Every finding on record at St John Kronstadt Convalescent Center

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when:1. (a) a stainless-steel pasta tong was dirty and was in poor condition. (b) two handheld can opener had rust and metal fragments on the blade and surrounding parts.2. water pitcher with thickened liquid was left at Resident 25's bedside for more than 24 hours.These failures had the potential to cause food contamination and food borne illness. 1. During the initial tour of the kitchen and concurrent interview on 11 at 9/18/25 at 9:44 a.m. with the Food and Nutrition Services Manager (FNSM), the following items were stored in the clean kitchenware storage drawer: (a) a stainless-steel tong had sticky white debris and rubber tip that holds food was ripped in half; (b) two handheld can openers with red-orange debris and metal fragments on its blades. The DM acknowledged the tong was dirty and two can openers were rusty. DM, stated these utensils should have not been stored because rusty and dirty utensils can contaminate food served to residents and can cause foodborne illness. DM then discarded all three kitchenware. During an interview on 11/19/25 at 10:59 a.m. with the Registered Dietitian (RD), RD stated, she did not know what the implications of rusty can opener to health and safety of residents. RD added, staff should not use rusty can openers due to potential for rust fragments to get into food and contaminate food that was served to the residents. A review of the Food and Drug Administration (FDA) Food Code 2022, under 4-204.19 Can Openers on Vending Machines, indicated, Since the cutting or piercing surfaces of a can opener directly contact food in the container being opened, these surfaces must be protected from contamination. 2. A review of Resident 25's admission Record indicated that resident was admitted to the facility in 2020 with diagnoses that included dementia (memory loss). A review of Resident 25's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 10/7/25, indicated Resident 25 had severely impaired cognition. The MDS also indicated Resident 25 was totally dependent (helper does all the effort) on all activities of daily living (ADLs), including eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident).A review of Resident 25's Physician Order Report, dated 11/01/25-11/30/25, indicated diet order date 10/13/25, Provide fortified diet, puree texture.mildly thick liquid. During an observation on 11/18/25, at 10:44 a.m., inside Resident 25's shared room, there were two water pitchers on top of Resident 25's nightstand. The blue-colored water pitcher was dated 11/17/25, pink-colored pitcher dated 11/18/25, and both pitchers contained thick-consistency liquid. During a concurrent observation and interview on 11/18/25, at 10:53 a.m., with the Infection Preventionist (IP), IP stated there were two color-coded water pitchers with thickened water (water of sticky consistency to help people with swallowing difficulties) on top of Resident 25's nightstand. IP stated the blue water pitcher was dated 11/17/25 and the pink water pitcher, 11/18/25. IP further added thickened water was good for 24 hours and should be removed from the resident's room once the new water pitcher has been delivered by night shift. IP also stated that old, thickened water had the potential for bacterial growth past 24 hours. During an interview on 11/20/25, at 2:14 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated night shift started at 11 p.m. and ended at 7 a.m. CNA 2 stated night shift should have removed the old water pitcher when the new water pitcher was delivered. CNA 2 also stated that the old, thickened water should not be offered to the resident because of risk of infection. CNA 2 stated he got busy and could not remove old water pitcher from the resident's room. A review of the facility's policy and procedure (P&P), titled Nutrition Care, dated 2023, indicated, Thickened foods and liquids are provided to residents with swallowing disorders to ensure a safe consistency for adequate nutrition and hydration to decrease the probability of aspiration.Thickened water and juices may be kept at bedside for up to 24 hours without danger of harmful bacterial growth.

Based on observation, interview and record review, the facility failed to ensure 2 out t of 2 residents did not have prefilled medication cups with ointment left at the bedside, expired medications were not available for use, best by date was printed on a medication box, internal and external medications were separated when in the same drawer, compromised medication bubble packs were returned to the pharmacy, and glucose monitoring device was separated from internal medications. The deficient practice had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date or best by date and medications with different routes of administration were not separated in accordance with facility policy and procedure (P&P). 9. A review of Resident 25's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 10/7/25, indicated Resident 25 was admitted to the facility in 2020, had diagnoses that included dementia (memory loss), and had severely impaired cognition. The MDS also indicated Resident 25 was totally dependent (helper does all the effort) on all activities of daily living (ADLs) with two or more-person assistance. A review of Resident 25's Physician Order Report, dated 11/01/25-11/30/25, indicated treatment order date 9/29/25, Apply Triad (hydrophilic paste used to help maintain a moist wound healing environment) to moisture-associated skin damage (MASD) to scrotum and scattered redness to bilateral groin until healed. During an observation on 11/18/25, at 10:44 a.m., inside Resident 25's shared room, there were two undated, unlabeled, pre-filled disposable plastic medication (med) cups, each with approximately two inch-sized (squeezed out from a tube) white paste/cream, left at Resident 25's nightstand. During a concurrent observation and interview on 11/18/25, at 10:53 a.m., with the Infection Preventionist (IP), IP stated the two unlabeled and undated med cups with white ointment on top of Resident 25's nightstand was for the resident's bottom. IP stated leaving the ointment at bedside was a potential hazard for a confused resident to take the ointment and put it in the mouth. IP further added the ointment should have been prepared and applied immediately to Resident 25's skin and not left unattended on the nightstand. During an interview on 11/20/25, at 2:14 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated he had requested the Triad ointment in the med cups from the Charge Nurse, but CNA 2 became pre-occupied with another resident and was unable to apply ointment on Resident 25. Charge Nurse/Registered Nurse 1 (RN 1) was unavailable for interview. A review of the facility's policy and procedure (P&P), titled Medication Administration General Guidelines, dated 2007, indicated, .Medications are to be administered at the time they are prepared. The person who prepares the dose for administration is the person who administers the dose. During a concurrent observation and interview, on 11/17/25 at 10:00 a.m. with Director of Nursing (DON) in Medication Storage room [ROOM NUMBER], the following were identified: 3 bottles of Vitamin B-12 (a crucial water-soluble vitamin for healthy nerve and blood cells, DNA production, and energy metabolism) were expired, dated 1/25, 5/25, 7/25 , and 1 opened box Veltassa (treat high levels of potassium in the blood in adults and pediatric patients) had no best by date on box. The DON confirmed the findings and stated the expired medications should have been thrown away on Saturday when the medication storage room was scheduled to be organized. DON confirmed the findings and stated all medications should have a best by date completed on the label, so the drugs full potency and safety are known before administering to residents. During an observation and interview on 11/18/2025 at 2:04 PM, with Medication Nurse, Registered Nurse 2 (RN 2) on station 2 medication cart, the following were identified: hearing aid cleaner stored was with 2 brown bags of nitroglycerine (to treat or prevent acute attacks of angina (chest pain) tabs 0.4 mg sublingual, Hyoscyamine used to treat conditions involving muscle spasms and excessive secretions in the gastrointestinal (GI) and urinary tracts) sublingual 0.125 mg expired 8/1/25, Linzess (treat chronic constipation) capsule, and Eliquis (blood thinner- used to prevent and treat blood clots) 2.5.mg, Calcium 600 mg + D 10 mg, and Fersol 25 mg had no date container was open Anoro had no date container opened printed on the container. The Anoro container label indicated discard after 6 weeks. RN 2 stated she did not know when the 6 weeks would end and the medication should have been thrown away. Amlodipine Besylate 10 mg section 1 in bubble pack had foil seal compromised (torn), Methocarbamol 500 mg tab section # 15 and # 16 in bubble pack had foil sealed broken, Omeprazole DR 20 mg capsule section #8 of bubble pack had foil seal broken. One drawer contained 15 oz Metamucil container, 2 bottles of Uni Stat 30 fluid oz, pain relief patch, retention tape, and hydrocortisone cream 1% items. Another drawer contained Ketoconazole shampoo in drawer with Assure blood sugar monitor and glargine. Drawers with internal, external medications and glucose monitoring device were not separated by dividers. RN 2 confirmed the findings and stated internal and external medications and glucose monitoring device should not be mixed together, but stored separately. RN 2 stated expired medications should be discarded when found. RN2 stated once a medication is opened, you need to print the date open on the label because some medications may break down and lose potency. RN 2 stated when a medication blister pack has been compromised ( opened by mistake) the pharmacy is notified for replacement. During an interview with the DON on 11/19/25 at 2:02 p.m., the DON stated nursing staff were expected prior to administration of a medication to ensure the medications had an open date on the container. Nurses should audit weekly for expired medications and destroy expired medications. If the medication is not destroyed, the medication is given to the DON and logged in the pharmacy logbook for disposition. The DON stated the medication room is organized weekly on Saturdays, and the Medication carts are to be cleaned and organized weekly on Sunday. She stated the expired medications should have been thrown out. Medications administered through different routes should have been separated. DON stated the pharmacy should have been notified about the compromised blister packs. She stated that if the medication blister pack foil is broken, they usually call the pharmacy for a replacement. During a review of the facility policy and procedure titled Medication Administration dated 2007, the policy indicated : The nurse shall place a date open sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. During review facility policy titled Storage of Medication dated 2007 indicated Medications should be stored so that various routes of administration are separated. Internally administered medications are stored separately from medications used externally such as lotions, creams, ointments and suppositories. Potentially harmful substances (such as cleaning supplies, disinfectants) are clearly identified and stored in an area separate from medications. Outdated, discontinued or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy. The medication storage and preparation areas should be kept clean , well lit, organized and free from clutter. Discontinued, outdated, or deteriorated medications drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interview and record review, the facility failed to: Ensure three of three sampled residents' (Residents 5, 6 and 9) Medication Regimen Review ([MRR]- a review of medications to identify problems/errors) was completed monthly. This deficient practice placed Residents 5, 6 and 9 at risk of not having medication irregularities identified.1. During a review of Resident 5's admission Record printed on 11/20/25, admission Record indicated Resident 5 was admitted to the facility on [DATE].During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/19/25, indicated Resident 5 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) Score of 10/15. Meaning Resident 5's mental cognition was moderately impaired. The MDS revealed Resident 5 had multiple diagnoses that included Depression (feeling of worry, fear, or dread), Bipolar Disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and Schizophrenia (a mental illness that is characterized by disturbances in thought). The MDS also showed, Resident 5 received antipsychotic (medications that help control symptoms of serious mental health conditions) and antidepressant (a prescription medication that help improve mood).During a review of Resident 5's Physician Order Report (POR) dated 11/1/25 - 11/30/25, order start date 2/26/25, indicated Resident 5 had the following medication orders (a) Invega Sustenna (paliperidone palmitate - an antipsychotic medication) 156mg/mL (milligram per milliliter) Give 1mL intramuscular, Once A Day on the 14th of the Month. Special Instructions: For schizophrenia manifested by episodes of yelling and screaming, (b) Depakote (divalproex - and mood stabilizer) tablet delayed release. 500mg 1 tablet oral Special Instructions: For bipolar disorder manifested by episodes of agitation. (c) Lexapro (escitalopram oxalate - antidepressant) tablet; 20 mg oral Special Instructions: For depression manifested by verbalization of sadness.During a concurrent interview and review of the facility's MRR binder, on 11/20/25 at 1:54 p.m. with the DON, the MRR dated April 2025 through November 2025 revealed, Resident 5 did not have an MRR documented for the months of April through November.2. During a review of Resident 6's admission Record printed on 11/20/25, admission Record indicated Resident 6 was admitted to the facility on [DATE].During a review of Resident 6's MDS dated [DATE] indicated Resident 6 had a BIMS score of 7/15. Meaning Resident 6's cognition was severely impaired. MDS revealed Resident 6 had multiple diagnoses that included, Anxiety disorder (feeling of worry, fear, or dread), Depression and Psychotic disorder (mental health condition that causes a person to have a loss of contact with reality). The MDS also showed, Resident 6 received antipsychotic medication.During a review of Resident 6's POR dated 11/1/25 - 11/20/25, order start date 8/28/25 indicated Resident 6 had medication orders for the following (a) Seroquel (quetiapine - an antipsychotic medication) tablet oral Special Instructions: for Anxiety. (b) Seroquel tablet 25mg 1 and 1/2 (total 37.5) Special Instructions: for Anxiety manifested by episode at night of seeing and hearing people, that are invisible to staff, fearful f being alone resulting in inability to sleep related to fears.During a concurrent interview and review of the facility's MRR binder, on 11/20/25 at 1:54 p.m. with the DON, the MRR dated June 2025 through November 2025 revealed, Resident 6 did not have an MRR documented for the months of June, July, August, October and November.3. During a review of Resident 9's admission Record printed on 11/20/25, admission record indicated Resident 9 was admitted to the facility on [DATE].During a review of Resident 9's MDS dated [DATE], MDS indicated Resident 9 had a BIMS score of 12/15. Meaning Resident 9's mental cognition was moderately impaired. MDS revealed Resident 9 had multiple diagnoses that included Anxiety and Depression. MDS showed, Resident 9 received antidepressant medications.During a review of Resident 9's POR dated 11/1/25 - 11/20/25, order start date 10/24/25 indicated Resident 9 had medication order for duloxetine (antidepressant) capsule delayed release; 60mg and 30mg (total of 90mg) in the morning for depression manifested by crying.During a concurrent interview and review of the facility's MRR binder, on 11/20/25 at 1:54 p.m. with the DON, the MRR dated April 2025 through November 2025, revealed Resident 9 did not have an MRR documented for the months of May, June and August through November. During a telephone interview on 11/20/25 at 2:28 p.m. with the Pharmacy Consultant (PC), PC stated, the medication regimen review was not done monthly for each resident. PC added, per facility policy, regimen review was done for residents that were on psychotropic medications (drugs that affect the brain to help manage mental health conditions like depression, anxiety, and schizophrenia) are only done quarterly.During an interview on 11/20/25 at 3:51 p.m. with the DON, DON confirmed Residents 5, 6, and 9 did not consistently have monthly medication regiment review done by the PC. DON added, because the MMR was not done monthly, there was risk for Residents 5, 6 and 9 for not being monitored for efficacy of their antipsychotic medications.During a follow up interview on 11/20/25 at 3:56 p.m. with the DON, DON stated, the MRR should have been done monthly for Residents 5, 6 and 9 according to federal regulations and per facility policy.During a review of the facility's policy and procedure (P&P) titled, MEDICATION REGIMEN REVIEW AND REPORTING, dated January 2024, the P&P indicated Medication Regimen Review (MRR) or Drug Regimen Review is a through evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The P&P also indicated under PROCEDURES .2. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated.

Based on observation, interview and record review, the facility failed to ensure the census and direct care service hours per patient day (DHPPD) posting was complete and was not missing information. This failure resulted in the actual direct care service hours and DHPPD not readily available to residents and visitors at any given time. During an interview and observation with the Director of Nursing (DON) on 11/21/25 at 12 noon of the posted DHPPD. The DON stated the DHPPD forms are posted daily outside of nursing station 1. The information is posted by the night shift nurse in charge and updated by the dayshift DON or charge nurse. It was noted the 11/21/25 actual direct care service hours and DHPPD were not completed. The DHPPD form dated 11/21/25 did not show the daily census changes for 8:00 a.m., actual care service hours, average patient census, the actual DHPPD, the actual total Certified Nursing Assistant (CNA) direct, care services hours and actual CNA DHPPD. The Director of Nursing had signed the form indicating she had reviewed the patient census and direct care services hours information and acknowledged the information was true and correct. During an interview on 11/21/25 at 12:30 p.m. with the Medical Records Director (MRD), the MRD stated she had not completed the section for the actual care service hours, average patient census, the actual DHPPD, the actual total Certified Nursing Assistant (CNA) direct. The MRD stated the care service hours and actual CNA DHPPD information for each 24-hour patient day had not been completed since September 2025. During an interview on 11/19/25 with Resident 32, Resident 32 stated he did not feel the nursing care was rushed and he only had to wait a few minutes before someone answered his call light. During a record review of Resident 32's admission face sheet indicated the resident was admitted on [DATE] with a diagnosis of congestive heart failure ( CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and atherosclerotic heart disease (caused by plaque buildup in arterial walls and refers to conditions that include: conditions such as myocardial infarction, angina, and coronary artery stenosis). During a review of the Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 08/19/25 for resident 32 indicated the BIMS score was 15/15. A score of 15 indicates intact cognitive response. During an interview on 11/19/25 with Resident 36, Resident 36 stated they had not observed any delay in the staff responding to the call light and stated there was adequate staff to assist with requests. During a record review Resident 36's admission face sheet indicated the resident was admitted on [DATE] with a diagnosis of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of the Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 09/03/25 for Resident 36 indicated the BIMS score was 15/15. A score of 15 indicates intact cognitive response. During an interview on 11/19/25 with Resident 15 , Resident 15 stated there was no issue with the staff responding to his call light or delay in the staff responding to the call light. Resident 15 stated the staff did not appear to be limited on time and did not rush to get task completed. During a record review the resident admission face sheet indicated Resident 15 was admitted on [DATE] with a diagnosis of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of the Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 11/11/25 for Resident 15 indicated the BIMS score was 15/15. A score of 15 indicates intact cognitive response. During a review of the census and direct care services hours per patient day (DHPPD) document dated September 2025 through November 2025, the DHPPD document indicated the actual care service hours, average patient census, the actual DHPPD, the actual total Certified Nursing Assistant (CNA) direct was not completed. The document indicated the actual direct care service hours and DHPPD section must be completed at the end of each 24-hour patient day.During a review of the Federal regulation titled Nurse Staffing Information 483.35(i)(1)(iii)(a)(b)(c)(iv) dated 4/25/25, the regulation indicated the facility must post the following information on a daily basis: (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses, (B) Licensed practical nurses or licensed vocational nurses, (C) Certified nurse aides and (iv) Resident census.

Based on observation, interview, and record review, the facility failed to ensure the physician was notified that one of four sampled residents (Resident 1) had been refusing his medications for two weeks. The failure to notify the physician had the potential to delay effective treatment for the resident, allow the physician to prescribe alternative pain management and adjust the plan of care.During an observation on 11/20/25 at 9:00 a.m., Resident 1 was awake, alert, oriented and sitting on the side of his bed. RN 1 asked Resident 1 if he wanted the 4% Lidocaine patch, (a type of topical anesthetic used for temporary pain relief by numbing the area where they are applied). The resident stated the Lidocaine patch was being refused.During a review of Resident 1's Resident admission sheet, the Residents admission Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis that included pneumonia (an infection/inflammation in the lungs), acute bronchitis (inflammation of the bronchial tubes) and Rhinovirus ( viral infectious agent).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care dated 9/23,25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's mental status in regard to attention, orientation , ability to register and recall information) score of 15 ( A BIMS score of 15 out of 15 indicate intact cognition). During an interview on 11/20/25 at 1:00 p.m. with License Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had refused the Lidocaine patch for 2 weeks and the physician was not notified. RN 4 stated the physician should have been notified when the resident initially refused. LVN 1 stated not notifying the physician does not allow the physician to evaluate the reason for the refusal or adjust the resident's treatment.During a record review of Resident 1's Medication Administration Record (MAR) dated 11/01/25 through 11/20/2025, the MAR indicated Resident 1 was to receive Lidocaine adhesive patch 4% topical to right lower back, on for 12 hours and off for 12 hours. Lidocaine patch on at 9:00 am and off at 9:00 p.m. The MAR dated 11/2/25 through 11/20/25 indicated the Lidocaine patch was not administered 26 times out of 26 scheduled times. The resident refused the Lidocaine patch 23 times out of 26 scheduled times. The MAR indicated 3/26 times the refusal was due to condition.During a record review of the facilities policy and procedure (P&P) titled, Medication Administration General Guidelines dated 01/24, the policy and procedure indicated If two consecutive doses of a vital medication are withheld or refused, the physician is notified.

Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 27, 39, 5 and 9), received care when following was noted:1. Resident 27 had overgrown and dirty fingernails in both hands.2. Resident 39 had overgrown and dirty fingernails in both hands.3. Resident 5 had long and dirty fingernails in both hands.4. Resident 9 had long and overgrown dirty fingernails in both hands. 1. During a review of Resident 27's face sheet, undated, indicated Resident 27 was admitted to the facility on [DATE] with multiple diagnoses that included, Parkinson's disease (progressive brain disorder that affects movement and balance) and Type 2 Diabetes Mellitus (DM -when body does not use insulin properly, which can weaken immune system placing a person at high risk for respiratory infections like pneumonia). During a review of Resident 27's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated, 10/27/25, indicated Resident 27 had a Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 4. Meaning, Resident 27 had severe cognitive impairment. The MDS revealed Resident 27 required substantial/maximal assistance with personal hygiene. During a review of Resident 27's care plan (CP - individualized guide developed to outline a person's health needs, goals and steps to achieve them), dated 11/3/25, indicated Resident 27's problem included decline in functional ADL (Activities of Daily Living) including personal hygiene. CP also showed Resident 27 required substantial to dependent assistance with ADL care and one of the approaches was for staff to provide assistance with ADLs as indicated. During a concurrent observation and interview on 11/18/25 at 10:31 a.m. in Resident 27's room with Certified Nursing Assistant (CNA) 4, CNA 4 agreed Resident 27 had dirty and long fingernails. CNA 4 added, regardless of medical condition, Resident 27's fingernails should be cleaned. 2. During a review of Resident 39's face sheet, undated, indicated Resident 39 was admitted to the facility on [DATE] with multiple diagnoses that included Cerebrovascular Disease (CVA- stroke). During a review of Resident 39's MDS dated [DATE], MDS indicated, Resident 39 had a BIMS score of 6, meaning Resident 39 had severe cognitive impairment. MDS revealed, Resident 39 required substantial/maximal assistance with personal hygiene. During a review of Resident 39's CP, dated 9/30/25, indicated Resident 39's problem included decline in functional ADL including personal hygiene. CP also showed Resident 39 required substantial maximum to total dependence assistance with ADL care and one of the approaches were for staff to provide assistance with ADLs as indicated. During a concurrent observation and interview on 11/18/25 at 10:33 a.m., CNA 3 was observed assisting Resident 39 with the transfer from bed to wheelchair. Resident 39 had black and brown matter underneath overgrown fingernails. CNA 3 acknowledged Resident 39's fingernails was long and dirty. CNA 3 stated, it looked like Resident 39 has not had her nails trimmed for a long time. 3. During a review of Resident 5's face sheet, undated, indicated Resident 5 was admitted to the facility on [DATE] with multiple diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 5's MDS dated [DATE], indicated Resident 5 had a BIMS score of 10, meaning Resident 5 had moderate cognitive impairment. MDS revealed Resident 5 required substantial/maximal assistance with personal hygiene. During a review of Resident 5's CP, dated 11/17/25, indicated Resident 5's problem included decline in functional ADL including personal hygiene. CP also showed Resident 39 required partial to substantial assistance with ADL care and one of the approaches was for staff to provide assistance with ADLs as indicated. During a concurrent observation and interview on 11/18/25 at 10:36 a.m., with Resident 5, Resident fingernails were overgrown and dirty with black matter underneath in both hands. Resident 5 stated, CNA 1 did not offer to clean his fingernails. Resident 5 added, he preferred to keep fingernails cleaned. 4. During a review of Resident 9's face sheet, undated, indicated Resident 9 was admitted to the facility on [DATE] with multiple diagnoses that included, Type 2 DM and Systemic lupus erythematosus (SLE-a chronic autoimmune disease where the immune system mistakenly attacks the body's own healthy tissues, causing inflammation and damage in multiple organs including the skin). During a review of Resident 9's MDS dated [DATE], MDS indicated, Resident 9 had a BIMS score of 12, meaning Resident 9 had moderate cognitive impairment. MDS revealed, Resident 9 required substantial/maximal assistance with personal hygiene. During a review of Resident 9's CP, dated 10/28/25, indicated Resident 9's problem included decline in functional ADL including personal hygiene. CP also showed Resident 9 required substantial to total assist with ADL care and one of the approaches was for staff to provide assistance with ADLs as indicated.During a concurrent observation and interview on 11/18/25 at 10:43 a.m., with Resident 9, Resident 9 had long overgrown with black matter underneath fingernails. Resident 9 stated, CNA 1 did not check her nails and did not offer to clean her nails whenever he was assigned to her. Resident 9 added she wanted her nails shorter and clean. During an interview on 11/18/25 at 11:06 a.m. with CNA 1, CNA 1 stated he did not check Resident 5 and Resident 9's nails during ADL care this morning. CNA 1 added, he was not the only one responsible for cleaning Resident 5 and Resident 9's nails. CNA 1 further stated, morning shift was busy so he did not have time to check resident nails. During an interview on 11/18/2025 at 2:40 p.m. w/ Infection Preventionist (IP), IP stated, direct care staff was responsible for ensuring nailcare was provided daily to Residents 5, 9, 27 and 39. IP added, overgrown nails can accumulate dirt and spread infection. IP also stated, it was important to keep fingernails trimmed and clean to prevent spread of infection. During a review of facility's policy and procedure (P&P) titled, GROOMING CARE OF THE FINGERNAILS AND TOENAILS, undated, the P&P indicated, Nail care is given to clean the nail bed and keep the nail trimmed. The P&P also indicated under Policy, I. Fingernails are trimmed by Certified Nursing Assistants (CNA's), except for residents with diabetes or circulatory impairments, this includes all toenails except for high-risk residents. Note: A licensed nurse will trim high-risk resident's nails.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 7) had a completed Pre-admission Screening and Resident Review (PASRR, a federal requirement to screen individuals for mental illness, intellectual disability, or related conditions to determine if the resident required specialized services) assessment when resident was newly diagnosed with schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).This failure resulted in the facility to not notify the State Mental Health Authority and caused Resident 7 to not receive an in-depth mental health evaluation and care appropriate to his needs. A review of Resident 7's admission Record, printed on 11/24/25, indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss), schizophrenia, and depression.A review of Resident 7's PASRR Screening, dated 11/1/21, indicated resident had a Level I Screening conducted in the facility on the 11/1/21, followed by a Level II Evaluation on 12/10/21. The facility received the results of the Level II Evaluation in the Determination Report, dated 12/15/21.A review of Resident 7's Comprehensive Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 6/6/22, indicated resident did not have a diagnosis of schizophrenia. A review of Resident 7's Physician Orders, dated 6/14/22, indicated an order of Perphenazine 4 milligrams (mg) by mouth three times a day starting on 6/20/22 for schizoaffective disorder.A review of Resident 7's medical records indicated Resident 7 did not have a new PASRR Screening after resident was diagnosed with schizophrenia/schizoaffective disorder later in 2022. Facility was unable to provide documentation to show the exact date when the physician had officially added Resident 7's new diagnosis of schizophrenia.A review of Resident 7's History and Physical, dated 10/18/23, indicated resident was with schizoaffective disorder (a mental health condition that combines symptoms of both schizophrenia (like hallucinations [seeing, feeling, or hearing things that are not there] and delusions [holding on to false beliefs]) and a mood disorder (such as bipolar disorder [high energy, racing thoughts, and risky behavior] or depression).During a concurrent interview and record review on 11/20/25, at 11:20 a.m., with the Minimum Data Set Coordinator (MDSC), a review of Resident 7's Quarterly MDS, dated [DATE], indicated the resident had diagnosis of schizophrenia. MDSC stated this Quarterly MDS was Resident 7's very first MDS Assessment that showed resident had a new diagnosis of schizophrenia since the new physician order of Perphenazine was ordered for resident's schizoaffective disorder.During a concurrent interview and record review on 11/20/25, at 12:52 p.m., with the Administrator (ADM), Resident 7's electronic clinical records were noted without a new PASRR Screening. The ADM stated there should have been a new PASRR Screening initiated when a more sufficient diagnosis of schizophrenia was added to resident's list of health illnesses. The ADM stated State Mental Health Authority should have been informed so that a more detailed assessment for Resident 7's appropriate mental illness services was provided.

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of two sampled residents (Resident 25) with right hand contracture and use of palm protector.This failure resulted in the lack of information regarding care and had potential to result in unmet care needs for Resident 25. A review of Resident 25's admission Record indicated resident was admitted to the facility in 2020 with diagnoses of dementia (memory loss) and dysthymic disorder (chronic depression).A review of Resident 25's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 10/7/25, indicated Resident 25 was rarely/never able to make self-understood, rarely/never had the ability to understand others, and had severely impaired cognition. The MDS also indicated Resident 25 was dependent (helper does all the effort) on all activities of daily living (ADLs), with two or more-person assistance.A review of Resident 25's Physician Order Report, dated 11/01/25-11/30/25, indicated an order date 9/2/25, for Restorative Nursing Assistant (RNA) to apply resident's right palm protector to prevent contracture and maintain skin integrity daily for four hours during the day when up in the wheelchair.A review of Resident 25's Care Plan, titled Mobility and Safety, created date 11/18/25, indicated a goal that resident will maintain range of motion to right hand.During a concurrent interview and record review on 11/20/25, at 9:39 a.m., with the Director of Nursing (DON), Resident 25's clinical records showed there was no care plan developed for resident's right-hand contracture and/or use of right-hand palm protector. DON stated the care plan should have been created in a timely manner. DON also confirmed there was no order for range of motion (ROM) exercises to at least the right hand and upper extremities other than for the Certified Nursing Assistant (CNA) and/or RNA to do exercises during provisions of resident care during ADLs. A review of the facility's policy and procedure, titled Care Plans, undated, indicated, The resident care plan is the vehicle employed by the interdisciplinary team from achieving desirable resident outcomes.It addresses the actual and potential physical, environmental, and psychosocial needs and problems identified by the interdisciplinary team.The care plan identifies the individual needs and problems of the resident, states the resident's goal in measurable terms, and documents realistic approaches.A comprehensive resident care plan will be completed within seven days after the conclusion of the resident's assessment process.The care plan will be reviewed and revised as necessary to reflect the changes in the resident's status. Any professional who recognizes the need for changing the care plan will initiate the change.

Based on observation, interview, and record review, for two of two sampled residents (Resident 25 and Resident 11), Certified Nursing Assistant 1 (CNA 1) failed to implement infection prevention and control practice when CNA 1 did not perform hand hygiene in between feeding residents in the Community Room (back dining room). This deficient practice had the potential to result in the spread of infection. A review of Resident 25's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 10/7/25, indicated Resident 25 was admitted to the facility in 2020 with diagnoses that included dementia (memory loss) and had severely impaired cognition. The MDS also indicated Resident 25 was totally dependent (helper does all the effort) on all activities of daily living (ADLs), including eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident).A review of Resident 11's MDS assessment, dated 9/30/25, indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a brain condition that causes a progressive decline in memory, thinking, learning, and organizing skills) and had severely impaired cognition. The MDS also indicated Resident 11 was totally dependent on all ADLs, including eating.During lunch dining observation on 11/18/25, at 12:55 p.m., in the back dining room, CNA 1 was seated next to Resident 25 and assisted resident with feeding. Resident 25 was up in his wheelchair, observed with eyes closed in between feedings, and after a few spoonsful of food, the resident refused to take any more feeding from CNA 1. CNA 1 stood up and walked towards the door where Resident 11 was situated. Resident 11 was up in her wheelchair and quietly waited for a staff member to feed her. Without performing hand hygiene, CNA 1 picked up the spoon from Resident 11's plate and began assisting feeding the resident. During an interview on 11/18/25, at 1 p.m., with CNA 1, in the hallway outside the dining room, CNA 1 stated he should have sanitized his hands in between feedings. He stated he forgot to do hand hygiene when he left Resident 25 to assist Resident 11 with her lunch tray. CNA 1 stated it was important to sanitize and/or wash hands in between feeding residents to minimize the spread of infection. During an interview on 11/18/25, at 2:06 p.m., with the Infection Preventionist (IP), IP stated Certified Nursing Assistants (CNAs), Licensed Nurses (LNs), and other staff members qualified to assist in feeding the residents should perform hand hygiene before assisting the residents to minimize spread of infection. A review of the facility's policy and procedure (P&P), titled Infection Control, undated, indicated, .Standard precautions are work practices required for the basic level of infection control. They include good hygiene practices, particularly washing and drying hands before and after patient contact.Wash hands immediately after gloves are removed, between patient contacts and when otherwise indicated avoid transfer of microorganisms to other patients or environments.A review of the facility's P&P, titled Procedure for Using Alcohol-Based Hand Rub, untitled, indicated, .When to Use Alcohol- Based Hand Rub - after contact with residents intact skin.After contact with inanimate objects.

Based on interview and record review, the facility failed to provide pneumococcal immunization for one of five sampled residents, when Resident 27 was not offered the pneumococcal immunization.This failure had the potential to not protect Resident 27 against serious illnesses like pneumonia (lung infection).During a review of Resident 27's face sheet, printed on 11/18/25, revealed Resident 27 was admitted to the facility on [DATE] with multiple diagnoses that included, Parkinson's disease (progressive brain disorder that affects movement and balance) and Type 2 Diabetes Mellitus (DM -when body does not use insulin properly, which can weaken immune system placing a person at high risk for respiratory infections like pneumonia).During a concurrent interview and record review on 11/18/25 at 2:10 p.m. with the Infection Preventionist (IP), Resident 27's vaccination record revealed, Resident 27 was administered pneumococcal vaccine on 11/9/17. IP stated, Resident 27 was due for revaccination in 2022, but she forgot to offer the pneumococcal vaccine to Resident 27. IP added, the risk to Resident 27 for not receiving pneumococcal vaccine was potential for exposure to respiratory infection. IP further added, Resident 27 was susceptible and at risk for any type of infection due to multiple co-occurring health conditions. During a review of facility provided immunization RESIDENT ROSTER, dated 11/18/25, revealed Resident 27 received pneumococcal vaccine (PCV 13) on 11/9/17. During a review of facility's policy and procedure (P&P) titled, RESIDENT IMMUNIZATION PROGRAM, dated 10/1/22 indicated, Residents will be immunized against vaccine preventable diseases that may be encountered in this facility. These vaccinations will be provided to residents at admission unless over-ridden by the resident's physician, medically, contraindicated, or if refused by the resident or his/her surrogate decision maker. The P&P also indicated under IMMUNIZATION SCHEDULE, the Pneumococcal Polysaccharide PPV23 was recommended for individuals [AGE] years old and above. Furthermore, schedule for routine and catch-up administration revealed, One time revaccination is recommended after 5 years for people at highest risk of fatal pneumococcal infection or rapid antibody loss and for people over [AGE] years old if the first dose was given prior to age [AGE] and more than 5 years has elapsed since previous dose. Review of the Center for Disease Control and Prevention's (CDC) Vaccine Information Statement, dated 5/29/25, provided to the surveyor by the facility, indicated Pneumococcal Conjugate Vaccine: What You Need to Know. Pneumococcal conjugate vaccine can prevent pneumococcal disease. Pneumococcal disease refers to any illness caused by pneumococcal bacteria. PCV was recommended for adults 50 years or older who have not previously received PCV should receive a PCV vaccine. Some adults in this group who have already received PCV might be recommended to receive another dose.

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet for each resident for one of 23 rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents.During a concurrent observation and interview on 11/18/25 at 10:33 a.m. Certified Nursing Assistant (CNA) 3 and CNA 1 was seen transferring Resident 39 from bed to wheelchair using a Hoyer Lift (a mechanical device used to lift and/or transfer a person from place to place). CNA 3 stated, there was plenty of space in Resident 16's room even when using Hoyer lift for transfer. There was no negative outcome in the delivery of nursing care and services. During a record review on 11/21/25 of the Client Accommodations Analysis (undated), the following Resident room was identified having below the required 80 square feet requirement per resident: room [ROOM NUMBER] had 4 beds and 77 sq.ft./bed

Based on interview and record review, the facility failed to ensure that Resident 1's alleged abuse incident was reported within the prescribed timeframes. This failure placed the Resident 1 at risk for further possible abuse incidents, mental anguish or emotional distress. This failure also resulted in the delay in the abuse investigation. Findings: During a review of Resident 1's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss and impaired decision-making capacity) and major depressive disorder (a mental disorder characterized by persistently depressed mood and loss of pleasure and interest in life). During an interview on 4/16/25 at 12:57 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/14/25 at approximately 7:30 a.m., Resident 1 was complaining of left arm pain and stated that the night shift Certified Nursing Assistant (CNA) 1 was mean and rough with her and hit her left arm. LVN 1 further stated that at around 12:15 p.m., she had observed Resident 1's left arm to be swollen so she obtained an order for left arm X-ray from the physician. LVN 1 stated Resident 1's left arm X-ray was done in the facility at around 4 p.m., and at around 5:00 p.m., the X-ray results revealed that Resident 1 had a fracture (broken bone) in her left arm. Stated at around 6:00 p.m., Resident 1 was transferred to the hospital for further evaluation. LVN 1 acknowledged she should have reported the alleged abuse accusation to the Administrator (Adm) and the Director of Nursing (DON) immediately when Resident 1 initially complained of the alleged abuse but stated she forgot to report the incident. Stated she was aware that alleged abuse with injury should be reported to the state department immediately or within two hours. During a review of Resident 1's left arm X-ray results dated 4/14/25 at 5:07 p.m., indicated: Acute minimally displaced mid ulnar diaphyseal fracture (a broken bone in the thinner and longer of the two bones in Resident 1's left forearm on the side opposite to the thumb). During a review of Resident 1's nurses progress notes 4/14/25 at 11:17 p.m., the notes indicated Resident 1 went to the hospital on 4/14/25 at 6:20 p.m. for evaluation of the pain in her left arm. The notes also indicated that the Adm was informed of the alleged incident at this time. During an interview on 4/16/25 at 3:00 p.m., with the DON, the DON acknowledged Resident 1's complaint of alleged abuse incident with injury should have reported to the department immediately or within 2 hours. During a phone interview with the Adm on 4/24/25 at 11:30 a.m., stated she only found out of Resident 1's alleged abuse incident at on 4/14/25 at 6:00 p.m. During a review of the SOC 341 submitted by the facility, the SOC 341 was faxed to CDPH on 4/14/25 at 8:15 p.m., eight hours after the left arm was observed to be swollen by LVN 1. (SOC 341 is a Report of Suspected Dependent Adult/Elder Abuse. It is a mandated reporting form used in California to report suspected abuse, neglect, or financial exploitation of elders or dependent adults). During a review of the facility's policy and procedure (P&P) titled, Abuse Protocols, revised 8/1/24, the P&P indicated, . Reporting: 1.Verbal notification to the Department of Public Health . shall be followed by an initial written notification using the SOC 341 and submitted within 24 hours of discovery .( The P&P did not mention to report an allegation of abuse with injury to the Adm of the facility and to other officials including CDPH immediately or within two hours). According to State Operations Manual, Appendix PP, Reporting Allegations, 483.12 (b): The facility must develop and implement written policies and procedures that, .483.12 (c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey agency .).( The State Operations Manual is a detailed information on regulations, policies, and procedures that facilities like nursing homes must follow to ensure compliance with federal or government requirements).

Based on observation ,interview and record review, the facility failed to provide adequate supervision for one of 5 sampled residents (Resident 1) who required supervision due to physical and verbal aggression. This resulted in an altercation between Resident 1 and Resident 2, and this also had the potential to result in Resident 1 in having more altercations with other residents which can result to a serious injury. Findings: Review of Resident 2's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment of unknown etiology (unknown cause). During an interview with Resident 2 on 12/13/24 at 12:58 p.m., stated on 11/21/24 at around 8:30 p.m., she was ready to go to bed and asked Certified Nursing Assistant (CNA)1 to turn off the light. Stated a few minutes later after CNA 1 left the room, her roommate Resident 1 went inside their room in a wheelchair and went to the light switch and turned on the lights. Resident 2 told Resident 1 to turn off the lights but Resident 1 refused and yelled No . Resident 2 then reached for the light switch, which was close to her bed and turned off the lights, but Resident 1 turned on the lights again. Resident 2 stated she stood up and walked to Resident 1 and patted Resident 1 lightly in her right cheek. Resident 1 in return, scratched Resident 2 in her left arm. Resident 2 stated she did not intend to pat Resident 1 in the cheek but stated she lost her patience. Resident 2 stated she apologized to Resident 1 later that night. Resident 2 stated, nobody saw the altercation between her and Resident 1, but she told the Social Service Director (SSD) about what happened the following day on 11/22/24 afternoon, because she felt bad about what she did. Stated she moved to another room after she talked to the SSD. Review of Resident 2's Minimum Data Set ( MDS, an assessment tool) dated 12/4/24, indicated she had a brief interview for mental status or BIMS of 15 (BIMS score of 13 to 15 indicates cognition is intact). The MDS indicated Resident 2 had no physical and verbal behavior symptoms directed toward others. The MDS also indicated that Resident 2 only needed supervision from the staff when moving from seated to standing position and walking ten feet in a room. Review of Resident 2's Departmental Notes dated 11/22/24 at 5:24 p.m., indicated Resident 2 mentioned to the SSD that she had an altercation with her roommate Resident 1 the previous night (11/21/24) because Resident 1 wanted their room lights on, and Resident 2 wanted the lights off. The residents disagreed verbally and then Resident 2 slapped Resident 1 and Resident 1 scratched Resident 2 which gave Resident 2 two scratches in her left arm. The notes also indicated that Resident 2 was moved to another room and the facility called the police department. During an interview with SSD on 11/10/24 at 1:39 p.m., SSD stated on 11/22/24, at around 4:00 p.m., Resident 2 told her that she had a disagreement with Resident 1 because Resident 1 wanted the lights on but Resident 2 wanted the lights off. Resident 2 stated the situation escalated, and Resident 2 lost her temper and slapped Resident 1 in the face, and Resident 1 scratched Resident 2 in her left arm. SSD stated Resident 2 said she was sorry for what happened because she reacted to what Resident 1 was doing when she kept turning on the lights. SSD stated Resident 2 was moved to another room. SSD stated Resident 2 obtained 2 scratches in her left arm and Resident 1 had no injuries. During an observation on 12/10/24 at 11:53 a.m., Resident 1 was seen wheeling herself around the facility's hallways repeatedly and independently in a wheelchair unaccompanied by staff. Review of Resident 1's indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Review of Resident 1's MDS dated [DATE], indicated BIMS of 4 (BIMS score 0 to 7 points indicates severe cognitive impairment). The MDS indicated that Resident 1 had physical and verbal behavioral symptoms directed toward others daily. The MDS also indicated that Resident 1 only requires setup or clean-up assistance with her wheelchair, meaning a helper will set up the wheelchair or clean up after use. The MDS further indicated Resident 1 was independent once sitting in the wheelchair and had the ability to wheel herself for at least 150 feet in corridor or similar space. The MDS revealed Resident 1 had wandering (travelling aimlessly from place to place) episodes. During an interview CNA 1 on 12/11/24 at 1:09 p.m., stated Resident 1 wandered around the facility, went to other residents' rooms, and sometimes took things that belonged to other residents. During an interview with the Director of Nursing (DON) on 12/13/24 at 2:16 p.m. and concurrent review of Resident 1's Departmental Notes, the notes indicated that there were three other incidents when Resident 1 had altercations with three other residents (Residents 3, 4 and 5). One incident was on 10/18/24 at 3:17 p.m., when Resident 3 reported that Resident 1 wandered in her room, and when she asked Resident 1 to leave, Resident 1 kicked her. Another incident happened on the same day of 10/18/24 at 10:11 p.m. when Resident 1 attempted to go to Resident 4's room and had a verbal altercation with Resident 4 (both of these incidents happened 35 days before the incident with Resident 2 on 11/21/24). Upon further review, Resident 1 had another verbal altercation with Resident 5 on 12/8/24 at 1:22 p.m.( happened 17 days after incident with resident 2 on 11/21/24), when Resident 1 took Resident 5's snowman decoration from Resident 5's board. The residents were separated right away on all three incidents, and no injuries were observed to the residents on all occasions. Further review with the DON of Resident 1's behavioral care plans, the DON could not find care plans that addressed Resident 1's altercations and behaviors with Residents 3 and 4 on 10/18/24, with Resident 2 on 11/21/24 and with Resident 5 on 12/8/24 . DON acknowledged a plan of care should have been developed and revised on all four altercations to monitor and prevent Resident 1's wandering and aggressive behavior towards other residents. DON also could not find Interdisciplinary Team (IDT-are an approach to healthcare that integrates multiple disciplines through collaboration) meeting notes which addressed or discussed interventions for Resident 1's altercations with Resident 2, 3, 4, and 5. During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents, revised September 2016, the P&P indicated, .Identifying Residents at Risk for Accidents: Procedure: 1. The interdisciplinary team will evaluate accident potential during admission, quarterly and annual assessments; and when a resident experiences a significant change of condition .3. Accident hazards identified by the interdisciplinary team will be recorded on the Interdisciplinary Team Notes. 4. the plan of care developed by the interdisciplinary team will be recorded on the resident care plan . Based on observation ,interview and record review, the facility failed to provide adequate supervision for one of 5 sampled residents (Resident 1) who required supervision due to physical and verbal aggression. This resulted in an altercation between Resident 1 and Resident 2, and this also had the potential to result in Resident 1 in having more altercations with other residents which can result to a serious injury. Findings: Review of Resident 2's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment of unknown etiology (unknown cause). During an interview with Resident 2 on 12/13/24 at 12:58 p.m., stated on 11/21/24 at around 8:30 p.m., she was ready to go to bed and asked Certified Nursing Assistant (CNA)1 to turn off the light. Stated a few minutes later after CNA 1 left the room, her roommate Resident 1 went inside their room in a wheelchair and went to the light switch and turned on the lights. Resident 2 told Resident 1 to turn off the lights but Resident 1 refused and yelled No . Resident 2 then reached for the light switch, which was close to her bed and turned off the lights, but Resident 1 turned on the lights again. Resident 2 stated she stood up and walked to Resident 1 and patted Resident 1 lightly in her right cheek. Resident 1 in return, scratched Resident 2 in her left arm. Resident 2 stated she did not intend to pat Resident 1 in the cheek but stated she lost her patience. Resident 2 stated she apologized to Resident 1 later that night. Resident 2 stated, nobody saw the altercation between her and Resident 1, but she told the Social Service Director (SSD) about what happened the following day on 11/22/24 afternoon, because she felt bad about what she did. Stated she moved to another room after she talked to the SSD. Review of Resident 2's Minimum Data Set ( MDS, an assessment tool) dated 12/4/24, indicated she had a brief interview for mental status or BIMS of 15 (BIMS score of 13 to 15 indicates cognition is intact). The MDS indicated Resident 2 had no physical and verbal behavior symptoms directed toward others. The MDS also indicated that Resident 2 only needed supervision from the staff when moving from seated to standing position and walking ten feet in a room. Review of Resident 2's Departmental Notes dated 11/22/24 at 5:24 p.m., indicated Resident 2 mentioned to the SSD that she had an altercation with her roommate Resident 1 the previous night (11/21/24) because Resident 1 wanted their room lights on, and Resident 2 wanted the lights off. The residents disagreed verbally and then Resident 2 slapped Resident 1 and Resident 1 scratched Resident 2 which gave Resident 2 two scratches in her left arm. The notes also indicated that Resident 2 was moved to another room and the facility called the police department. During an interview with SSD on 11/10/24 at 1:39 p.m., SSD stated on 11/22/24, at around 4:00 p.m., Resident 2 told her that she had a disagreement with Resident 1 because Resident 1 wanted the lights on but Resident 2 wanted the lights off. Resident 2 stated the situation escalated, and Resident 2 lost her temper and slapped Resident 1 in the face, and Resident 1 scratched Resident 2 in her left arm. SSD stated Resident 2 said she was sorry for what happened because she reacted to what Resident 1 was doing when she kept turning on the lights. SSD stated Resident 2 was moved to another room. SSD stated Resident 2 obtained 2 scratches in her left arm and Resident 1 had no injuries. During an observation on 12/10/24 at 11:53 a.m., Resident 1 was seen wheeling herself around the facility's hallways repeatedly and independently in a wheelchair unaccompanied by staff. Review of Resident 1's indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Review of Resident 1's MDS dated [DATE], indicated BIMS of 4 (BIMS score 0 to 7 points indicates severe cognitive impairment). The MDS indicated that Resident 1 had physical and verbal behavioral symptoms directed toward others daily. The MDS also indicated that Resident 1 only requires setup or clean-up assistance with her wheelchair, meaning a helper will set up the wheelchair or clean up after use. The MDS further indicated Resident 1 was independent once sitting in the wheelchair and had the ability to wheel herself for at least 150 feet in corridor or similar space. The MDS revealed Resident 1 had wandering (travelling aimlessly from place to place) episodes. During an interview CNA 1 on 12/11/24 at 1:09 p.m., stated Resident 1 wandered around the facility, went to other residents' rooms, and sometimes took things that belonged to other residents. During an interview with the Director of Nursing (DON) on 12/13/24 at 2:16 p.m. and concurrent review of Resident 1's Departmental Notes, the notes indicated that there were three other incidents when Resident 1 had altercations with three other residents (Residents 3, 4 and 5). One incident was on 10/18/24 at 3:17 p.m., when Resident 3 reported that Resident 1 wandered in her room, and when she asked Resident 1 to leave, Resident 1 kicked her. Another incident happened on the same day of 10/18/24 at 10:11 p.m. when Resident 1 attempted to go to Resident 4's room and had a verbal altercation with Resident 4 (both of these incidents happened 35 days before the incident with Resident 2 on 11/21/24). Upon further review, Resident 1 had another verbal altercation with Resident 5 on 12/8/24 at 1:22 p.m.( happened 17 days after incident with resident 2 on 11/21/24), when Resident 1 took Resident 5's snowman decoration from Resident 5's board. The residents were separated right away on all three incidents, and no injuries were observed to the residents on all occasions. Further review with the DON of Resident 1's behavioral care plans, the DON could not find care plans that addressed Resident 1's altercations and behaviors with Residents 3 and 4 on 10/18/24, with Resident 2 on 11/21/24 and with Resident 5 on 12/8/24 . DON acknowledged a plan of care should have been developed and revised on all four altercations to monitor and prevent Resident 1's wandering and aggressive behavior towards other residents. DON also could not find Interdisciplinary Team (IDT-are an approach to healthcare that integrates multiple disciplines through collaboration) meeting notes which addressed or discussed interventions for Resident 1's altercations with Resident 2, 3, 4, and 5. During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents, revised September 2016, the P&P indicated, .Identifying Residents at Risk for Accidents: Procedure: 1. The interdisciplinary team will evaluate accident potential during admission, quarterly and annual assessments; and when a resident experiences a significant change of condition .3. Accident hazards identified by the interdisciplinary team will be recorded on the Interdisciplinary Team Notes. 4. the plan of care developed by the interdisciplinary team will be recorded on the resident care plan .

Based on observation, interview, and record review, the facility failed to store and label mediations in accordance with manufacturer specifications and currently accepted professional principles when: 1. The medication refrigerator temperature was below recommended temperature range for storage of refrigerated medications. 2. The medication refrigerator temperature was not consistently monitored and recorded twice daily for seven out of seven months, from [DATE] to [DATE]. 3. The temperature log had an incorrect temperature range for monitoring. 4. Nursing staff failed to notify the Maintenance Supervisor (MS) when the medication refrigerator temperature was out of range. 5. Six (6) bottles of eyedrops and one (1) insulin pen were not correctly labeled. These failures had the potential to result in 44 residents receiving medications or vaccines of unknown effectiveness and seven (7) residents potentially receiving an incorrect or expired medication. Findings: 1. During a concurrent observation and interview on [DATE] at 10:34 a.m. with the Director of Nursing (DON), the medication refrigerator was 29 degrees ( ) Fahrenheit (F). DON stated that the thermometer read 29 F and the appropriate temperature range was between 36 F and 46 F. The medication refrigerator contents included one (1) pneumovax vial (vaccine for pneumonia), one (1) Fiasp pen (a type of insulin pen), one (1) box containing five (5) Humalog Kwik pens (a type of insulin pen), one (1) Basaglar Kwikpen (a type of insulin pen), two (2) vials of TB test (used to test for tuberculosis), six (6) vials of open insulin, one (1) unopened emergency box containing one (1) vial of insulin (a medication to lower blood sugar) and one (1) vial of Lorazepam (a medication given for anxiety), one (1) vial of NPH (a type of long acting insulin), two (2) boxes of influenza vaccine (a vaccine for the flu) containing a total of 13 vials, and one (1) container of lantoprost eye drops (a medication to treat high pressure in the eye). During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated ,d+[DATE], the policy indicated that medications requiring refrigeration or temperatures between 36 F and 46 F should be kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log is maintained to verify that temperature has remained within accepted limits. 2. During a concurrent interview and record review on [DATE] at 10:40 a.m. with the DON, the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE], the document indicated the last recorded temperature of the refrigerator was 34 F on [DATE] during the night shift, and the appropriate temperature should be between 36 F and 46 F. DON stated the temperature log was supposed to be monitored twice daily. The log was not filled out [DATE], and there were four (4) missing entries from [DATE], and three (3) missing entries in [DATE]. DON was requested to provide temperature logs for four (4) additional months, from [DATE] to [DATE]. During a review of the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE] to [DATE], the [DATE] log contained eight (8) missing entries and five (5) entries that were below 36 F. The [DATE] temperature log contained 12 missing entries and 44 that were below 36 F. The February 2024 temperature log had six (6) missing entries and 12 that were below 36 F. The [DATE] temperature log had eight (8) missing entries. The [DATE] temperature log had three (3) missing entries. The [DATE] temperature log had four (4) missing entries. The [DATE] temperature log (as of [DATE]) had three (3) missing entries and one (1) entry that was below 36 F. During a review of the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE], the document indicated the temperature of the refrigerator should be monitored twice daily during NOC (night) and P.M. (evening) shifts. 3. During a concurrent interview and record review on [DATE] at 01:14 p.m. with DON, DON stated that the correct range for the refrigerator was 36 F to 46 F and the facility's refrigerator temperature log, titled Record of Refrigeration Temperatures, dated [DATE], indicated that the acceptable temperature range for the medication refrigerator is between 36 F and not greater than 41 F. DON stated the temperature range of between 36 F and not greater than 41 F is incorrect and needs to be changed. 4. During a concurrent interview and record review on [DATE] at 10:40 a.m. with DON, the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE], DON stated the document indicates that if the recorded temperatures are below 36 F, MS should be notified. During an interview on [DATE] at 12:11 p.m., the MS stated he learned about the medication refrigerator being too cold today, and there had been no issues previously reported. The MS stated the temperature was 32 F when he checked it today, which is colder than the acceptable range of 36 F to 46 F. During a concurrent interview and record review on [DATE] at 3:50 p.m., Licensed Vocation Nurse (LVN) 5 stated that she entered 29 F on the temperature log on [DATE] and she does not remember if she entered it on the maintenance log. LVN 5 stated that the reason refrigerator temperatures are checked is to make sure that all the medications are in good standing and regulated well. LVN 5 stated that all issues with the medication refrigerator should be entered into the maintenance log. During a concurrent interview and record review on [DATE] at 11:21 a.m. with the DON, DON reviewed the Maintenance Request Log and stated there were no entries in the Maintenance Request Log for the dates in January and December when the medication refrigerator was recorded as being outside of range. DON stated that the expectation is that the nurses will notify maintenance and enter temperatures that are outside range in the maintenance log. DON stated that the potential consequences for the refrigerator being too cold is that the insulin and vaccines stored in the refrigerator are not supposed to be frozen, which could cause decreased effectiveness of the medications. In a concurrent record review and interview on [DATE] at 4:08 p.m., LVN 3 stated that she signed the Record of Refrigeration Temperatures twice in January ([DATE] and [DATE]) indicating that the temperature of the medication refrigerator was 32 F. LVN 3 stated that she did not notify maintenance because she was not aware that 32 F was too cold. LVN 3 stated that the form Record of Refrigerator Temperature indicates that temperatures below 36 F should be reported to Maintenance Supervisor. During a telephone interview on [DATE] at 1:11 p.m., the Pharmacy Consultant (PC) stated that she recommended that the medication kept in the medication refrigerator be replaced because there are no studies on what happens to medications when kept in that temperature range, so it is unknown what the effects would be. The PC stated that the correct temperature range for the medication refrigerator is between 36 F to 46 F. During a review of the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE], the document indicated that adequate temperature was Refrigeration: 36 F and not greater than 41 F and indicated report to Maintenance Supervisor when recorded temperatures are not adequate. 5. During a concurrent observation and interview on [DATE] at 2:25 p.m. with LVN 4 at Medication Cart #1, there were five (5) bottles of artificial tears (an over the counter product that lubricates dry eyes) with the only patient identifier as the resident room number for Residents 14, 10, 35, 17, and 13. LVN 4 stated that the risk of not having the resident name on the bottle is that there's a risk to giving the product to the wrong resident if they change rooms. LVN 4 stated that a bottle of latanoprost (a medication given to treat high pressure in the eye) eye drops, prescribed for Resident 16, does not have an open date. During a review of Lexicomp, a nationally recognized drug information resource, Lexicomp indicated the following for the storage of latanoprost: Once opened, the container may be stored at room temperature . for 6 weeks. During an interview on [DATE] at 11:21 a.m., DON stated that eyedrops should be labeled with the resident's name, room number, and date that they were opened. DON stated that a potential consequence of not correctly labeling eye drops is that the wrong eyedrop could be given to the wrong resident and a consequence of not writing open dates is that expired eyedrops could be given. In a concurrent observation and interview on [DATE] at 12:12 p.m. with LVN 2, at Medication Cart #2, LVN 2 stated there was no open date for the Basaglar Kwikpen (a type of insulin administration pen) for Resident 37. LVN 2 stated that medications should be labeled with an open date and if there is no open date there is a risk that residents could receive expired medication. A review of Lexicomp indicated the following for storage of Basaglar Kwikpen: Store in-use prefilled pens at room temperature . and use within 28 days. During a review of facility policy titled Medication Administration: Subcutaneous Insulin, dated ,d+[DATE], the document indicated that the device should be dated after the first use.

Based on observation, interview, and record review, the facility failed to provide gender specific bathrooms to five of five sampled residents (Residents 1, 30, 32, 33 and 41). A female resident (Resident 32) shared a [NAME] and [NAME] bathroom (a bathroom that has two doors and is accessible from two bedrooms) with two male residents (Resident 30 and Resident 33) in the adjacent room. A female resident (Resident 1) shared [NAME] and [NAME] bathroom set up with a male resident (Resident 41). This failure placed Residents 1, 30, 32, 33 and 41 at risk for humiliation and discomfort. Findings: 1. During a concurrent observation and interview on 6/3/24 at 11:00 a.m., in Resident 41's room, Resident 41 was sitting in wheelchair. Resident 41 stated he shared the bathroom with a female resident (Resident 1) residing in the adjacent room. Resident 41 stated sharing the bathroom with a female resident was unacceptable. Resident 41 stated it was concerning for him as he would look bad if he happened to enter the bathroom if Resident 1 was already in the bathroom. During a record review of Resident 41's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/10/24, Section H - Bladder and Bowel of the assessment indicated Resident 41 was always continent (able to always control bladder voluntarily and/or bowels) with bowel and bladder. During an interview on 6/4/24 at 11:48 a.m. with Certified Nursing Assistant (CNA) 2, Resident 1 was observed sitting in a wheelchair in the hallway. CNA 2 stated Resident 1 was able to use the bathroom with assistance. CNA 2 stated she was aware Resident 1 shared a bathroom with a male resident (Resident 41) and that's why she preferred to take Resident 1 to the common bathroom by the dining room instead. CNA 2 stated female and male residents were not supposed to share one bathroom and she was concerned because it could cause discomfort to the residents especially the female residents. During a record review of Resident 1's Bowel and Bladder Record, dated April and May 2024, the record showed Resident 1 had multiple episodes of bowel continence. 2. During an interview on 6/4/24 at 9:28 a.m. with Resident 30, in Resident 30 and Resident 33's shared bedroom, Resident 30 stated their bathroom was shared with a female resident (Resident 32) in the adjacent room. Resident 30 stated he felt it was inappropriate for men and women to share the bathroom together. Resident 30 stated there was an incident when another resident from the adjacent room exited the bathroom and entered their room. Resident 30 stated the facility did not inform him that he would be sharing the bathroom with female residents before he was moved to this room. During a record review of Resident 30's MDS assessment, dated 4/25/24, the MDS assessment Section H - Bladder and Bowel indicated Resident 30 was frequently incontinent (able to have at least one episode of continent voiding and bowel movement) with bowel and bladder. During an interview on 6/4/24 at 09:30 a.m. with Resident 33, Resident 33 stated he did not feel good about having to share their bathroom with female residents. Resident 33 stated it was not right to have two genders share the bathroom and the facility also did not inform him about it. During an observation and interview on 6/5/25, at 9:03 a.m., Resident 32 was observed inside the bathroom with Certified Nurse Assistant (CNA 1). Resident 32 stated she did not think it was right to share the bathroom with male residents. Resident 32 stated it made her uncomfortable sharing the bathroom with male residents from the adjacent room. She also stated there were incidents when other residents or staff did not knock the before opening the bathroom door. Resident 32 stated she did not feel good about it because her privacy was compromised. Resident 32 also stated she was not informed that the bathroom will be shared between male and female residents. During a record review of Resident 32's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 3/21/24, the MDS assessment Section H - Bladder and Bowel indicated Resident 32 was occasionally incontinent with bladder (able to have less than 7 episodes of involuntary voiding) and frequently incontinent (able to have at least one episode of continent bowel movement) with bowel. During an interview on 6/4/24 at 12:25 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was the nurse caring for Residents 1, 30, 32, 33 and 41. LVN 2 stated she was aware of the shared bathrooms between male and females and that it was not appropriate because it could compromise the resident's privacy and dignity. During an interview on 6/4/24 at 12:33 p.m. with Director of Nursing (DON), DON stated the shared bathrooms had locks and signage posted on the bathroom doors to knock before entering. During an observation on 6/4/24 at 12:35 p.m. with DON, the shared bathroom between Residents 30, 33 and 32 did not have locks. The signage stating Knock before entering was only on the door for Residents 30 and Resident 33's side and not on Resident 32's side of the door. During a concurrent observation and interview on 6/4/24 at 12:40 p.m., the DON stated both the bathroom doors to the bathroom shared between Resident 41 and Resident 1 did not have a lock or signage stating Knock before entering. During an interview on 6/5/24, at 9:04 a.m. with Director of Nursing (DON), she stated she was unable to locate any records that Residents 1, 30, 32, 33 and 41 and/or their families were informed about the shared bathrooms between male and female residents when the residents were moved to their respective rooms. During a record review of the facility's Policy and Procedure (P&P) titled Dignity and Respect, last revised 5/1/22, the P&P showed the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 16, Resident 23, and Resident 11) received proper grooming including nailcare when: 1) Resident 16 had long sharp fingernails. 2) Resident 23 had long sharp fingernails. 3) Resident 16 had long, thick fingernails. This failure placed residents at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails and compromise physical and psychosocial wellbeing. Findings: 1. During a review of Resident 16's Resident Face Sheet, printed on 6/5/24, the Face Sheet showed Resident 16 was admitted to the facility in November 2023 and had multiple medical diagnoses including glaucoma (a group of eye diseases that damage the optic nerve and can cause blindness) and Parkinson's disease (a progressive disease of the nervous system that affects movement). During a record review of Resident 16's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/17/24, Resident 16's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 9 out of 15, which indicates moderately impaired mental status. Review of Section GG Functional Abilities and Goals indicated Resident 16 was dependent on staff for self-care including shower and personal hygiene. During an observation and interview on 6/3/24, at 10:10 a.m., Resident 16 was lying in his bed and was scratching his arm with long sharp nails causing redness to skin. Resident 16 stated he cannot trim his nails by himself because he cannot see and has asked the facility staff to trim his nails for him, but no one has helped him so far. Resident 16 stated he would like to have his nails trimmed and short. During a concurrent observation and interview on 6/3/24 at 10:22 a.m. with Licensed Vocational Nurse (LVN)1, Resident 16's fingernails were observed. LVN 1 stated Resident 16 has long fingernails. LVN 1 stated Resident 16 is diabetic and Licensed Nurses should be trimming the fingernails. LVN 1 also stated if nails are not trimmed there is risk, that resident can scratch himself and get skin tear. During a review of Resident 16's Care Plan-Self-care deficit, dated 5/22/24, the care plan indicated to assist resident 16 in ADL (Activities of daily living, things needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). 2. During a review of Resident 23's Resident Face Sheet, printed on 6/5/24, the Face Sheet showed Resident 23 was admitted to the facility in February 2024 and had multiple medical diagnoses including cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During a record review of Resident 23's MDS, dated [DATE], Resident 23's BIMS was 14 out of 15, which indicates intact mental status. Review of Section GG indicated Resident 23 was dependent on staff for self-care including shower and personal hygiene. During a concurrent observation and interview on 6/3/24 at 10:46 a.m., Resident 23 was lying in his bed and was noted with long sharp fingernails. Resident 23 stated he has requested the facility staff to trim his nails for him many times, but no one has helped yet. Stated he like to have short nails and cannot trim his nails by himself. During a concurrent observation and interview on 6/3/24 at 10:50 a.m. with LVN 4, Resident 23's fingernails were observed. LVN 4 stated Resident 23 has long fingernails. LVN 4 also stated licensed Nurse or Certified Nursing assistant can help resident with nails care. LVN 4 stated the risk of not trimming the nails, is that Resident 23 can scratch himself and cause bleeding and wound and dirt can settle underneath nails which can cause infection. During a review of Resident 16's Care Plan-Self-care deficit, dated 5/22/24, the care plan indicated to assist resident 16 in ADLs, including personal hygiene /showering. 50474 3. During a review of Resident 11's Face Sheet, printed on 6/4/24, the Face Sheet indicated Resident 1 was admitted to the facility in October 2019. During a record review of Resident 11's MDS, dated [DATE], the MDS assessment Section GG indicated Resident 1 was totally dependent on staff for showers and needed staff's maximum assist to maintain personal hygiene and grooming. During a record review of Resident 11's Activities of Daily Living Care Plan, dated 10/17/19, the care plan showed Resident 11 had a self-care deficit due to blindness and needed limited assistance with personal hygiene. During an observation and interview on 6/4/24, at 11:56 a.m. with Certified Nursing Assistant (CNA) 2, Resident 11 was lying in the bed. Resident 11 had about two inch long and thick fingernails on his left hand. Resident 11 stated he preferred his fingernails shorter. CNA 2 stated she only filed Resident 11's fingernails because they were already too long and thick, and a regular nail clipper did not work. CNA 2 stated the nurse has been informed about Resident 11's long and thick fingernails. CNA 2 stated the risk of having long and thick fingernails could provide discomfort to Resident 11. During an interview on 06/4/24, at 12:25 a.m. with LVN 2, LVN 2 stated she was aware that Resident 11 had long and thick fingernails. She stated Resident 11's fingernails have been long and thick since last year, but they could not use a regular nail clipper. LVN 2 stated they would need a special tool to trim Resident 11's fingernails. LVN 2 stated the risk of having long and thick fingernails could lead to a skin breakdown and infection. During an interview on 6/4/24, at 12:42 p.m. with Director of Nursing (DON), DON stated she was aware that Resident 11's fingernails were long and thick. DON stated Resident 11's fingernails were approximately between 1-2 inches long. DON stated the social worker was already informed about it, but no one had come to the facility yet to trim Resident 11's fingernails. During an interview on 6/4/24, at 12:44 p.m., Social Services Designee (SSD), stated she had not set up the appointment yet for Resident 11's fingernails. During a review of facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, revised on 2/1/2017, the P &P indicated, Nail care is given to clean the nail bed and keep the nails trimmed .Policy. I. Fingernails are trimmed by Certified Nursing Assistants (CNA's), except for residents with diabetes or circulatory impairments, this includes all toenails except for high - risk residents. Note: A licensed nurse will trim high-risk resident's nails.

Based on observation, interview, and record review the facility failed to ensure effective medication administration and accurate accountability of a controlled substance (medications that can be easily abused and are under strict government control) when: 1. Nursing staff did not correctly prime the pen needle during the administration of insulin (medication to lower blood sugar) for one of two sampled residents (Resident 27) receiving an insulin injection. This had the potential to result in Resident 27 to not receive a full dose of insulin. 2. One of 31 sampled residents (Resident 19) received calcium and iron at the same time. This had the potential for an interaction leading to the decreased absorption of iron, and the resident not receiving the full therapeutic effect of the medication. 3. During a random controlled medication use audit, one of two randomly sampled residents (Resident 7) did not have all administered medications correctly documented on the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medication) and on the Medication Administration Record (MAR) to indicate they were administered to the resident. This failure had the potential to result in misuse or diversion of controlled medications and had the potential to make it more difficult to monitor if medication dosages need to be adjusted. Findings: 1. During an observation on 06/03/24 at 11:59 a.m., Licensed Vocational Nurse (LVN) 4 primed the insulin pen (a device used to administer medication to lower blood sugar), named Fiasp (a rapid-acting insulin) Flexitouch pen, by holding it horizontally while having the needle cap on, prior to administering insulin to Resident 27. During an observation and interview on 6/3/24 at 12:40 p.m., LVN 4 explained the insulin pen priming process by holding the pen horizontally while keeping the needle cap on and turned the pen dial to 2 units and pressed the bottom of the pen (the dose button) to prime the needle. During an interview on 06/05/24 at 01:11 p.m., the Pharmacy Consultant (PC) stated that the correct way to prime an insulin pen is to hold the pen upright, and if pen is not primed correctly, the dose could be incorrect. A review of the manufacturer's Instructions for Use, for Fiasp Flextouch, revised 6/2023, retrieved from: https://www.novo-pi.com/fiasp.pdf indicated: Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top . Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. During a review of facility's policy and procedure (P&P), titled Medication Administration Subcutaneous Insulin, dated 05/2016, the P&P indicated the pen should be held with the needle pointing upwards. 2. During a medication administration observation on 06/04/24 at 04:25 p.m., LVN 6 was observed giving Resident 19 seven medications, including a tablet of Oyster Shell Calcium (a supplement) 500 mg and a tablet of iron sulfate (to treat iron deficiency) 325 mg. A record review of Resident 19's MAR, dated May 2024, indicated the facility scheduled both the calcium and iron sulfate to be given daily at 5 p.m. During an interview with the Director of Nursing (DON) on 06/05/2024 at 11:21 a.m., DON stated her quick online research showed iron sulfate's absorption may be affected by the co-administration with calcium carbonate, and their administration should be spaced out two (2) hours apart. During an interview on 06/05/24 at 01:11 p.m. with Facility's Pharmacy Consultant (PC), PC stated Resident 19 was receiving calcium and iron at the same time. PC stated she was aware of the interaction between the two medications, made herself a note in her computer, but did not communicate with the facility because it was a minor interaction. A record review, Lexicomp, a nationally recognized drug information resource, indicated the concurrent use of calcium carbonate and ferrous sulfate would lead to Risk Rating D (meaning consider therapy modification) drug-drug interaction. Specifically, Lexicomp indicated calcium carbonate may decrease the absorption of Iron Preparations . The absorption of ferrous sulfate has been shown to be reduced by 15% to 24% with calcium carbonate. It further indicated to consider separating the doses of the two medications as much time as possible in patients who require chronic use of both agents and monitor for decreased therapeutic effects of oral iron preparations. 3: During a concurrent interview and record review with DON on 6/4/2024 at 1:46 p.m., the CDR and MAR for Resident 7 were reviewed. DON stated the records indicate that the CDR was signed when oxycodone HCL 5 mg (a pain medication with potential for abuse) was removed for Resident 7 three times: on 1/10/24, on 2/[date unclear]/24, and 2/21/24, and the medication administration was not entered on the MAR. DON stated the nurse should sign the CDR and document in the MAR when controlled medications are given. DON stated LVN 3 signed the CDR for Resident 7 on 2/21/24, but did not enter the administration on the MAR. During an interview with LVN 3 on 6/4/2024 at 4:08 p.m., LVN 3 stated she signed the Controlled Drug Record for Resident 7 on 2/21/24, and the correct procedure is to always document in the CDR and in the MAR after giving a controlled substance. During an interview with DON on 06/05/24 at 11:21 a.m., DON stated the risk to not entering controlled doses on the MAR is that it makes it more difficult to monitor if the medication is effective and to monitor if medication dosages need to be adjusted. During a review of facility's P&P titled Medication Administration Controlled Substances, dated 11/2017, the P&P indicated when a controlled medication is administered, the licensed nurse administering the medication should document the administration on the MAR.

Based on observation and interview, the facility had one resident room (room [ROOM NUMBER]) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied the room. This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents. Findings: During an interview on 6/3/24 at 9:35 a.m. with Administrator (ADM), ADM stated the facility had a room waiver for room [ROOM NUMBER]. ADM stated room [ROOM NUMBER] had less than 80 sq ft per resident and had four resident beds. During an interview on 6/5/24 at 12:35 p.m. with the Maintenance Supervisor (MS), MS stated room [ROOM NUMBER] was the only room that had four residents. The following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area 16 Resident room [ROOM NUMBER] sq. ft 77 sq.ft/bed During an observation on 6/3/24 at 9:40 a.m., Residents 2, 6, 7 and 42 were observed in their bed. The privacy of residents in room [ROOM NUMBER] was not impacted by shortage of space. Storage spaces were sufficient to accommodate the needs of residents. The ADM requested a continuous room waiver for the above residents' room.

Based on observation, staff interviews, and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time dietetic supervisor when the dietitian was not full time. The lack of a full-time, competent supervisor resulted in Food and Nutrition Services staff not having adequate training and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. In addition, when the dietitian was not full-time, frequent consultation was not provided from the dietitian to ensure Food and Nutrition Services was carried out in a safe and sanitary manner, when the dietitian went into the kitchen 1 hour a month. The lack of full-time, competent oversight of food and nutrition staff placed 34 residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) which had the potential to result in death, for a facility census of 34. An Immediate Jeopardy situation (IJ, a situation in which facility noncompliance has placed the health and safety of a resident at risk for serious harm, injury, serious impairment or death) was declared on February 16, 2023, at 10:30 a.m., in the presence of the Administrator (ADM) for not having full-time, competent oversight in the Food and Nutrition Services Department which left staff, who were not competent or with the skill sets, to carry out to carry out necessary tasks within the department. An acceptable plan of action was provided by ADM on February 17, 2023, at 1:06 p.m. The actions to remove the immediate jeopardy situation included: a contract was signed between the facility and a consulting company for a full-time Director of Food and Nutrition Services (also referred to as a dietary or kitchen supervisor); a qualified, full-time Dietary Services Supervisor (DSS 2) was hired to supervise the kitchen beginning 2/17/23 and moving forward until a permanent solution is implemented; and DSS 2 was to immediately begin in-servicing and training current dietary staff on all operational policies and procedures for the kitchen including, but not limited to the following: general operating policies for the dietary department, proper sanitation of the kitchen, proper food storage, any areas of concern or opportunities for improvement identified by the Registered Dietitian and/or State Surveyors. When DSS 2 was onsite and began in-servicing the Food and Nutrition Services staff, the IJ was removed on 12/17/23, at 1:06 p.m. while the surveyors were onsite. Findings: A. There was no full-time, competent oversight of the Food and Nutrition Services Department: According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. Review of the Dietary Supervisor Job Description dated 1/1/15, showed the duties and responsibilities of a Dietary Supervisor for Food and Nutrition Services, included but not limited to: inspecting storage areas and the dietary department regularly for proper temperature and cleanliness; providing in-service educational programs for the Dietary Department; and ensuring compliance with Federal regulations. Review of the Consultant Dietitian Nutritionist Job Description dated 2023, showed the Consultant Dietitian Nutritionist (RDN) provided oversight of the operations of the Department of Food and Nutrition Services. The responsibilities included but were not limited to: evaluating and participating in implementing in-service programs for the Department of Food and Nutrition Services; monitoring and recommending food service standards for sanitation, safety, and infection control; advising and counseling the dietary supervisor in all areas of food service; evaluating and monitoring the food service department to assure the department is providing adequate, acceptable quality food; reporting to the Administrator and the dietary supervisor, monthly or as needed regarding findings and concerns regarding the Department of Food and Nutrition Services. Review of the Agreement to Provide Consultant Services signed by ADM on 7/19/21, showed the purpose of the RDN consultant was to provide guidance and council to the Nutrition Services Department. The responsibilities of the consultant included but were not limited to offering in-service education to facility staff and reviewing sanitation in accordance with current regulatory standards. The contract showed hours as PRN [as needed] as negotiated with [the consulting company] and administrator. The number of hours shall be determined by the needs of the facility. Hours will be based on the average census, acuity rate of the facility and qualifications of the Director of Food and Nutrition Services. Review of the Cook Job Description dated 11/10, showed the basic purpose of the position was to prepare and serve food to residents of the facility in accordance with current Federal regulations, corporate standard regulations and guidelines, and may be directed by the Administrator or Dietary manager. The job description stated every effort has been made to identify the essential duties and responsibilities of this position. However, the functions listed below should not be considered a complete list of duties the position may be required to perform. The omission of specific statements of duties does not exclude them from the position of the work is similar, related, or is an essential function of the position. Duties and responsibilities listed included but were not limited to: ensuring all dietary procedures and sanitary regulations were followed in accordance with established policies; performing dishwashing/cleaning procedures; ensuring the department was maintained in a clean and safe manner by assuring that necessary equipment and supplies were maintained; cleaning work station and all equipment utilized, following each meal to maintain sanitary conditions; and assisting in maintaining food storage areas in a clean and properly arranged manner at all times. Review of the Dietary Aide Job Description showed the primary purpose of the position was to provide assistance in all dietary functions as directed/instructed and in accordance with established dietary policies and procedures. The job description read every effort has been made to identify the essential duties and responsibilities of this position. However, the functions listed below should not be considered a complete list of duties the position may be required to perform. The omission of specific statements of duties does not exclude them from the position of the work is similar, related, or is an essential function of the position. Duties and responsibilities listed included but were not limited to: cleaning workstation and all equipment utilized following each meal; cleaning worktables; performing dishwashing/cleaning procedures; and assist in maintaining food storage areas in a clean and properly arranged manner at all times. Review of the Policy titled Performance Reviews revised 5/1/22, showed each employee shall receive a review of their job performance at least annually. The performance review shall include an assessment of the employee's performance based on the stated job description, identified objectives, and professional standards for the individual and the facility as necessary and appropriate. The guidelines showed each employee shall be scheduled for a performance review during the month of the anniversary of that employee's seniority date with the facility. The performance review shall be completed by the employee's direct supervisor or the head of the department within which the employee spends the majority of their hours worked. Each performance review shall include an assessment of performance based on the job description and/or standards of practice for the employee's position, evaluation of performance against previously established goals, and a developmental action (as necessary and appropriate). On 2/13/23 at 8:55 a.m., during the initial tour of the kitchen, an observation, and concurrent interviews with Diet Aide 3 (DA 3) and Cook 1, showed DA 3 and Cook 1 working in the kitchen and a kitchen supervisor was not present. DA 3 washed dishes using the dish machine and stated she worked at the facility for two months, mornings and afternoons. Cook 1 stated he worked at the facility for six months and stated there was no kitchen supervisor during the week. He stated, he thought a new supervisor was hired but did not know when the new supervisor was going to start. On 2/13/23 at 9:35 a.m., an observation and interview with the Dietary Services Supervisor 1 (DSS 1), showed DSS 1 arrived in the kitchen and stated she was the new supervisor. In an interview on 2/13/23 at 12:23 p.m., DSS 1 stated she worked at another facility and was just at this facility to help during the survey. In an interview on 2/13/23 at 12:33 p.m., the Administrator (ADM) stated there was a Registered Dietitian who worked for the facility one day a week for 8 hours. ADM also stated a dietary supervisor (DSS 1) was just hired and she was coming into the facility three to four hours in the afternoons to get used to the kitchen. ADM confirmed currently there was no full-time supervisor for the kitchen. Review of the Employment Offer Letter signed by DSS 1 on 2/2/23, read Employee will begin as an hourly employee due to continuous arrangements of departure from previous employer. She will begin her employment as on on call hourly employee and will coordinate hours with administrator. Once she has departed from her previous employer, she will begin her full time salaried exempt position as Dietary Manager. Review of the Employee Timesheet for the DSS 1 dated 2/1/23 - 2/15/23, showed DSS 1 worked at the facility on 2/7/23 from 1:03 p.m., to 4:34 p.m. for a total of 3 hours and 31 minutes; 2/8/23 from 3:50 p.m. to 6:14 p.m. for a total of 2 hours and 24 minutes; 2/9/23 from 2:21 p.m. to 6:04 p.m. for a total of 3 hours and 43 minutes. These times showed a week total of 9 hours and 38 minutes. For the consecutive week (the week of the survey start date on 2/13/23), the time sheet showed DSS worked on 2/13/23 from 9:32 a.m. to 6 p.m. for a total of 8 hours and 28 minutes; 2/14/23 a start time was not shown and worked until 4:09 p.m. In an interview on 2/14/22 at 8:55 a.m., Diet Aide 1 (DA 1) stated Kitchen Staff 2 (KS 2) use to be a supervisor and now came in on the weekends to order food and do the food inventory. In an interview on 02/15/23 9:04 a.m. ADM stated Kitchen Staff 1 (KS 1) was the last full-time supervisor and had to check to find out the last date KS1 worked at the facility. ADM stated it was her understanding that DSS 1 was to be full-time eventually but right now she was transitioning part-time. The surveyor informed ADM that DSS 1 stated she was only going to work at the facility until the end of the survey. Review of an email from KS 1 to ADM dated 9/20/22, showed a KS 1 gave her formal notice of resignation on 9/20/22 making her last day of employment 10/3/22 (2 weeks from the formal resignation date). Review of the document titled All Timesheets for dates from 1/1/22 to 12/31/22, showed the last time sheet for KS 1 was from 10/1/22 to 10/15/22. In an interview on 2/15/23 at 11 a.m., Registered Dietitian 2 (RD 2) arrived at the facility and stated he worked for the same consulting company as Registered Dietitian 1 (RD 1). He stated he worked at this facility in the past and was like a supervisor for RD 1. He said if the surveyors had questions about the kitchen, the kitchen staff had to be asked, not RD 1. On 02/15/23 1:36 p.m., a phone interview was conducted with RD 1 in the presence of ADM. RD 1 stated she worked at the facility eight hours a week and she went into the kitchen for maybe one hour a month to complete a report of any concerns which she provided to ADM and the Director of Nursing (DON). RD 1 repeated she went into the kitchen once a month for about an hour said she did not go into the kitchen at any other time. RD 1 also stated she did not provide in-services to kitchen staff. On 2/15/23 3:30 p.m., DSS 1 stated she just came into the facility in the p.m. (afternoon/evening) She said she did not meet the a.m. (morning) staff until the survey began on Monday (2/13/23) because she was only at the facility helping in the p.m. In a phone interview with the DSS 1 on 2/16/23 at 8:09 a.m., DSS 1 stated she did not provide any documented in-services for kitchen staff. In an interview with ADM on 2/16/23 at 8:47 a.m., ADM stated she was aware that DSS would no longer work at the facility, and she did not know who was going to supervise the kitchen on Friday (2/17/23) this week or thereafter. On 02/16/23 at 12:46 p.m., ADM stated there were no records for competency evaluations done for any of the kitchen staff including Cook 1, Cook 2, Dietary Aide 1 (DA 1), Dietary Aide 2 (DA 2), and Dietary Aide 3 (DA 3). On 2/17/23 at 1:15 p.m., ADM stated there was not a supervisor to supervise kitchen staff during day-to-day operation since KS 1 left. She stated Kitchen Supervisor 2 (KS 2) was also a past supervisor and now came into the kitchen on the weekends mainly for the task of ordering food. She stated recruitment for a kitchen supervisor was advertised on one online recruiting site, and she had only one qualified candidate from the site during the time the job was posted. ADM provided documentation printed from the one recruiting website which showed Dietary Manager was posted on September 20, 2022, and on December 8, 2022. ADM said the facility did not hire the only qualified candidate for the Dietary Manager position through the recruiting site because the facility decided to hire DSS 1. ADM stated the Regional Administrator (RADM) researched a company to contract with for nutritional services, who would provide staffing, but the facility decided not to contract with them. She said she did not remember if she contacted any consulting agencies to recruit a kitchen supervisor. On 2/17/23 at 2:02 p.m., ADM stated the facility did not contact any consulting companies or recruit in any other way other than advertising for the kitchen supervisor position on the one internet site. B. There was no full-time, competent supervision of the Food and Nutrition Department to ensure safe food storage: According to the 2022 Federal Food Code, the person in charge is to ensure that employees are properly maintaining the temperature of time/temperature control for safety foods during cold holding and thawing through daily oversight of the employees' routine monitoring of food temperatures. Time/Temperature Control for Safety (TCS) Food (Time/Temperature for safety food means a food that requires time/temperature control for safety to limit pathogenic microorganism (an organism which can cause disease) growth or toxin (a naturally occurring organic poison) formation. Examples of TCS foods include animal food that is raw or heat-treated, cut melons, cut leafy greens). Except during preparation, cooking, cooling or when time is used as the public health control, TCS food is to be held at 41 degrees F or less. Also, when TCS foods are thawed using refrigeration, the food temperature is to be maintained at 41 degrees Fahrenheit (F) or less. In addition, in the Food Code Annex, it is stated that after being cut, certain produce such as melons and leafy greens should be stored at 41 degrees or below to prevent any pathogens that may be present from multiplying. Also, freezing prevents microbial growth (increased number of bacterial [bacteria is a large group of single-cell microorganisms. Some cause infections and disease in animals and humans] growth) in foods, but usually does not destroy all microorganisms (microscopic [cannot be seen by the human eye but can be seen under a microscope] organisms, especially a bacterium, virus, or fungus). Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins (a naturally occurring poison produced by organisms). In the Food Code Annex, it is also said that Epidemiological (the branch of medicine which deals with finding the cause of diseases) outbreak (a sudden start of a disease in a community or geographical area) data repeatedly identify improper holding temperatures as a major risk factor related to employee behaviors and preparation practices in food service establishments as contributing to foodborne illness. Review of the policy and procedure titled Sanitation and Infection Control Subject: Refrigerated Storage dated 2023, showed refrigerator temperatures should be recorded two times each day. It is recommended temperatures be recorded in the a.m. (morning) immediately after opening the kitchen and the p.m. (evening) before closing. Perishable foods should be stored less than or equal to 41 degrees F (Fahrenheit). Review of the policy and procedure titled Food Preparation Subject: Food Defrosting Methods dated 2023, showed food will be thawed in a manner as to keep food out of the danger zone (41 - 140 degrees F) for the entire thawing process. When defrosting in the refrigerator, foods must be labeled and dated with the item name, pull dates and use-by date with no more than three days past the pull-by date. On 2/13/23 at 8:55 a.m., during the initial tour of the kitchen, an observation and concurrent interviews with Diet Aide 3 (DA 3) and Cook 1, showed 2 staff (DA 3 and Cook 1) were working in the kitchen and a kitchen supervisor was not present. Cook 1 stated he worked at the facility for 6 months and stated there was no kitchen supervisor. He stated, he thought a new supervisor was hired but did not know when the new supervisor was going to start. As the initial tour of the kitchen continued on 2/13/23 at 9 a.m., and observation and concurrent interview with Cook 1 showed a 3-door reach-in refrigerator filled with food. An internal thermometer showed the refrigerator was 50 degrees Fahrenheit (F). The surveyors asked Cook 1 if there was documentation for refrigerator temperatures. Cook 1 showed the surveyors a clipboard hanging on the wall next to the refrigerator. He showed that the last documented temperatures for the refrigerator were from November 2022. Then he looked through a binder and found documented refrigerator temperatures documented for 1/25/23. Cook 1 was not able to find any refrigerator temperature documentation for February. Review of the document titled Food Temperature/Sanitation Record dated 1/25/23 showed two documented refrigerator temperatures documented at 5:30. As the initial tour continued on 2/13/23 at 10 a.m., the three-door, reach-in refrigerator was observed in the presence of DSS 1, DA 3, and Cook 1 (DSS 1, DA3, and Cook 1 were also interviewed at this time). The thermometer inside the refrigerator showed 46 degrees F. Food temperatures were measured with calibrated surveyor thermometers. A nutrition supplement shake taken from a box holding multiple shakes and dated 2/7 had a temperature of 48.6 degrees F. DA 3 stated he thought the shakes had been in the refrigerator and not removed from refrigeration for 5 days. A yogurt in an individual container was 43.9 degrees F. Sour cream from an opened container was 43.5 degrees F. DSS 1 confirmed the temperatures taken. She said the temperature of food stored in the refrigerator should be 34 degrees or lower. Other items in the refrigerator included thawing raw chicken in a metal container with a label which showed it was placed in the refrigerator on 2/11 and was to be used by 2/16 and 2 packages of raw thawing pork with a label that showed it was placed in the refrigerator on 2/12 and was to be used by 2/16. The chicken appeared soft and fully thawed and the pork was soft to the touch and felt fully thawed, and there were red juices inside the metal container holding the thawing pork. Cook 1 stated the raw chicken in the refrigerator was leftover and he might cook it tomorrow. The temperature of the chicken stored in the refrigerator measured 44.6 degrees F. DSS 1 stated thawing meat should only be held for 3 days. In an interview on 2/13/23 at 2:55 p.m., the DSS 1 stated after reviewing refrigerator temperature logs, the last documentation available was on 1/25/23. On 2/14/23 at 8:22 a.m., an observations and concurrent interviews with Diet Aide 1 (DA 1) and Cook 2, showed DA 1 and Cook 2 working in the kitchen without a supervisor. The 3-door refrigerator temperature was checked. The thermometer read 42 degrees F. Cook 2 and DA 1 stated they did not check the refrigerator temperature today. The Record of Refrigeration Temperatures dated February 2023 was blank in the space designated to record a temperature on 2/13/23. Temperatures of food stored in the refrigerator were measured with surveyor calibrated thermometers. Tuna salad dated 2/10/23 was 46.2 degrees F. Cut cantaloupe dated 2/11 - 2/16 was 44.8 degrees F. An undated package of raw, thawed pork was 48 degrees F and 46.8 degrees F (the temperature was measured in two places inside the pork), shredded cabbage stored in an opened plastic bag labeled prep [preparation] date 2/10/23 Use by 2/16/23 was 46.2 degrees F, shredded mozzarella cheese in an opened plastic bag labeled prep 2/8/23 use by 3/8/23 was 44.4 degrees F, shredded cheddar cheese in an opened plastic bag labeled prep date 2/9/23 use by 3/9/23 was 46 degrees F, an opened container of Caesar salad dressing was 45 degrees F, a nutrition supplement shake in a cardboard box dated February 7 and containing multiple shakes all dated use by Feb [February] 18 was 48.4 degrees F. DA 1 and Cook 2 both stated all the food measured for temperature were stored in the refrigerator overnight and not removed from refrigeration that morning. In an interview and observation with DSS 1 and Cook 2 on 2/14/23 at 11:20 a.m., showed DSS 1 arrived at the facility to begin work. The surveyor informed the DSS 1 of the food temperatures found in the refrigerator at 8:22 a.m. The DSS 1 stated okay. Cook 2 stated he documented the refrigerator temperature at 11:10 a.m. He said the refrigerator temperature should not be above 42 degrees F and 45 degrees F was okay because the refrigerator temperature can go up when the door was opened and closed many times. DSS 1 informed Cook 2 the refrigerator temperature had to be 41 degrees or below. Review of the document titled Record of Refrigeration Temperatures dated February 2023, showed 45 degrees documented for the refrigerator on 2/14/23. Directions typed at the bottom of the documented showed Refrigeration: Not greater than 41 degrees F . Report to Supervisor when recorded temperatures are not adequate. On 2/14/23 at 1:30 p.m., an observation and concurrent interview with the DSS 1 showed two thermometers on inside the 3-door reach-in refrigerator with temperatures measuring 42 degrees F and 45 degrees F. The DSS 1 stated new thermometers were needed and the food inside the refrigerator was okay. On 2/14/23 at 1:47 p.m., an observation and interview with the DSS 1 and DA 1, showed the same foods stored in the 3-door reach-in refrigerator that were observed in the morning (on 2/14/23 at 8:22 a.m.). The temperature of the food was measured with the surveyors' calibrated thermometers in the presence of DSS 1. Two temperatures were taken of the raw, thawed pork and were 48.7 degrees F and 46.8 degrees F. The cut cantaloupe was 45.5 degrees F, shredded cabbage in an opened plastic bag dated 2/10/23 - 2/16/23 was 46.8 degrees F, the opened bag of shredded cheddar cheese dated 2/9/23 - 3/9/23 was 47.5 degrees F, opened bag of shredded mozzarella cheese 46.9 degrees F, a nutrition supplement shake from the cardboard box dated 2/7 was 48.2 degrees F, the opened container of Caesar dressing was 48.2 degrees F. DA 1 stated all the food that was measured for temperatures were not removed from refrigeration that day. DSS 1 stated the foods with high temperatures needed to be discarded. The surveyor asked if other food stored in the refrigerator was safe, she stated she needed to speak with RD 1. In an interview on 2/14/23 at 2:04 p.m., DSS1 stated RD 1 said to discard all the food in the refrigerator. She also stated maintenance had to adjust the temperature of the refrigerator. On 02/15/23 at 10:13 a.m., an observation, interview, and review of the refrigerator temperature log with Cook 2 and DA 1, showed the log titled Record of Refrigerator Temperatures revised 4/11/16, had a total of 3 documented temperatures on the log for February 23 which included one documented temperature on 2/13/23, 2/14/23, and 2/15/23. Cook 2 stated there were no temperatures documented by an afternoon staff, but there should be. He stated an afternoon temperature should be documented as well as the morning temperature. Food items which were observed in the refrigerator on 2/14/23 continued to be stored in the refrigerator and not discarded. These items included a bag of mixed green lettuce labelled opened 2/11/23, the opened container of Caesar dressing, the opened bag of shredded cabbage labeled prep date 2/10/23 Use By Date 2/16/23, the opened bag of shredded mozzarella cheese labeled Prep Date 2/8/23 Use By 3/8/23, the opened bag of cheddar cheese. In an interview on 2/15/23 at 12:15 p.m., Cook 2 stated he planned to use the opened bag of shredded cabbage labeled prep date 2/10/23 Use by 2/16 for the pepper slaw on the menu for lunch on 2/16/22. Review of the Daily Spreadsheet dated Wednesday - Day 4 showed mixed pepper slaw on the menu for dinner. In an interview on 2/15/23 at 12:20 p.m., ADM stated the refrigerator was fixed about 8:30 p.m. on 2/14/23. She said she did not know if the refrigerator temperatures were checked again to make sure the refrigerator was working. On 2/15/23 at 1:36 p.m., RD 1 was interviewed over the phone in the presence of ADM. RD 1 stated she thought there was a log for refrigerator temperatures and that the kitchen staff were responsible for checking refrigerator temperatures. She stated she thought refrigerator temperatures had to be checked at least once or twice a day. She said if the refrigerator temperatures were high then maintenance should be informed. RD 1 also stated the temperature of the food should be taken and to discard the food if the temperature was high. She said she did not know if kitchen staff knew the correct procedures to follow if refrigerator temperatures were high. RD 1 said she did not provide any in-services to the kitchen staff. She stated she did tell the staff to discard the food in the refrigerator on 2/14/3, but she did not know if the food was discarded. She said the reason the food had to be discarded was because the food temperature was high and was in the potentially hazardous zone. An observation on 2/15/23 at 3 p.m., the DSS 1 arrived at the facility. In an interview on 12/15/23 at 3:30 p.m., DSS 1 stated yesterday (2/14/23), she left about 5:30 p.m. She stated all food was supposed to be discarded from the refrigerator except for unopened shelf stable food (food that does not require refrigeration). She said shredded cabbage, cheese, and lettuce was supposed to be discarded. On 2/16/23 at 11:55 a.m., an observation and interview with the Director of Nursing (DON), the DON showed the surveyor a binder containing documented in-services provided to kitchen staff. She said these were the only in-services she could find having to do with the kitchen. The documents showed all the in-services were dated 2022 and did not show who conducted the trainings. There was no in-service available to show any kitchen staff, including Cook 1, Cook 2, DA 1, DA 2, and DA 3, were trained regarding monitoring refrigerator temperatures and safe food storage temperatures. In an interview with DA 1 and Cook 1 on 2/16/23 at 2 p.m., DA 1 stated she never received training from an RD, including the current RD 1. DA 1 stated when RD 1 came into the kitchen, RD 1 looked at things, filled out her report, and then left the kitchen. Cook 1 also stated he did not receive training from an RD. He stated he just started looking at refrigerator temperatures in the evening. He said the refrigerator temperature should be 32 to 35 degrees F and stated 45 degrees F was okay because the temperature could go up when the refrigerator door was opened. He stated he would only take action if the refrigerator temperature was 50 degrees F because 50 degrees was too high. He stated he did not document the temperature when he checked it. C. There was no full-time, competent oversight to ensure proper use of the dish machine: According to the 2022 Federal Food Code, the person in charge is to ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of chemical concentration and temperature for chemical sanitizing. In addition, a warewashing machine and its auxiliary components are to be operated in accordance with the machine's data plate and other manufacturer's instructions. A test kit or other device that accurately measures the concentration of sanitizing solution is to be provided. In the Food Code Annex, it is said to ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. The effectiveness of chemical sanitizers is determined primarily by the concentration and pH of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution. In addition, the Food Code Annex explains Epidemiological outbreak data repeatedly identify contaminated equipment as a major risk factor related to employee behaviors and preparation practices in food service establishments as contributing to foodborne illness. Review of the policy and procedure titled Sanitation and Infection Control Subject: Dishwashing Procedures (Dish machine) dated 2023, showed the dish machine will be used per manufacture guidelines. Chemical low temperature dish machines must maintain a water temperature of 120 degrees F - 140 degrees F. Use a chemical sanitizing rinse to achieve and maintain 50 - 100 ppm (parts per million) of chlorine at the dish surface or according to manufacturer's specifications. Obtain test' strips form your local chemical distributor for testing ppm on low temperature machines. Dish machine temperature logs must be documented prior to the start of washing at each meal to ensure proper sanitation of all dishware and trays. If temperatures are out of standards, circle and record action plans on form. Refer out of standard temperatures to the Director of Food and Nutrition Services. Facilities are to follow the manufacturer's recommendations in dishwashing to ensure sanitation of dishes and utensils. During the initial tour of the kitchen on 2/13/23 at 8:55 a.m., an observation and interview with DA 3, showed two staff (DA 3 and Cook 1) working in the kitchen without a supervisor. DA 3 washed dishes and stated she worked at the facility for 2 months. As the initial [TRUNCATED]

Based on observation, interview, and facility document review, the facility failed to ensure the planned menu was followed when: 1. Cake was not served to 10 of 10 Controlled Carbohydrate diets (CCHO; a diet to control the amount of carbohydrate or sugar a person receives at each meal); 2. A smaller portion of vegetables and potatoes than what was indicated on the menu were served to 9 of 9 residents on regular portion/regular textured diets; 3. A smaller portion of meat, a larger portion of vegetable, and a larger portion of cake than what was indicated on the menu were served to 7 of 7 residents on regular pureed diets; 4. A larger portion of meat and a larger portion of potatoes than what was indicated on the menu and traycard was served to Random Resident 1 (RR1) 5. A smaller portion of meat than what was indicated on the menu and traycard was served to Resident 6. This failure had the potential for residents to not receive the nutrients intended by the physician's order and the planned menu for 29 residents out of a facility census of 35. Findings: Review of the policy and procedure titled Food Preparation Subject: Portion Control dated 2023, showed portion control assures correct quantities are served to residents to meet the nutritional specifications as determined by the menu. Portions served ore those listed on the menu for each food item. Standard tools are utilized to assure portion control. Scoops sizes include number 6 (2/3 cup), number 8 (1/2 cup), number 10 (3/8 cup), number 12 (1/3 cup) number 16 (1/4 cup). Ladle sizes include 2 ounce (1/4 cup), 4 ounce (1/2 cup) 6 ounce (3/4 cup) 8-ounce (1 cup). A diet scale should be used to weigh meats. Review of the policy and procedure titled Menus dated 2023, showed menus are planned to meet the Dietary Reference Intakes (DRI; a set of scientifically developed reference values for nutrients) from the Food and Nutrition Board of the institute of Medicine. Menus will provide adequate nutrients to meet the special needs of the residents, including special dietary modifications. Menus will provide a variety of foods and indicate standard portions to be served. 1. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed regular textured, CCHO diets and Mechanical Soft diets (foods that can be easily chewed) received a piece of lemon cake. The spreadsheet also showed pureed (foods that do not require chewing) CCHO diets received pureed lemon cake. In interviews with DA 1 and DS and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed lunch trays with diet tickets that indicated regular textured, CCHO diets and CCHO Mechanical Soft diets, received a bowl of fruit cocktail on the tray. In addition, tray tickets that indicated pureed CCHO diets received a bowl of applesauce on the tray. The regular textured CCHO and Mechanical Soft CCHO diets did not have cake on the tray and the pureed CCHO diets did not have pureed cake on the tray. DA 1 confirmed CCHO diets were not served cake and regular texture CCHO diets and Mechanical Soft CCHO diets received fruit cocktail and pureed CCHO diets received applesauce. DS stated he instructed the staff to serve fruit cocktail and applesauce to CCHO diets because he thought the cake was too sweet. In an interview with Registered Dietitian 1 (RD 1) on 4/24/23 at 1:35 p.m., he stated CCHO should have received cake as indicated on the menu. 2. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed regular portion diets received a number 8 scoop (1/2 cup or 4 ounces) of Herb Yukon Potatoes and a number 8 scoop of Mixed Vegetables. In an interview with DS and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed Cook 1 used a 3-ounce ladle to serve potatoes and a 3-ounce ladle to serve vegetables to all regular portion/regular texture diets. DS confirmed Cook 1 served a smaller portion of potatoes and vegetables than what was indicated on the menu to regular portion/regular texture diets. 3. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed regular portioned pureed diets received a number 6 scoop (2/3 cup) of pureed pot roast, a number 10 scoop (3/8 cup) of pureed vegetables, and a number 10 scoop of pureed cake. An observation on 4/24/23 at 11:45 p.m., showed DS placed cake in a blender with thickened dairy beverage then blended the ingredients into a puree. DS used a number 8 scoop (1/2 cup) to place one scoop of pureed cake into individual bowls. In an interview with DS and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed the bowls containing the of pureed cake prepared by DS were served to residents who received pureed diets (excluding residents on pureed CCHO diets). Also, Cook 1 used a number 8 scoop (1/2 cup) to serve pureed pot roast and number 8 scoop to serve pureed vegetables for all regular portion pureed diets. DS confirmed the portions of meat and vegetables Cook 1 served for the pureed diets were incorrect according to the menu. In an interview with DS on 4/25/23 at 10:30 a.m., he confirmed he served the wrong portion of pureed cake to pureed diets. 4. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed a small portion of potatoes was a number 16 scoop (1/4 cup) and a regular portion of meat was three ounces. In an interview with DS and Cook 1 and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed the tray ticket for Random Resident 1 (RR 1) showed the Resident was on a No Added Salt Regular Portion diet with a large portion of vegetables and small portions of starch. Cook 1 served RR 1, two pieces of pot roast and a number 8 scoop (1/2 cup) of potatoes. Cook 1 stated he served RR 1 two pieces of pot roast because the resident was supposed to get double portions. DS weighed the meat on a scale served to RR 1. The scale showed the meat weight 5.7 ounces. DS confirmed RR 1 received almost double the amount of meat according to the tray ticket and the menu. Cook 1 also confirmed he served the incorrect portion of potatoes. In an interview on 4/25/23 at 10:30 a.m., DS stated he thought the tray tags had too much information for the Cook to read and some of the information on the tray tickets was confusing. 5. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed Mechanical Soft diets received a number 8 scoop (1/2 cup) of pot roast. In an interview with Cook 1 and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed the tray ticket for Resident 6 showed the Resident was on a Regular Mechanical Soft diet with small portions and large protein portions. Cook 1 served Resident 6 a number 12 scoop (1/3 cup) of mechanical soft pot roast. Cook 1 confirmed he did not serve a large portion of meat to Resident 6. In an interview on 4/25/23 at 10:30 a.m., DS stated he thought the tray tags had too much information for Cook 1 to read and some of the information on the tray tickets was confusing.

Based on interviews and record review, the facility failed to provide one (1) of three sampled residents, the therapeutic diet ordered by the physician to ensure that Resident 1 was not given a food that was unsafe to eat. Resident 1 had a history of [REDACTED]. The facility failed to assure that CNA 1 and AA knew that Resident 1 was to have a mechanical soft (soft chopped, blended or ground food, mechanically altered to make it easier to chew and swallow) diet. During the ball game, the staff bought the three residents hot dogs for lunch. While Resident 1 was eating his hot dog on a bun, he began to choke. Facility and ball park staff attempted to clear the hot dog from Resident 1's airway. The resident lost consciousness, was taken to a hospital, where he died . The failure to provide Resident 1 with his prescribed diet resulted in his choking incident and death. Findings: Review of the clinical record on [DATE] at 9:30 a.m., showed that Resident 1 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on [DATE], of the Minimum data Set ((MDS) dated [DATE], showed that Resident 1 required assistance in setting up his meals. The Physician admission orders [REDACTED]. A Physician order, dated [DATE] showed, "Change diet to NCS (no concentrated sweets)Puree thin liquids secondary to poor mastication (chewing) of food. A Physician order [REDACTED]. The "Therapy Progress Documentation" form dated [DATE] reflected that Resident 1 reported a choking incident that occurred on [DATE], while eating a sandwich with crust for dinner. The therapist documented that he, "Tolerated a small amount of his mechanical soft lunch tray today with lengthy mastication but no overt signs or symptoms of aspiration (accidental inhalation of food or liquids into bronchi or lungs) noted. Patient able to (I) detail his swallow precautions. Changing diet to Mechanical Soft, ground meat with thin liquid - No crust." A physician order, dated [DATE], reflected that Resident 1 could go out of the facility on outings with his responsible party, and on facility outings. Care plans dated [DATE], and [DATE] for, "Potential for Constipation", showed Resident 1 was identified with "Swallowing problems." Care Plans for "Nutritional Status" dated [DATE], and [DATE] reflected that Resident 1 had swallowing problems. Review of "Interdisciplinary Team Conference Notes" dated [DATE] included physician's orders [REDACTED]. The Summary portion of the Interdisciplinary Team Conference Notes, Dietary section indicated, "Resident is on mechanical soft NCS diet with ground meat." physician's orders [REDACTED]. A nurses note, dated [DATE], reflected that Resident 1 was excited about going to a ball game that day. The [DATE] nurses note for 4 p.m., reflected that the assistant activities director called the facility at 3:30 p.m., to report that Resident 1 was choking, and losing consciousness. An entry at 4:30 p.m., reflected that Resident 1 was admitted to the hospital. In an interview on [DATE], at 5 p.m., the Administrator stated that Resident 1 was in the hospital intensive care unit, on a ventilator (mechanical breathing machine). During an interview on [DATE], at 9:30 a.m., the Administrator stated that when residents went out on pass, no medical information was sent with them. He stated that the facility sent, "Contact info" with residents who went out of the facility for outings. The Admin further stated, "We have taken measures so this won't happen again." In an interview on [DATE], at 13:30 p.m., the Director of Nursing stated that the staff should have been aware of Resident 1's current diet, but, "Obviously they did not, or they wouldn't have given him a hot dog." The DON also stated that the staff did not have any records with them on the outing, except, "Contact info." During an interview with AA, on [DATE] at 10 a.m., she said she did not know if Resident 1 had a history of [REDACTED]. When asked if she knew whether an uncut hot dog on a bun was allowed according to Resident 1's diet order, she said she did not know. AA stated that she and CNA 1 tried the Heimlich maneuver, and a man tried, but nothing came out. During an interview with Certified Nursing Assistant (CNA) 1 on [DATE] at 10:30 a.m., she stated that she did not have information about the residents' diets, medications, or special precautions when she took Residents 1, 2, and 3 to the ball game. She stated she did not know if Resident 1 had a history of [REDACTED]. When asked if she knew if eating an uncut hot dog on a bun was allowed according to Resident 1's diet order, she stated she did not know. In an interview with the DON (Director of Nurses), on [DATE], at 10 a.m., she stated that Resident 1's daughter called the facility to report that he died at the hospital on [DATE]. She stated that prior to Resident 1's choking incident, the facility did not have a policy or procedure for residents going out of the facility. She stated that the practice was to notify the responsible parties that their resident was going on an outing. The DON stated that, as a result of Resident 1's incident, the facility developed an information form, to be filled in when a resident goes on an outing.