence. Resident will be assessed for wandering/elopement upon admission, quarterly, and change of condition. A review of facility's Policy and Procedure titled Policy and Procedures on patient Safety, undated, indicated . It is the policy of this facility to provide services to each resident that will allow them to maintain their highest practicable level of function and wellbeing, without jeopardy for their safety. A review of facility's policy and procedure titled Routine Resident Checks, undated, indicated . Routine resident checks involve entering the resident's room and/or identifying elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. A review of the facility's policy and procedure titled, Alarm System, dated October 2014, indicated . Our facility always maintains an operable alarm system. Alarms on exit doors are tested weekly. A review of the facility's policy and procedure titled, Charge Nurse, undated, indicated . primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistance. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the director of nursing services or nursing supervisor to ensure that the highest degree of quality care is maintained at all times.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of hazards when water temperatures within the facility reached 136.6 °F (Fahrenheit - unit of measure for temperature) in areas where hot water was accessible to residents. This failure lead to unsafe hot water temperatures which had the potential to cause [MEDICAL CONDITION] scalding to a vulnerable population of 103 Residents. Findings: On (MONTH) 12, 2019, at 8:46 AM, during the recertification survey, a surveyor returned from using the common restroom located near Nurses Station 2 and across from room [ROOM NUMBER]. The surveyor informed the survey team, the water coming from the sink was noted to feel extremely hot to the touch. The surveyor stated he had to pull his hands back quickly due to how hot the water was despite his attempts to try and balance the temperature with cold water. On (MONTH) 12, 2019, at 8:51 AM, a surveyor calibrated a digital probe thermometer per the manufacturers recommendations and requested the presence of a member from the maintenance department. The Assistant Maintenance Supervisor (AMS) arrived to assist the surveyor. During an observation and concurrent interview with the AMS, on (MONTH) 12, 2019, at 9:00 AM, The AMS placed his hand under the running water from the sink in the common restroom and snatched his hand back immediately and stated the water was really hot . The AMS further stated he did not have a thermometer with him and that he would use the surveyor's thermometer to test the temperature of the hot water in the sink. The AMS filled a cup with hot running water from the sink and placed a thermometer into the cup for the reading. The AMS read the hot water temperature reading aloud 133.8 °F. The surveyor viewed the thermometer reading for verification and the display showed 133.8 °F. During an observation and interview with AMS, on (MONTH) 12, 2019, at 9:17 AM, the AMS stated the water temperature in the common restroom was too high and could cause an accident. The AMS rechecked the hot water temperature from the sink in the common restroom located near Nurses Station 2 and stated the temperature was 133.8 °F. The surveyor viewed the thermometer reading for verification and the display showed 133.8 °F During an observation and concurrent interview with the AMS, on (MONTH) 12, 2019, at 9:24 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 131 °F. The surveyor viewed the thermometer reading for verification and the display showed 131 °F. The AMS stated the temperature was too high and could cause injury. During an observation and concurrent interview with the AMS, on (MONTH) 12, 2019, at 9:28 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 129.4 °F. The surveyor viewed the thermometer reading for verification and the display showed 129.4 °F. The AMS stated the temperature was too high. During an observation and concurrent interview with the AMS, on (MONTH) 12, 2019, at 9:32 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 132 °F. The surveyor viewed the thermometer reading for verification and the display showed 132 °F. The AMS stated the temperature should be less than 120 °F. He further stated he did not understand why the temperature was so high. During an observation and concurrent interview with the AMS, on (MONTH) 12, 2019, at 9:37 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 132.4 °F. The surveyor viewed the thermometer reading for verification and the display showed 132.4 °F. The AMS stated he would need to discuss the findings with the Maintenance Supervisor (MS). During an observation and concurrent interview with the AMS, on (MONTH) 12, 2019, at 9:41 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 136.6 °F. The surveyor viewed the thermometer reading for verification and the display showed 136.6 °F. The AMS stated the water temperature was not getting better. He further stated the water temperature needed to be adjusted for safety. During an observation and concurrent interview with the AMS, on (MONTH) 12, 2019, at 9:47 AM, in room [ROOM NUMBER]'s bathroom, the AMS checked the hot water temperature from the sink and stated it was 136 °F. The surveyor viewed the thermometer reading for verification and the display showed 136 °F. The AMS stated he needed to discuss the high water temperatures with the Maintenance Supervisor (MS). He stated the temperatures needed to be adjusted immediately. He further stated he knew it would take only a minute or two for a burn to occur with water temperatures at 136 °F. During an observation and concurrent interview with the MS, on (MONTH) 12, 2019, at 9:58 AM, the MS stated he had turned the water temperature up for residents to shower and had forgot to turn the water temperature back down. He further stated the water temperature was turned up to 136 °F, from 6:00 AM to 8:30 AM. The MS stated he monitors the temperature of the water by the gauge in the boiler room. He stated he rarely monitored the water with a thermometer in individual resident rooms. During an observation and concurrent interview with the MS, on (MONTH) 12, 2019, at 10:15 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from the sink and stated it was 135.7 °F. The surveyor viewed the thermometer reading for verification and the display showed 135.7 °F. The MS stated the water temperature should be between 105-120 °F and water temperatures above 120 °F could cause injury to the residents and staff. MS further stated he had been turning the water up to 136 °F since (YEAR). During an observation and concurrent interview with the MS, on (MONTH) 12, 2019, at 10:24 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from the sink and stated it was 136 °F. The surveyor viewed the thermometer reading for verification and the display showed 136 °F. The MS stated too hot. During an observation and concurrent interview with the MS, on (MONTH) 12, 2019, at 10:33 AM, in the boiler room, the MS stated the boiler room gauge was previously set at 136 °F but he recently adjusted the temperature back to 118 °F after the AMS had notified him of the water temperature findings. The MS demonstrated on the gauge where he set the temperature. He stated he would set the boiler temperature at 136-138 °F. The MS stated it was no determining factor about turning the temperature to 136 °F versus 138 °F, he stated those numbers were just the ones he had used. During an observation and concurrent interview with the MS, on (MONTH) 12, 2019, at 10:48 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from the sink and stated it was 134.2 °F. The surveyor viewed the thermometer reading for verification and the display showed 134.2 °F. The MS stated he did not know how long it took for the temperature of the water to reach 120 °F after turning the boiler/heater down. He stated the cooling of the water would depend on if the shower was in use or the hot water was being used. He further stated the water in the resident's sink could possibly burn a resident during shower time. During an observation and concurrent interview with the MS, on (MONTH) 12, 2019, at 10:55 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from the sink and stated it was 133.9 °F. The surveyor viewed the thermometer reading for verification and the display showed 133.9 °F. The MS stated the water temperature was not safe. During an observation and concurrent interview with the MS, on (MONTH) 12, 2019, at 11:05 AM, in room [ROOM NUMBER]'s bathroom, the MS checked the hot water temperature from room [ROOM NUMBER]'s bathroom sink and stated it was 134.8 °F. The surveyor viewed the thermometer reading for verification and the display showed 134.8 °F. The MS stated he had not ever timed how long it took for the water temperature to reach a safe temperature in the residents' room after he had turned the water temperature back to 118 °F. During an interview with Resident 66, on (MONTH) 12, 2019, at 11:25 AM, Resident 66 stated sometimes the water temperature in the shower gets too hot. Resident 66 further stated while showering, she has tried to turn the knob to balance the water temperature but due to weakness of her hands, she cannot balance the water temperature and would throw the nozzle away from her body to keep from being scalded. During an interview with Resident 75, on (MONTH) 12, 2019, at 11:33 AM, she stated the water in the sink gets too hot. During an interview with Resident 51, on (MONTH) 12, 2019, at 11:39 AM, she stated the water gets hot and the knobs are hard to turn due to her hand weakness. During an interview with the Registered Nurse Supervisor (RN/SUP) on (MONTH) 12, 2019, at 11:50 AM, the RN/SUP stated contact with water temperatures in excess of 120 °F can [MEDICAL CONDITION] seconds. During a follow up interview with MS, on (MONTH) 12, 2019, at 12:20 PM, the MS stated he would manually increase or decrease the water temperature on the water heaters/boilers. The MS stated he routinely overrode the automatic shutoff temperature control safety valve. He further stated if the temperature was set at 120 °F, when the temperature reached 120 °F, the boiler would shut off. The MS stated he knew the valve was a safety device but he would override the safety device to warm up the water quickly and had been doing so since (MONTH) (YEAR). The MS stated he forgot to decrease the boiler temperature on (MONTH) 12, 2019. The MS stated he could not explain how each resident was monitored to ensure there were no accidents when the water was turned up during shower time. During an interview with the ADMIN, on (MONTH) 12, 2019, at 1:44 PM, the ADMIN stated the override of the water temperatures were very disappointing. She further stated she was not aware the water temperatures were being overridden at any time. Review of the facility policy and procedure titled Policy and Procedure on Patient's Safety dated (MONTH) 2014, indicated Policy. It is the policy of this facility to provide services to each resident that will allow them to maintain their highest practicable level of function and well-being, without jeopardy to their safety. Review of the facility policy and procedure titled Maintenance Service dated (MONTH) 2009, indicated Policy Interpretation and Implementation. 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. b. Maintaining the building in good repair and free from hazards .j. Maintaining water temperatures daily in patient rooms and nursing areas M-F (selected areas on floor plan) maintaining the degrees between 105 degrees to 120 degrees. An Immediate Jeopardy (IJ, a crisis situation in which the health and safety of individual(s) are at risk) was called on (MONTH) 12, 2019, at 1:38 PM, after water temperature readings taken from one common facility restroom sink and ten resident's bathroom sinks reached temperatures of up to 136.6 ° F. It was discovered a staff member of the facility manually overrode the automatic shutoff temperature control safety valve for the hot water and increased the water temperature of the heaters/boilers to 136 ° F for two and a half hours every day (between 6:00 AM and 8:30 AM). The IJ was called in the presence of the Administrator (ADMIN), the Director of Nursing (DON), the Assistant Director of Nursing (ADON) , and the RN Supervisor (RN/SUP). A Corrective Action Plan (CAP-a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and was received on (MONTH) 12, 2019, at 4:22 PM. A review of the CAP conducted on (MONTH) 12, 2019, at 4:57 PM, indicated water heaters/boilers supplying hot water to shower rooms, common restrooms, and residents bathrooms, were returned or remained at a maximum temp of 120 °F and hot water temperature checks were to be taken every hour to ensure water temperatures were no longer a danger to residents. Residents were assessed [MEDICAL CONDITION]/or scalding and the staff member who manually overrode the automatic shutoff temperature control safety valve, was given directives to never override the water safety valve. Additionally, an in-service was conducted with all staff members instructing them to report to the maintenance department, any water temperatures that feel too hot. During a follow up interview with the ADMIN, on (MONTH) 15, 2019, at 9:46 AM, the ADMIN stated she was shocked the MS was manually adjusting the water temperature on the water heaters and increasing the temperature above the safety guidelines indicated by the state. She further stated it is not ok to override the automatic shutoff temperature control safety valve and increase the water temperature of the boilers because it can [MEDICAL CONDITION] the residents. During an interview with the ADON on (MONTH) 15, 2019, at 10:18 AM, the ADON stated the water temperature in sinks and showers should always be between 105 °F and 120 °F. She further stated if the water exceeds 120 °F, it can [MEDICAL CONDITION] the residents. After the acceptable corrective action plan was verified with the facility to be implemented through observation, interview, and record review the IJ was lifted on (MONTH) 15, 2019, at 1:50 PM, in the presence of the ADMIN, ADON and RN/SUP.

Based on observation, interview, and record review, the facility failed to ensure resident food was stored, prepared, distributed, and served under sanitary conditions when: 1. Unpasteurized shelled eggs served to the residents were not cooked to ensure all parts of the eggs were completely firm to eliminate the risk of salmonella infection (salmonella is a bacteria and a common cause of food borne illness, sometimes called food poisoning), 2. The can opener blade was noted to be worn and chipped and the silver colored plating was worn off, 3. An employee's personal mug with coffee and cream was observed on a food preparation table during meal service, 4. A wall mounted fan in the dishwashing room directed toward clean resident dishes was observed to be dusty and dirty 5. A blender cup and a food processor cup were found stored and put away wet, not air dried, and 6. Four fluorescent light bulbs were noted in the dish room without any shielding (covering) over them . These failures had the potential to result in food borne illness in a highly susceptible population of 112 residents. An Immediate Jeopardy situation was declared on February 22, 2016, at 2:24 PM, in the presence of the Administrator due to the facility's failure to ensure residents' unpasteurized shelled eggs were cooked so that all parts of the eggs were completely firm to eliminate the risk of salmonella infection. Findings: 1. During a tour of the kitchen in the walk-in refrigerator, on February 22, 2016, at 6:45 AM, a box of 15 dozen shelled eggs was observed. The shell of the eggs did not contain the red P stamp to indicate they were pasteurized (a pasteurized egg has been gently heated to eliminate bacteria. The process makes the pasteurized egg safe to use in recipes that call for a raw or undercooked egg.) Pasteurized eggs are distinguishable from unpasteurized eggs by a red P stamped on the shell. The label on the box did not indicate the eggs were pasteurized. During an observation on February 22, 2016, at 6:52 AM, Cook 1 was observed asking Dietary Staff 1 (DS 1) to fry two eggs for one (1) Sampled Resident (Resident 17). DS 1 was observed frying the two eggs. During a concurrent interview with the Dietary Service Supervisor (DSS), when asked if she knew Cook 1 and DS 1 were using unpasteurized shelled eggs to serve undercooked eggs, she stated, Now I do. She further stated she has previously told the staff not to use the unpasteurized shelled eggs for fried eggs. She could not explain why her staff was still undercooking the unpasteurized shelled eggs. She stated that they usually have pasteurized shelled eggs. A review of the facility's grocery company's invoices from December 24, 2015, through February 22, 2016, indicated the facility had not received pasteurized eggs during that timeframe. During an interview with Sampled Resident 17, on February 22, 2016, at 7:30 AM, the resident stated the facility cooked him two eggs over medium with sausage for breakfast every morning . He stated the yolk of the eggs were .a little bit runny, I like them a little bit runny. During a concurrent interview with the DSS at 7:40 AM, she stated she could not remember when the last time the facility had pasteurized shelled eggs. During a concurrent interview with Cook 1, at 7:42 AM, she stated she cooked breakfast the day before and used a flat of eggs that did not have the P stamped on them to indicate that they were pasteurized. She stated she couldn't remember the last time the facility had pasteurized eggs. She further stated, I was never told that we have to use pasteurized eggs for poached or fried eggs. During a concurrent interview with Unsampled Resident AA, at 7:54 AM, (in her room) she stated she had received over easy (fried eggs which are gently flipped over to completed frying without breaking the yold) eggs every morning at the facility. During a concurrent interview with DS 1, at 8:02 AM, she stated, I didn't think about looking at the shell (of the eggs) for the 'P.' I noticed before that there was a 'P' on the eggs, but not lately. I don't remember when the last time we had pasteurized eggs. During an interview with Samplied Resident 17, on February 22, 2016, (while on the initial tour of the facility) at 8:15 AM, he stated I usually get two over easy eggs. Yesterday I got my two over easy eggs, I've had them every day for two years. Today I got the fake scrambled eggs. I don't like the fake scrambled eggs. Over easy is always on my card (meal tray card that details resident's diet order, likes and dislikes). During an interview with Sampled Resident 14, on February 22, 2016, at 8:25 AM, in the hallway of Station 1, she stated she liked her eggs .barely glossed over. I like the poached eggs and the fried soft eggs best. During an interview with Unsampled Resident BB, on February 22, 2016, at 8:50 AM, she stated, I'm used to sunny side up eggs. But today I got scrambled. I'll eat them today, but not tomorrow. I like the runny yolk. I eat them every day. During an interview with the Registered Dietitian, on February 22, 2016, at 2:42 PM, she stated she conducted sanitation checks in the kitchen at least once a month. She stated, .it is very rare that I am here at breakfast time because I live (not close). I would think they would have purchased pasteurized eggs. Honestly, I have not noticed that they didn't have them. In my opinion, I would prefer that they use pasteurized eggs. I should have known. (The DSS) never told me. A review of the facility's policy titled Egg Preparation, dated 2009, stated Pasteurized eggs must be used for residents requesting soft cooked, over easy, and soft poached eggs. It further indicated for fried eggs, Pasteurized in-shell eggs should be used. During an interview with Cook 2 on February 23, 2016, at 6 AM, she stated, it's probably been months since we last had pasteurized eggs. During an interview with Unsampled Resident DD, on February 23, 2016, at 7:30 AM, she stated she always got two fried eggs, over easy with runny yolks every morning. During an interview with Sampled Resident 3, on February 23, 2016, at 8:10 AM, he stated he always got his eggs sunny side up with runny yolks. During an interview with Unsampled Resident CC, on February 23, 2016, at 8:12 AM, he stated he was served two fried eggs every morning at breakfast. He stated the yolks on the fired eggs were runny. On February 23, 2016, at 1:52 PM, the Immediate Jeopardy situation was lifted in the presence of the Administrator when the survey team approved the facility's Corrective Action Plan and after observation, interview, and record review, confirmed the dietary staff was knowledgeable on safe handling of unpasteurized shelled eggs. The Corrective Action Plan also included the following components: a. Residents who had preferences for undercooked shelled eggs were identified and educated, when pasteurized eggs were not available, the facility could not serve soft or partially cooked eggs. Those residents who had been receiving undercooked unpasteurized shelled eggs were placed on alert charting for 72 hours to observe for any complications; as an example of, nausea, stomach upset, vomiting, diarrhea, abdominal pain, fever and dehydration. b. The facility's egg preparation policy was revised to include, in the event of using unpasteurized eggs, they will ensure all parts of the egg will be cooked until firm. All effort would be made to obtain pasteurized eggs. c. Training was provided to the dietary department on the new policy. No dietary staff would begin their shift before receiving the training. The nursing staff was also provided the training. d. The administrator or designee would check all incoming shipment of eggs each week. Daily, for three months, the administrator or designee would observe the kitchen food production to ensure, if only unpasteurized eggs were used, they were being cooked firmly. During an interview with the Administrator on February 25, 2016, at 1:30 PM, she stated the last time the facility had received pasteurized shelled eggs was June 18, 2015. She stated the facility had ordered the pasteurized eggs, but the grocery company had substituted unpasteurized shelled eggs due to an industry shortage of the pasteurized eggs. According to the 2013 Food and Drug Administration Food Code, raw animal foods such as eggs and foods containing raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with the following method: 145 °F or above for 15 seconds for raw eggs that are broken and prepared in response to a consumer's order and for Immediate service. And, a partially cooked food such as soft cooked eggs may be served or offered for sale upon consumer request or selection in a ready-to-eat form if the food establishment serves a population that is not a highly susceptible population. According to the Code, 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; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home, or nutritional or socialization services such as a senior center. Also, according to the Centers for Disease Control (CDC), to avoid Salmonella, you should never eat raw or lightly cooked (runny whites or yolks) eggs. Cooking reduces the number of Salmonella bacteria present in an egg. However, a lightly cooked egg with a runny egg white or yolk still poses a greater risk than a thoroughly cooked egg. Lightly cooked egg whites and yolks have both caused outbreaks of Salmonella infections. Although anyone can get a Salmonella infection, older adults, infants, and people with impaired immune systems are at increased risk for serious illness. In these people, a relatively small number of Salmonella bacteria can cause severe illness. 2. During an observation in the kitchen on February 22, 2016, at 7:05 AM, the can opener blade was noted to be worn and chipped. The silver colored plating was worn off. During a concurrent interview with the Dietary Services Supervisor (DSS), she was asked how often the blade should be changed. She verified that the blade was worn, and stated, It should not be like that, I will put this on the maintenance log (a communication form with the maintenance department to inform them of tasks that need to be done in the facility). The facility dietetic policy and procedure titled Operating and Cleaning Bench Can Opener dated January 2006, indicated to report dull blades to the Dietary Service Supervisor (knife should cut smoothly with not metal fragments resulting.) According to the 2013 Food and Drug Administration Food Code, .cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. 3. During an observation in the kitchen on February 22, 2016, at 7:08 AM, an employee's personal mug with coffee and cream was observed on a food preparation table during the tray line (when food is being placed on trays for resident meals). During a concurrent interview, the Dietary Services Supervisor (DSS) stated this should not be here.Who's is this? During a concurrent observation Dietary Staff 2 removed the cup to a back storage room with her gloved hand, and then returned to the tray line without changing the gloves or washing her hands. The facility Dietetic policy and procedure titled Personal Hygiene and Appearance dated January, 2006, indicated . Dietary staff are not allowed to eat in the kitchen. 4. During an observation on February 22, 2016, at 7:12 AM, in the facility kitchen, a wall mounted fan, in the dishwashing room was observed to be dusty and dirty. The fan was directed toward clean resident dishes. During a concurrent interview with the Dietary Services Supervisor (DSS), she stated .it (the fan) is not clean; it should be (clean). I am not sure of the cleaning schedule. According to the 2013 Food and Drug Administration Food Code, .non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 5. During an observation in the kitchen on February 26, 2016, at 6:44 AM, a blender cup and a food processor cup were found stored wet, not air-dried. During a concurrent interview with the Dietary Services Supervisor (DSS), she verified they were wet and should not be stored that way. The facility policy and procedure, in the Dietetic Manual, identified as Policy number 640, dated January, 2006 indicated, Place pots and pans on drain sink to thoroughly air dry. According to the 2013 Food and Drug Administration Food Code, equipment and utensils shall be air-dried or used after adequate draining. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking or storing of wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 6. During an observation in the kitchen on February 22, 2016, at 7:10 AM, four fluorescent light bulbs were noted in the dish room without any shielding (cover) over them. During a concurrent interview with Dietary Services Supervisor (DSS), she verified that the light bulbs had no shielding over them and did not know how long they had been like that. According to the 2013 Food and Drug Administration Food Code, shielding of light bulbs helps prevent breakage. Light bulbs that are shielded, coated, or otherwise shatter-resistant are necessary to protect exposed food, clean equipment, utensils and linens, and unwrapped single-service and single-use articles from glass fragments should the bulb break.

Based on observation, interview and record review, the facility failed to ensure that 1 of 23 sampled residents (Resident 11) and 1 of 16 unsampled residents (Resident B), were free of significant medication errors when: 1. An [MEDICATION NAME] (inhaler) medication ordered on March 1, 2014, for Resident 11 was not administered from March 1, 2014 through March 25, 2014, twenty five days from the time it was initially ordered by the physician. This failure had the potential to affect the overall respiratory condition and safety of Resident 11, who was already medically vulnerable. 2. During a medication pass observation, the manufacturer's guidelines or the medication label for Potassium solution medication administration was not followed. This failure had the potential for Resident B to experience an even lower below normal serum potassium level (Normal range of Potassium is 3.5-5.3 mEq/L {milliequivalents per liter}) which could have resulted in a life threatening arrhythmia (a problem with the rate or rhythm of the heartbeat). Findings: 1. During a review on May 9, 2014 of Resident 11's face sheet and the physician orders, it noted that the resident was admitted on [DATE] and had [DIAGNOSES REDACTED]. Resident 11 was also on hospice services (type of care that focuses in helping a person facing end of life situation to be comfortable). A physician's order dated March 1, 2014 listed a medication order for "[MEDICATION NAME] 250/50 (a medication inhaler that helps with breathing and used for individuals with [MEDICAL CONDITION]) 1 puff BID (twice a day) for [MEDICAL CONDITION]." A review of the hospice physician's progress record dated March 1, 2014 indicated " ...lungs rhonchi to rales (abnormal lung sounds which can indicate there is fluid in the lungs and narrowing of the airway passages) ...2. [MEDICAL CONDITION] continue [MEDICATION NAME] {an inhaler} QID (4 times a day) as needed for wheezing. Add [MEDICATION NAME] BID (twice a day)." The licensed nurses progress notes dated February 24, 2014 through March 1, 2014 noted that Resident 11 was also receiving an antibiotic for cough. A licensed nurses progress note dated March 1, 2014 at 2:15 PM noted that the physician order for [REDACTED]. Licensed nurses progress notes further indicated the following: On March 10, 2014 at 10:30 AM, Resident 11 had "...Coarse crackles (abnormal brief, popping lung sounds which can indicate there is fluid in the lungs) all lung lobes..." On March 17, 2014 at 7:30 PM, there was documentation to indicate that Resident 11's left lung lobes had coarse crackles. On March 25, 2014 at 5:30 PM, "...pt (patient) found to be SOB (short of breath) with labored breathing O2 saturation (O2 sats - oxygen level) of 84% (normal O2 sats typically range from 95%-100%) on RA (room air)..." The hospice physician was notified and ordered an antibiotic medication for an upper respiratory tract infection (URI) and oxygen. On March 25, 2014 at 10 PM, Resident 11 had "...audible crackle sounds noted to bilateral (both sides) upper chest, O2 sating (saturation) 92% via NC (nasal canula - the tubing that is used to provide oxygen) at 3 LPM (liters per minute)..." On March 26, 2014 at 9:50 AM, Resident 11 was using "accessory muscles to breath (the use of other muscles to breath which can indicate there is a sign of labored or abnormal breathing patterns)" and was medicated for pain and shortness of breath and was transferred to the acute hospital due to a "COC (change of condition) and SOB (shortness of breath)." A review of the March 2014, Medication Administration Record [REDACTED]. The [MEDICATION NAME] medication listed in the MAR, which was ordered on March 1, 2014, had no nursing initials to indicate that it had been administered from March 1, 2014 through March 25, 2014 (25 days). An interview was conducted with a Licensed Vocational Nurse (LVN 3) on May 9, 2014 at 10:35 AM and a concurrent review of the clinical records including the MAR for March 2014 and the licensed nurses progress notes was also conducted. LVN 3 confirmed that the [MEDICATION NAME] medication ordered on March 1, 2014 was not administered until March 26, 2014 at 9 AM. She stated, "It looks like it was just caught and they started giving it to (name of Resident 11)." She also confirmed that there was no documented evidence why the medication was not administered as ordered. During an interview with the DON (Director of Nurses) on May 14, 2014 at 8:20 AM and a concurrent review of the MAR for March 2014, licensed nurses progress notes and the physician orders, she confirmed that the medication was not administered until March 26, 2014. She also stated that it had already been identified by the facility as a "med (medication) error." The DON stated that the medication order was missed and was not noted by the licensed nurses because the physician and telephone orders form where the medication order was written, was filed under the physician's progress notes tab when it should have been filed under the physician orders tab. During an interview with LVN 4 on May 14, 2014 at 9 AM, she confirmed that she documented that she acknowledged the medication order on March 1, 2014 at 2:15 PM. She also confirmed that the [MEDICATION NAME] medication was not started and administered as ordered until March 26, 2014 because the medication was never ordered and it was not available. She explained that when she was checking the medication cart during her shift on March 26, 2014, she noticed that there was no [MEDICATION NAME] medication available. LVN 4 stated that when she called the facility's pharmacy and the hospice agency to find out why it was not available, she found out that the order for the medication ([MEDICATION NAME]) was never placed since March 1, 2014 (the day it was initially ordered). She further stated that since Resident 11 was under hospice care, the medication order should have been communicated to the hospice licensed nurse who would have ordered the medication from the pharmacy that serviced the hospice agency. She also confirmed that the [MEDICATION NAME] order was never communicated by the facility licensed nurse to the hospice licensed nurse and that it was a "miscommunication between the facility and hospice." A review of the facility's policy and procedure titled "MEDICATION AND TREATMENT ADMINISTRATION" effective January 2014, it noted under procedure," ...2. Medications and treatments shall be administered as prescribed ..." Due to the facility's failure to carry out the physician's order for [MEDICATION NAME] medication dated March 1, 2014, Resident 11 did not receive the inhaler ([MEDICATION NAME]) for 25 days. This failure could have contributed to Resident 11's episodes of shortness of breath (episode of low oxygen level saturation), presence of crackles in the lungs and the use of the accessory muscles to breathe, that eventually led to Resident 11 being transferred to the general acute care hospital. The facility's failure could have contributed to Resident 11's health and safety being compromised. 2. During a review of the clinical record of Resident B, it was noted that the resident was admitted on [DATE] with the admitting [DIAGNOSES REDACTED]. A review of the clinical lab report, dated May 12, 2014 at 12:57 PM indicated that Resident B's Potassium (K) was low at 2.8 mEq/L (milliequivalents per liter normal range of Potassium is 3.5-5.3 mEq/L). A medication pass observation was conducted on May 13, 2014 at 9:55 AM. A licensed vocational nurse (LVN 2) was observed preparing medications including Potassium liquid oral solution (a mineral which is essential for several body functions; it is given as a supplement when the level of potassium in the blood is low due to disease or effects of other medications), 45 milliliters (three tablespoons) which was equal to 60 MEq, ordered for Resident B. LVN 2 then administered the Potassium solution undiluted (no added water or other liquid) to Resident B, who tasted the medication then refused it and stated, "I can't handle that" pointing to the liquid Potassium. LVN 2 did not follow the manufacturer's guidelines or the medication label, which directed the nurse to dilute the Potassium solution medication (by adding water or other liquid to the medication because if given undiluted, Potassium can cause nausea, vomiting and gastrointestinal distress) before administration. During an interview with LVN 2 on May 13, 2014 at 10:20 AM, he stated, "I just go by the MAR (Medication Administration Record [REDACTED]." When asked about the label on the Potassium bottle reading "dilute before administration," he said he followed what was written on the physician's order and the Medication Record exactly as it is written, not the label (on the medication bottle). During a review of the clinical record for Resident B, the "Medication Administration Record" dated May 12, 2014 noted the following order: "Potassium 60 mEq (milliequivalents) PO (oral) liquid QD (daily) for [DIAGNOSES REDACTED]." During an interview with the Director of Nursing (DON) on May 14, 2014 at 1:10 PM she was asked what her expectation was for the medication nurse regarding Potassium dilution and refusal of the medication by Resident B. She stated, "I would as a nurse call the doctor." The DON further stated she would, "Call Doctor right away" if the Potassium was low. There was no documentated evidence to indicate that Resident B's physician was notified of the refusal of Potassium or the low Potassium level. A review of the manufacturer's guidelines for Potassium Chloride Oral Solution 10%, received from the facility during survey, indicated that directions regarding dilution must be followed to minimize gastrointestinal (stomach-intestinal) irritation, and each tablespoon (15 milliliters) should be diluted with three fluid ounces or more of water or other liquid. LVN 2 attempted to administer three tablespoons to Resident B before the resident refused it. A review of the facility policy and procedure titled "Medication and Treatment Administration" dated January 2014, indicated, "... 16. Before administering medication or treatment, check every medication/treatment against physician's order and transcription in the Medication Administration or Treatment Record. Information on the label of each medication/treatment should match physician's order."

Based on interview and record review, the facility failed to provide sufficient fluid intake to maintain proper hydration and health for one of three sampled residents (Resident A). Additionally, the facility failed to ensure that Resident A was monitored for factors that contributed to dehydration. These failures resulted in the resident being sent to the hospital, on [DATE], where he was diagnosed with [REDACTED]. Resident A did not respond to treatment, was sent home, on [DATE], and expired (dying) at home, about 30 hours after discharge from the hospital. Findings: A review of the medical record for Resident A was conducted on [DATE]. The record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's history and physical, from the acute care hospital, dated [DATE], revealed that Resident A's medical history documented that he suffered from "dehydration" and kidney disease. This medical history was just prior to admission to the skilled nursing facility on [DATE]. The history and physical from the acute care hospital was located in the skilled nursing facility's medical record. A review of the nursing weekly summary, dated [DATE], 2 days after Resident A's admission to the skilled facility and documented by Licensed Vocational Nurse (LVN 1), revealed that the resident was "dehydrated" and had "vomiting". A review of the "Dehydration Potential Assessment", documented by the Director of Nursing (DON) on [DATE], revealed that the resident was not at risk for dehydration. On the form, there was an area for "Awareness Level" (the resident's ability to independently take fluids) that was not filled out. Further review of the form revealed that there was an area for "Predisposing factors to dehydration." The predisposing factors listed, "Prior [DIAGNOSES REDACTED]. This area was marked as 0, meaning no predisposing factors. A review of the MDS (minimum data assessment, a required tool for facilities to perform an assessment for resident care needs), dated [DATE], revealed a section, "Section J", for documenting "Health Conditions". The section had an area for documenting "dehydrated". This area was not checked as applicable for Resident A. A review of the plan of care for the resident, conducted on [DATE], revealed no plan for the prevention of dehydration. A review of Resident A's record, conducted on [DATE], revealed that there was no Intake and Output (I&O) documented for the resident. (I&O is commonly done to give an actual measurement of the resident's fluid status. It is usually done for a resident who is a new admission to determine a baseline fluid status and for residents who have a risk of dehydration, such as a history of dehydration, difficulty swallowing, or a urinary tract infection.) On [DATE], a review was conducted of the certified nursing assistant flow sheet and there was no documentation of the resident's fluid intake noted. On [DATE] a review of the facility's policies titled "Measuring and Recording Intake" and "Measuring and Recording Output", no dates, was conducted. The review revealed that these policies were just instructions on how to physically perform the functions. They had no information on which resident's should have I&O measured. On [DATE] the area in the medical record for Interdisciplinary Team (IDT) notes was reviewed and the review revealed that no assessment was conducted by the team for the resident's hydration status or needs. A review of the nursing notes for the resident's admission, from [DATE] to discharge on [DATE], revealed the following: There was no assessment conducted for the possibility of dehydration, since the resident had a history of [REDACTED]. (An assessment for a resident's hydration status would include looking at areas such as the resident's mucus membranes {lining of areas such as the mouth and nose} skin turgor {pinching the skin to measure the skins ability to return to normal} and a quantitative {number} measurement of urine or the color and characteristic of urine.) On several occasions including [DATE] at 10:30 PM, [DATE] at 10:30 PM, and [DATE] at 2 PM, the nurse documented "encourage fluids"; however, there was no mention of the resident's consumption of fluids. On [DATE] at 10:30 PM, the nurse documented, in the nursing notes, that the resident was started on an antibiotic for a urinary tract infection. On [DATE] at 3:30 AM, the nurse documented, in the nursing notes, that the resident's urine was "dark amber" (Dark urine can mean concentrated urine which can be an indicator of dehydration or infection.); however, there was no further assessment conducted. On [DATE] at 3 PM, RN 1 documented, in the nursing notes, that the resident had difficulty swallowing and a decreased oral intake. There was no mention of an assessment for fluid status or if the resident's decreased oral intake was food, liquids, or both. On [DATE] at 2 AM, the nurse documented, in the nursing notes, that resident A's urine was "dark golden in color"; however, there was no follow up assessment to that statement. On [DATE] at 9:30 AM, the Registered Nurse (RN 1) documented, in the nursing notes, that the resident went to a physician's appointment with his family. It was planned that the resident would have a special intravenous line placed for the administration of [MEDICAL CONDITION] (medication used to [MEDICAL CONDITION]). There was no assessment documented for the AM shift, before Resident A left the facility for an appointment with his physician. Resident A was sent directly to the hospital from his physician's office on [DATE]. A review was conducted, on [DATE], of the medical record for the resident's hospitalization on [DATE] to [DATE]. The review revealed that the patient arrived in the Emergency Department (ED) on [DATE] at 11:36 AM. The resident's blood pressure was ,[DATE] (normal 100 to ,[DATE] to 80) and his heart rate was 121 (normal 60 to 100) beats per minute. (This was a dangerously low blood pressure, with corresponding elevated heart rate, and could lead to death if not treated. A very low blood pressure causes a lack of blood flow to major organs and the heart rate elevates to attempt to compensate.) The ED nursing notes revealed that the resident was sent to the ED by his primary physician. The notes revealed that the resident was jaundice (yellowing of the skin, can occur with [MEDICAL CONDITION], and cause a lack of appetite), had a very low blood pressure, was lethargic(very sleepy), and had no urine output upon placement of a urinary catheter. A review of the ED physician's notes, dated [DATE], revealed that the "clinical impression" was "severe dehydration" and that the resident had acute (sudden onset) kidney failure. The physician's notes also revealed that the patient had jaundice for two to three days. The resident's laboratory values, dated [DATE], were reviewed. The results of the testing were as follows: BUN (blood urea nitrogen, if elevated can reveal dehydration) was 73 (normal ,[DATE] and previously on [DATE] was 34). Creatinine (if elevated can reveal a problem with kidney function) was 2.54 (normal XXX,[DATE].3 and previously on [DATE] was 1.41). White Blood Cell count (if elevated can reveal infection) was 28.0 (normal 4XXX,[DATE].0 and previously on [DATE] was 17.5). Total Bilirubin (related to the resident's jaundice) was 18.8 (normal 0XXX,[DATE].0). A review of the physician's discharge summary, dated [DATE], revealed that the hospital gave the resident intravenous fluids and medications to raise his blood pressure. The physician documented that the resident did not respond to treatment and he was sent home with his family on hospice comfort care. An interview was conducted with the Director of Nursing (DON) on [DATE] at 8:40 AM. She stated that she conducted the dehydration assessment for Resident A on [DATE]. She was asked how she completed the assessment. The DON stated she asked the resident how he was drinking and he stated that sometimes he drank half of his pitcher of water and sometimes all of the pitcher. She stated that she also asked the nurse's aide if the resident's urinary output was ok and the nurse's aide stated that it was ok. The DON stated that she conducted a hydration assessment, on [DATE], of the residents skin turgor and mucus membranes; however, she did not document the assessment. The DON stated that she did not document information regarding the resident's awareness for fluids. She was asked to review the physician's documentation that the patient suffered from dehydration during the hospitalization prior to the facility admission, on [DATE], and she stated that she "missed" the physician's documentation of dehydration. The DON was asked to review the nursing note from [DATE] which included documentation that the resident had vomiting and was dehydrated. She acknowledged the documentation and stated that she was not aware of this documentation when she conducted the dehydration assessment for Resident A. During the same interview, the DON was asked for a facility policy on hydration or prevention of dehydration, and she stated that there was no policy. The DON stated that the facility's policy for I&O did not include many things that should trigger the nurse to place the resident on I&O and that the facility was in the process of developing a new policy for I&O. The DON acknowledged that there was no plan of care developed for the resident's hydration status. She acknowledged that given all the information on hand prior, there should have been. The DON acknowledged that there was no IDT meeting done to assess and plan for the resident's hydration needs. She also acknowledged that the resident did not have I&O done throughout his stay at the facility. She acknowledged that the resident was a new admission, developed a urinary tract infection after admission to the facility, and had a history of [REDACTED]. The DON acknowledged that Resident A was sent to the hospital by his primary physician and arrived in the ED where he was diagnosed with [REDACTED]. An interview was conducted with RN 1 on [DATE] at 9:30 AM. She stated that she did not do an assessment on Resident A prior to him being taken to the physician's office on [DATE]. She stated that she did not assess his hydration status or realize that he had developed jaundice. She stated that the resident's family had made the physician's appointment and that the resident "kind of slipped by them (staff)" that morning. In the same interview, RN 1 was asked about her documentation on [DATE] regarding the resident's difficulty swallowing and decreased oral intake. She reviewed the meal percentages that revealed a fairly steady intake until [DATE], and stated that it might have been the family telling her or that her assessment revealed that he was "sickly" and weak. RN 1 stated that he was having a problem with eating and that a speech evaluation was done. She stated that because of the speech evaluation, the facility changed his diet to a pureed diet (blended diet) because of difficulty swallowing. RN 1 acknowledged that there was documentation by the nursing staff regarding "dark" urine and no follow up assessment on Resident A's hydration status. RN 1 also stated that there should have been another weekly summary (which could include information regarding the resident's hydration status) conducted by the primary nurse a week after the [DATE] summary; however, she acknowledged that it was not done. An interview was conducted with the Certified Nursing Assistant (CNA) CNA 1 who was on duty on [DATE] in the morning. CNA 1 confirmed that she was the CNA assigned to the resident in the morning on [DATE] and she had also been assigned to the resident on other days. She stated that the resident's family was there, at the facility with Resident A, most of the time and that the family provided much of the care. CNA 1 stated that the resident ate with his family many times. She stated that the resident did drink thickened cranberry juice, some of his water, and milk; however, there was no measurement of his intake conducted because he was not placed on I&O. CNA 1 stated that she did not remember the resident looking bad that morning and did not remember his color being yellow. An interview was conducted with LVN 2 on [DATE] 8:15 AM. (LVN 2 was assigned to Resident A on [DATE], in the morning.) LVN 2 stated that she took care of Resident A on the AM shift on [DATE] and that she had cared for him on prior occasions. She stated that she was not aware that the resident was going to a doctor's appointment that morning and that she had only looked in at him. She stated that the family was with him when she saw him in the morning. LVN 2 stated that the resident "seemed normal" and that she did not notice him being unusually jaundice. She stated that she thought that was his normal color. An interview was conducted with the facility's MDS Nurse (the nurse responsible for completion of the MDS assessment) on [DATE] at 10 AM. She stated that she completed the MDS assessment on [DATE], when the resident was first admitted to the skilled facility. She was asked if she reviewed the physician's information from the hospital admission that was available in the medical record. She stated "no" and that may have not been included in the timeframe. The MDS Nurse was asked what she looked at when she completed the area for "Health Conditions" that included documentation for dehydration. The MDS Nurse stated that she looked at the resident and asked him and the nurses if he was drinking all right. The MDS Nurse was asked if she reviewed the nursing documentation from [DATE], where the nurse had documented vomiting and dehydration and she stated that she had not. The MDS Nurse confirmed, after seeing all the information, that the resident did have a history of dehydration. An interview was conducted with a member of the resident's family on [DATE] at 3:30 PM. The family member stated that the resident was admitted to the facility for rehabilitation and that he had become progressively weaker at the facility. The family member stated that he went to the facility in the morning, on [DATE], to pick up the resident to take him to the doctor's office. He stated that the resident was extremely weak and that he had to dress him and lift him up to place him in the wheel chair by himself. He stated that there was no one from the facility that came into the room to assess the resident or to help get him ready to go to the doctor's office. The family member stated that the resident had developed jaundice about 4 days prior. He stated that the yellowing had started with his eyes and progressed to his skin. He stated that no one in the facility had talked with the family regarding the jaundice. The family member stated that the staff did not "check in" very often, to see how the resident was doing when he was with him. In the same interview, the family member stated that the resident was having difficulty swallowing and required a swallowing evaluation. He stated that the resident wasn't eating very well and was not able to drink the water because it was like pudding (thickened water). He stated that the resident was thirsty and wanted to drink, but could not drink the thick water. The family member was asked if the facility spoke to the family regarding his ability to drink the thickened water and if a plan was developed, and he stated "no". He stated that when the resident did not eat, the staff would just take the tray away and did not "do anything to help." The family member stated that on [DATE], he took the resident to the doctor's office and that the doctor took his blood pressure and sent him to the hospital. He stated that the resident never really got better after being so sick when he was admitted to the hospital on [DATE]. The family member stated that the resident was sent home from the hospital on [DATE] and that he died at home about 30 hours later.