Every finding on record at Stoney Point Healthcare Center

Based on interview and record review, the facility failed to notify a physician and/or a resident's responsible party (RP - the person who helps manage a resident's paperwork, care decisions, and financial arrangements) for one of four sampled residents (Resident 1) when: 1.Resident 1 refused to undergo an endoscopy (a medical test where a doctor looks inside the body using a long, thin, flexible tube with a tiny camera and light on the end) on 5/27/2026. 2. Resident 1 refused to undergo a fasting blood sugar (FBS - A blood test that measures glucose [sugar] levels after not eating overnight) and lipid panel (a blood test that measures the amounts of different fats and cholesterol in the blood to check a risk for heart disease) test on 6/22/2026. These failures may result in worsening symptoms, increased risk of hospitalization or complications and a decline in the resident's overall health status. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/20/2026 with diagnoses that included heart disease (a general term for conditions that affect the heart) and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. The admission Record further indicated that Family Member 1 (FM 1) was Resident 1's RP. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/27/2026, the MDS indicated Resident 1's speech was clear, and the resident was able to be understood by others and understand others. The MDS also indicated that Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired, and required moderate assistance from staff with eating, oral hygiene, and personal hygiene and required maximal assistance from staff with toileting hygiene and showering/bathing self and transferring. During a review of Resident 1's history and physical (H&P - the initial evaluation and examination of a resident), dated 5/22/2026, the H&P indicated, Resident 1 was able to make needs known, however, independent medical decision-making capacity appeared limited based on available documentation. 1. During a review of Resident 1's physician order dated 5/21/2026, the physician order indicated that Resident 1 had endoscopy return appointment on 5/27/2026 at a general acute care hospital 1 (GACH 1) on 5/27/2026. During a concurrent interview and record review on 8/19/2026 at 3:35 p.m., with Registered Nurse 1 (RN 1), RN 1 reviewed Resident 1's physician order for endoscopy and progress notes. RN 1 stated that Resident 1 refused to go and cancelled the endoscopy appointment on 5/27/2026. RN 1 stated Resident 1's physician was notified of the cancelled endoscopy appointment. RN 1 was unable to provide documentation that Resident 1's RP was notified of Resident 1's refusal to go to the endoscopy appointment on 5/27/2026. RN 1 stated that the licensed nurses should have notified Resident 1's RP when Resident 1's refused to go to the endoscopy appointment. During a concurrent interview and record review on 8/19/2026 at 4:02 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed Resident 1's physician order for endoscopy and progress notes written by LVN 1. LVN 1 stated that LVN 1 received the report from the previous shift's licensed nurse that Resident 1 self-cancelled the appointment for endoscopy. LVN 1 stated she notified Resident 1's physician, but she did not notify Resident 1's RP of the resident's refusal to go to the endoscopy appointment on 5/27/2026.During a concurrent interview and record review on 8/19/2026 at 5:17 p.m., with the Director of Nursing Director (DON), the DON reviewed Resident 1's physician order for endoscopy and progress notes. The DON stated that the licensed nurses should have notified Resident 1's RP of Resident 1's refusal to undergo the scheduled endoscopy on 5/27/2026.2. During a review of Resident 1's physician order dated 6/20/2026, the physician order indicated orders for FBS and lipid panel every night shift every six (6) months starting on the 22nd for one day for the use of Abilify (used to treat schizophrenia [a mental illness that can affect thoughts, mood, and behavior] in adults and bipolar [mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks]) per pharmacy recommendations. During a review of Resident 1's physician progress notes dated 8/10/2026, the progress notes indicated that the care planning included regular laboratory test monitoring and that Resident 1 was on Abilify, and was monitored for medication side effect and compliance, renal, liver function, and therapeutic serum levels where indicated.During a concurrent interview and record review on 8/18/2026 at 4:47 p.m., with the DON and the Assistant Director of Nursing (ADON), reviewed Resident 1's physician order for FBS and lipid panel checks ordered on 6/20/2026 and progress notes. The ADON stated that if a resident refused a blood draw (medical procedure a healthcare worker takes a small amount of blood from a vein in the arm so a laboratory can test it), the resident would be offered on the following day, and the physician would be notified. The DON stated that Resident 1 refused the blood draw on 6/22/2026 three times, however, the licensed nurses did not notify the physician or the RP. The DON stated it was important to notify the physician of Resident 1's refusal for the blood draw because the physician may need to change the resident's plan of care. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status last reviewed on 1/20/2026, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of change in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status,

Based on interview and record review, the facility failed to ensure a resident received unopened mail delivered to the facility for a resident through the postal service for one of four sampled residents (Resident 1). This failure resulted in the violation of the residents' rights. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/20/2026 with diagnoses that included heart disease (a general term for conditions that affect the heart) and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. The admission Record further indicated that Family Member 1 (FM 1) was Resident 1's responsible party (RP - the person who helps manage a resident's paperwork, care decisions, and financial arrangements). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/27/2026, the MDS indicated Resident 1's speech was clear, and the resident was able to be understood by others and understand others. The MDS was also indicated that Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired, and required moderate assistance from staff with eating, oral hygiene, and personal hygiene and required maximal assistance from staff with toileting hygiene and showering/bathing self and transferring. During a review of Resident 1's admission agreement, signed by FM 1 on 6/2/2026, the admission agreement indicated FM 1 was Resident 1's RP. During a review of Resident 1's history and physical (H&P - the initial evaluation and examination of a resident), dated 5/22/2026, the H&P indicated Resident 1 was able to make needs known, however, independent medical decision-making capacity appeared limited based on available documentation. During a review of Resident 1's social security administration (SSA) letters, dated 7/24/2026 and 7/27/2026, the two SSA letters were delivered to the facility for Resident 1. During a concurrent interview and record review on 8/19/2026 at 2:27 p.m. with the Social Services Director (SSD), Resident 1's SSA letters, dated 7/24/2026 and 7/27/2026, were reviewed. The SSD stated the two SSA letters delivered to the facility, indicated the recipient's name with Resident 1. The SSD stated the SSD did not know that those mails were delivered to the facility for Resident 1, so the SSD did not deliver them to Resident 1. The SSD stated the business office department was in charge and did not ask the social services department to deliver those letters related to the resident's financials. During a concurrent interview and record review on 8/19/2026 at 2:53 p.m. with the SSD and the Business Office Manager (BOM), Resident 1's SSA letters, dated 7/24/2026 and 7/27/2026, were reviewed. The BOM stated the BOM did not give Resident 1's SSA letters to the social services department to deliver the SSA letters to Resident 1. The BOM stated the BOM or business office personnel did not deliver Resident 1's SSA letters to Resident 1 either, because the SSA officers informed the BOM that those letters were delivered to the resident's old address as well, so the BOM thought the family probably received the SSA letters. The BOM stated that Resident 1 was not alert and oriented to handle those letters, and FM 1 was Resident 1's RP. The BOM stated the BOM did not contact FM 1 to inform FM 1 of the SSA letter addressed to Resident 1. The SSD stated that all mail addressed to residents that are delivered to the facility should be delivered to the residents or the RPs should be contacted if the residents are not alert and/or confused to handle the delivered letters. During a review of the facility's policy and procedure (P&P) titled, Confidentiality of Information and Personal Privacy, last reviewed on 1/20/2026, the P&P indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. The facility will strive to protect the resident's privacy regarding his or her: . c. written and telephone communications. During a review of the facility's P&P titled, Resident Rights, last reviewed on 1/20/2026, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to. q. access personal and medical records pertaining to him or herself.bb. communicate In person and by mail, email and telephone with privacy.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards by failing to document a resident's refusal to undergo an endoscopy (a medical test where a doctor looks inside the body using a long, thin, flexible tube with a tiny camera and light on the end) on 5/27/2026 for one of four sampled residents (Resident 1). This failure resulted in incomplete resident medical care information for Resident 1 and had the potential to result in confusion with the care and services for Resident 1 which could place the resident at risk of not receiving appropriate care. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/20/2026 with diagnoses that included heart disease (a general term for conditions that affect the heart) and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. The admission Record further indicated that Family Member (FM) 1 was Resident 1's responsible party (RP - the person who helps manage a resident's paperwork, care decisions, and financial arrangements). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/27/2026, the MDS indicated Resident 1's speech was clear, and the resident was able to be understood by others and understand others. The MDS indicated that Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired, and the resident required moderate assistance from staff with eating, oral hygiene, and personal hygiene and required maximal assistance from staff with toileting hygiene and showering/bathing self and transferring. During a review of Resident 1's history and physical (H&P - the initial evaluation and examination of a resident), dated 5/22/2026, the H&P indicated, Resident 1 was able to make needs known, however, independent medical decision-making capacity appeared limited based on available documentation. During a review of Resident 1's physician order, dated 5/21/2026, the physician order indicated that Resident 1 had an endoscopy return appointment on 5/27/2026 at general acute care hospital 1 (GACH 1) on 5/27/2026. During a concurrent interview and record review on 8/19/2026 at 4:02 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's physician order for endoscopy and the progress notes written by LVN 1 were reviewed. LVN 1 stated that LVN 1 received the report from the previous shift nurse that Resident 1 self-canceled the appointment for endoscopy, LVN 1 notified Resident 1's physician but notified Resident 1's RP about the resident's refusal for endoscopy scheduled on 5/27/2026. LVN 1 stated Resident 1's cancelation should have been documented on that day, 5/27/2026, but LVN 1 did not. LVN 1 stated if the cancelation was not documented, then it did not happen. LVN 1 stated not documenting can make other staff confused about whether the physician order for endoscopy was carried out or not. LVN 1 further stated that LVN 1 documented the resident's refusal on 8/18/2026 as a late entry. During a concurrent interview and record review on 8/19/2026 at 5:17 p.m. with the Director of Nursing Director (DON), Resident 1's physician order for endoscopy and the progress notes that LVN 1 created on 8/18/2026 timed at 7:09 p.m. were reviewed. The DON stated that LVN 1 documented the resident's endoscopy refusal that happened on 5/27/2026 on 8/18/2026 after the investigation was started and brought up to the staff. The DON further stated Resident 1's endoscopy refusal was a late entry and documented two and a half months after it occurred. The DON stated if it was not documented, then it did not happen. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed on 1/20/2026, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, last reviewed on 1/20/2026, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of change in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) . The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, that facility failed to ensure residents' Preadmission Screening and Resident Review Level II (PASRR- an in-depth, mandatory assessment conducted when a PASRR Level I screen [a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care] indicates a potential serious mental illness [SMI], intellectual disability, or related condition) recommendations were provided to two of three sampled residents (Resident 2 and Resident 3). This deficient practice resulted in the facility not arranging specialized services per PASRR Level II recommendations for Resident 2 and Resident 3.Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/16/2021 with diagnoses that included unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 6/5/2026, the MDS indicated Resident 2's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 2 required setup or clean up assistance from staff with eating, required supervision or touching assistance from staff with oral hygiene, toileting hygiene, and personal hygiene. During a concurrent interview and record review on 7/30/2026 at 10:40 a.m., with the MDS Nurse (MDSN), reviewed Resident 2's PASRR Level I screening dated 4/16/2021. The MDSN stated that Resident 2's PASRR Level I screening was positive. The MSDN stated that Resident 2 required a PASRR Level II mental health evaluation referral. During a concurrent interview and record review on 7/30/2026 at 12:38 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 2's PASRR Level II personalized care recommendations dated 5/3/2021 and Resident 2's progress notes. The ADON stated that there was no documented evidence that Resident 2's PASRR II personalized recommendations for a referral for a neuropsychology (scientific study of how the human brain relates to thinking, behavior, and emotion) consultation and a sleep specialist consultation were implemented. The ADON stated that social services department should have referred Resident 2 to neuropsychology and sleep specialist per the recommendations of PASRR Level II. b. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 6/23/2025 with diagnoses that included unspecified psychosis not due to a substance or known physiological condition, unspecified dementia (a progressive state of decline in mental abilities), depression (common mental health condition that causes a lasting feeling of deep sadness, emptiness, and a loss of interest in things you normally enjoy), and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was moderately impaired. The MDS indicated Resident 3 required setup or clean up assistance from staff with eating and oral hygiene, required supervision or touching assistance from staff with personal hygiene, and required partial/moderate assistance from staff with toileting hygiene. During a concurrent interview and record review on 7/30/2026 at 10:50 a.m., with the MDSN, reviewed Resident 3's PASRR Level I screening dated 10/12/2023. The MDSN stated that Resident 3's PASRR Level I screening was positive. The MSDN stated that Resident 3 required a PASRR Level II mental health evaluation referral. During a concurrent interview and record review on 7/30/2026 at 12:52 p.m., with the ADON, reviewed Resident 3's PASRR Individualized Determination Report dated 10/16/2023 and Resident 3's progress notes. The ADON stated that Resident 3 is a smoker. The ADON stated that there was no documented evidence that Resident 3's PASRR II personalized recommendation of a smoking cessation program was implemented. The ADON stated that is the responsibility of the MDSN to coordinate with social services. The ADON stated any PASRR II recommendations should have been relayed to the interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) and to residents' physicians for proper coordination of care. The ADON stated that potential negative outcomes that may occur from not referring to the recommended recommendations could be worsening of mental health behaviors and potential for decline in residents' physical and mental wellbeing. During a review of the facility's policy and procedures (P&P) titled, PASRR, last reviewed on 1/20/2026, the P&P indicated all new admissions and readmissions are screened or mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. A. the facility conducted a Level I PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. b. If the Level 1 screen indicated that the individual may meet the criteria for a MD, ID, RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. (2) The social worker is responsible for making referrals to the appropriate state-designated authority. The Interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.

Based on interview and record review, the facility failed to ensure an electrocardiogram (EKG- a test that measures the electrical activity of the heart) that was ordered by a physician on 6/20/2026 was completed for one of three sampled residents (Resident 1). This deficient practice resulted in the delay of necessary care and services for Resident 1.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/25/2026 with diagnoses that included heart disease (a general term for conditions that affect the heart) and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/27/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance from staff with eating, oral hygiene, and personal hygiene and required substantial/maximal assistance from staff with toileting hygiene and showering/bathing self. During a review of Resident 1's physician order dated 6/20/2026 timed at 12:07 p.m., the physician order indicated an order for EKG every day shift every 12 months starting on the 22nd for one day for the use of Abilify (used to treat schizophrenia [a mental illness that can affect thoughts, mood, and behavior] in adults and bipolar [mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks]) per pharmacy recommendation. During a concurrent interview and record review on 7/28/2026 at 2:28 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 1's physician's orders. The ADON stated that Resident 1 is currently taking Abilify and Resident 1 has a physician's order for an EKG to be done per pharmacy recommendations. The ADON reviewed Resident 1's nursing progress notes and stated that Resident 1's EKG was not done per physician's order. The ADON stated that Resident 1 should have had an EKG done on 6/22/2026 per physician's order. The ADON continued to state that it is important for the EKG to be done because it was a pharmacy recommendation based on Resident 1's use of Abilify. The ADON further stated that negative outcomes related to Resident 1's EKG not being done could be worsening of Resident 1's heart disease. When asked why Resident 1's EKG was not done, the ADON stated that there was no documented evidence that indicated the reason why Resident 1's EKG was not done. During a review of the facility's policy and procedure (P&P) titled, Availability of Services, Diagnostic, last reviewed on 1/20/2026, the P&P indicated clinical laboratory and radiology services of our residents are provided by our facility. The following diagnostic services are available twenty-four (24) hours a day, seven (7) days a week, including holidays; h. Electrocardiography.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to administer Resident 1's Abilify Maintena injection (prescription medicine given as a once-monthly injection to treat schizophrenia [a mental illness that can affect thoughts, mood, and behavior] in adults and bipolar [mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks]) as prescribed by the physician. This deficient practice resulted in Abilify Maintena injection not being administered on 6/2/2026 and could have resulted in worsening symptoms such as agitation or aggression.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/25/2026 with diagnoses that included unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/27/2026, the MDS indicated Resident 1's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance from staff with eating, oral hygiene, and personal hygiene and required substantial/maximal assistance from staff with toileting hygiene and showering/bathing self. During a review of Resident 1's physician order dated 6/1/2026, the physician order indicated an order for Abilify intramuscular (medicine delivered directly into a muscle) prefilled syringe 300 milligram (mg- unit of measurement), inject 300 mg intramuscularly one time a day every 30 day (s) for psychosis, manifested by calm to aggressive behavior towards staff as evidence by trying to hit staff during activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent interview and record review on 7/28/2026 at 12:59 p.m., with the Assistant Director of Nursing (ADON), reviewed Resident 1's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 6/2026. The ADON stated that Resident 1's Abilify intramuscular injection was not administered on 6/2/2026 as ordered. During a concurrent interview and record review on 7/28/2026 at 1:23 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that on 6/2/2026, LVN 1 was Resident 1's charge nurse. LVN 1 stated that on 6/2/2026 she did not administer Resident 1's Abilify intramuscular injection because the medication was not delivered and the medication was not available in the facility. LVN 1 stated that she called the pharmacy to ask about the medication and was waiting for the medication to be delivered. LVN 1 further stated that by the end of her shift on 6/2/2026, Resident 1's Abilify intramuscular injection was still not delivered. During a follow-up interview on 7/28/2026 at 2:38 p.m., with the ADON, the ADON stated that Resident 1's Abilify intramuscular injection should have been administered. The ADON stated that nursing staff should have followed up with the pharmacy regarding the delivery of the medication and should have made Resident 1's physician aware. The ADON stated that potential negative outcomes that could have occurred by not administering Abilify intramuscular injection could be exacerbation of symptoms such as aggressiveness towards staff and others which is what the medication was prescribed to treat. During an interview on 7/30/2026 at 2:33 p.m., with the Director of Nursing (DON), the DON stated that Resident 1's Abilify intramuscular injection should have been administered. The DON stated that nursing staff should have followed up with the pharmacy and should have documented their efforts in resolving the medication delivery issue. The DON further stated that nursing staff should have also informed the prescribing provider that Resident 1's Abilify intramuscular injection was not administered and was not delivered for their awareness. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 1/20/2026, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review the facility failed to ensure that one of three sampled residents (Resident 1) had Bioethics Committee (a multidisciplinary group that provides guidance, education and case consultations on complex moral and ethical dilemmas related to resident care) assess the need for continued psychotropic medication (medication that changes how a person, feels, or acts by adjusting brain chemicals) and sign the consent form for a psychotropic medication, Lorazepam (medication used to treat anxiety disorders [a mental health condition featuring excessive, ongoing fear and worry]) upon readmission to the facility.This deficient practice violated Resident 1's right to have bioethics committee make an informed decision regarding the use of psychotropic medications and had the potential for Resident 1 to receive unnecessary medications.Findings:During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 5/27/2011 with diagnoses that included dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range for the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 1's Interdisciplinary Conference Form (a form used by the facility when having an interdisciplinary team [a multidisciplinary group of facility staff that meets to discuss resident care within the facility] meeting) dated 8/2/2018, the Interdisciplinary Conference Form indicated Resident 1 had no resident representative, resident (Resident 1) had impaired cognition thus, unable to make his/her own decisions. The team discussed and agreed that the IDT will act on resident's behalf in selecting Resident 1's attending physician.During a review of Resident 1's History and Physical (H&P-a comprehensive assessment of a resident's medical condition) dated 8/28/2020, the H&P indicated Resident 1 does not have the capacity to understand and make decisions.During a review of Resident 1's Nursing Progress Note dated 7/3/2021, the Nursing Progress Note completed by Registered Nurse (RN) 1 indicated Resident 1 was readmitted to the facility on [DATE] following a hospitalization.During a review of Resident 1's Physician Order Summary dated 7/3/2021, the Physician Order Summary indicated a physician order for Lorazepam 0.5 milligram (mg-unit of measurement) twice a day for anxiety manifested by increased agitation.During a review of Resident 1's Facility Verification of Informed Consent dated 7/3/2021, completed by RN 1, the Facility Verification of Informed Consent indicated Resident 1 and Resident 1's Responsible Party (RP) 1 provided consent for Lorazepam 0.5mg twice a day for anxiety manifested by increased agitation and Resident 1 and RP 1 were provided information related to the risk and benefits of the psychotropic drug (Lorazepam). The Facility Verification of Informed Consent form further indicated that Resident 1 did not require bioethics committee for care decisions.During a concurrent record review and interview on 7/17/2026 at 3:00 p.m. with the Director of Nursing (DON), the Facility Verification of Informed Consent dated 7/3/2021 was reviewed, The DON confirmed that RN 1 documented that Resident 1 and RP 1 provided verbal consent for Lorazepam 0.5 mg twice day for agitation and that Resident 1 did not require a bioethics committee for care decisions. The DON confirmed that Resident 1 was under the Bioethics Committee for care decisions at that time during his admission at the facility. The DON confirmed that Bioethics Committee should have been notified and involved in making decisions regarding Resident 1's psychotropic medications upon readmission to the facility.During a review of the facility Policy and Procedure (P&P) titled admission Criteria last reviewed on 1/20/2026, the P&P indicated the objectives of our admission criteria policy are to provide uniform criteria for admitting residents to the facility, admit residents who can be cared for adequately by the facility, address concerns of residents and families during the admission process, review with the resident, and/or his/her representative, the facility's policies and procedures relating to resident rights and resident care.During a review of the facility P&P titled Psychotropic Medication Use, last reviewed on 1/20/2026, the P&P indicated residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical records.psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes determining adequate indication for use, establishing appropriate does and duration.psychotropic medications are never used to sedate or alter a resident's behavior for discipline or for the convenience of staff.prior to initiating the use of increasing the dose of, or switching a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal.the resident's/representative right to accept or decline the treatment.

Based on observation, interview, and record review, the facility failed to provide proper foot care and treatment to maintain good foot health for one of two sampled residents (Resident 10) by failing to: 1. Inspect Resident 10's skin during daily provisions (everyday care, services, and basic necessities provided to the resident to keep them safe, comfortable, and health) on 6/15/2026 to 6/28/2026 and on 7/1/2026 to 7/15/2026 as indicated in Resident 10's care plan (a document that summarizes a person's health conditions, specific care needs, and current treatments) titled, At Risk for Skin Breakdown related to Braden Risk (a scoring tool used to predict resident's risk of developing a pressure ulcer, total score ranges from zero to 18) score (Resident 10's Braden Risk score is 13 - indicates moderate risk for developing pressure ulcers/injuries [also known as pressure sores and decubitus ulcers, localized damage to skin and/or underlying tissue caused by prolonged pressure or friction, often over bony areas) and fragile skin condition 2. Provide skin and foot care to Resident 10, who had an admitting diagnosis of type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic polyneuropathy (a condition in which a person's peripheral nerves [network of cable-like nerve fibers outside the brain and spinal cord] are damaged) upon admission of Resident 10 to the facility on 5/27/2026 to 6/28/2026 and on 7/1/2026 to 7/16/2026 in accordance with the facility's policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus, last reviewed on 1/20/2026, which indicated to provide skin and foot care to residents with DM. 3. Conduct daily foot inspections and washing of feet every day for Resident 10 on 6/26/2026 to 6/28/2026 and on 7/1/2026 to 7/16/2026 in accordance with the Podiatry (a medical specialty focused on the diagnosis, treatment, and prevention of conditions affecting the feet, ankles, and lower legs) Nurse Practitioner's (NP's) recommendations, dated 6/26/2026. 4. Offload (to reduce or remove pressure on the affected area to promote healing and prevent further damage) Resident 10's heels using a pillow when in bed in accordance with Resident 10's care plan titled, Skin: Resident has a diabetic ulcer (open sore or wound on the foot that fails to heal properly, often associated with condition like diabetes and poor circulation) on left lateral (outer side) foot and is at risk for complications related to delayed healing, initiated on 6/26/2026. These failures resulted in Resident 10 developing two facility-acquired diabetic foot ulcers. Resident 10 developed on 6/26/2026 a left lateral diabetic foot ulcer measuring 0.9 centimeters (cm-unit of measurement) in length x (by) 0.9 cm in width x 0.1 cm in depth and, on 7/9/2026, it (left lateral diabetic foot ulcer) increased in size to 1.8 cm x 1.8 cm x UTD (unable to determine). Resident 10 developed, on 7/9/2026, another ulcer on Resident 10's right great toe measuring 0.8 cm in length x 0.8 cm in width x 0.2 cm in depth with necrotic (dead) tissue on wound bed (the base or bottom part of a wound, where new skin and tissue grow as the wound heals), and was tender (painful) to palpation (touched or pressed during examination). Findings: During a review of Resident 10's undated admission Record, the admission Record indicated the facility originally admitted Resident 10 on 5/27/2026 and readmitted on [DATE], with diagnoses including type 2 DM with diabetic polyneuropathy and foot ulcer, protein-calorie malnutrition (lack of sufficient nutrients in the body), difficulty in walking, chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal [relating to kidneys] failure), and vascular dementia (a progressive state of decline in mental abilities). During a review of Resident 10's Minimum Data Set (MDS-a resident assessment tool), dated 6/3/2026, the MDS indicated Resident 10 had moderately impaired cognitive skills (refers to a stage of mental decline where thinking and memory problems are noticeable to others and begin interfering with independent, everyday activities) for daily decision making. The MDS indicated Resident 10 required partial/moderate assistance (helper does less than half the effort) for bed mobility (movement) including rolling to the left and right. The MDS indicated Resident 10 did not have a diabetic foot ulcer and was identified as being at risk for developing pressure injury. During a review of Resident 10's History and Physical Examination (H&P- a comprehensive assessment of a resident's medical condition), dated 7/6/2026, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Braden Scale Assessment, dated 5/27/2026, the Braden Scale Assessment score was 13, indicating Resident 10 was at moderate risk for developing a pressure ulcer. During a review of Resident 10's care plan report titled, At risk for skin breakdown related to Braden Risk Score and fragile skin condition., initiated on 5/28/2026, the care plan report indicated interventions to check Resident 10's skin during daily provisions and to notify the physician of abnormal findings (test results, exam observations, or medical signs [any objective, observable, or measurable piece of evidence that a person has an injury, illness, or medical condition] that fall outside the usual or healthy reference range). During a review of Resident 10's Podiatry NP's Progress Note, dated 6/26/26, the Progress Note indicated a podiatry consultation was requested following Resident 10's report of painful, thick toenails and complaints regarding numbness and tingling in the bilateral (both) feet. The Progress Note indicated that the Podiatry NP assessed Resident 10 and identified a diabetic ulcer on the lateral side of the left foot measuring 0.9 cm in length x 0.9 cm in width x 0.1 cm in depth. The Progress Note indicated the Podiatry NP's recommendations included aggressive pressure offloading using heel protectors (cushioned pads designed to keep the heels floating above the bed surface) and pillows to minimize pressure; performing daily inspections for cracks, blisters, and sores; avoiding barefoot walking; washing the feet daily with warm water and drying thoroughly between the toes; applying lotion to prevent dry skin from cracking; and wearing well-fitting, supportive shoes, and clean socks. The Progress Note indicated a treatment plan to apply xeroform (a moist yellow dressing that covers the wound and promotes wound healing) and cover with dry dressing on the left lateral foot daily, continuing preventive foot care measures, and protecting the affected area from pressure, friction, and moisture-related injury (is inflammation and breaking down of the outer skin layer when the skin stays wet for a long time from body fluids like sweat, urine, stool, or wound). The Progress Note also indicated a referral order for a wound consultation (is a formal visit with a wound care specialist to evaluate a slow-healing or complex wound, find the root cause, and build a personalized treatment plan). During a review of Resident 10's Treatment Administration Record (TAR-a daily documentation record used by a licensed nurse to document treatments given to a resident), dated 7/1/2026 to 7/15/2026, the TAR indicated a physician order dated 6/26/2026 to cleanse with normal saline (NS - sterile water used to cleanse and moisten wounds), pat dry, apply xeroform to Resident 10's left lateral foot topically (applied directly), and cover with dry dressing every day shift for diabetic ulcer for 14 days. During a review of Resident 10's Change in Condition (when there is a sudden change in a resident's condition) Evaluation, dated 6/26/2026, timed at 2:11 p.m., Treatment Nurse (TN) 1 documented in the Change in Condition Evaluation indicating that this condition (diabetic ulcer) had not occurred before. The Change in Condition Evaluation indicated that during the Podiatry NP's rounds, the Podiatry NP assessed Resident 10 and observed small openings on the left lateral foot without active bleeding with a wound bed (exposed surface of an open wound) that appeared bright pink or red. The Change in Condition Evaluation indicated the Podiatry NP diagnosed the wound as diabetic ulcer on the left lateral foot and recommended treatment. During a review of Resident 10's Wound Care Consultant's (WCC-a healthcare professional who specializes in assessing, treating, and managing complex wounds to promote healing) Progress Note, dated 7/9/2026, the Progress Note indicated the WCC provided wound evaluation and treatment services. The Progress Note indicated that the left lateral foot wound measured 1.8 cm x 1.8 cm x UTD, the wound bed consisted of approximately 80 percent (%-out of every 100) necrotic eschar (dead tissue that forms a thick, dry, leathery covering over a wound and is usually attached to the wound bed) and 20% slough (soft moist, yellow, white, or gray dead tissue that is often stringy or loose), and debridement (surgical procedure to remove non-viable [not able to live, grow, or succeed] tissue) was performed. The Progress Note indicated there was a new diabetic ulcer on the right great toe measuring 0.8 cm in length x 0.8 cm in width x 0.2 cm in depth with necrotic tissue on wound bed and was tender (pain level not indicated) to palpation. The Progress Note indicated WCC's recommendations that included aggressive offloading measures, daily foot inspections, washing Resident 10's feet with warm water each day, drying carefully between the toes, and using lotion to help prevent skin from drying and cracking. During a review of Resident 10's Change in Condition Evaluation, dated 7/9/2026 timed at 4:42 p.m., the Change in Condition Evaluation indicated that during the WCC routine rounds, the WCC noted a new skin issue on Resident 10's right great toe with a small, indented scab. The WCC classified the right great toe as a diabetic ulcer. The Change in Condition Evaluation further indicated that the WCC measured the left lateral foot diabetic ulcer, and the size increased with 80 % eschar and 20 % slough and performed debridement. During a concurrent observation and interview on 7/15/2026 at 09:32 a.m. with Certified Nursing Assistant (CNA) 1 inside Resident 10's room, observed Resident 10 wearing brown socks, with both heels in contact with the bed surface. CNA 1 stated that Resident 10 had foot wounds and required assistance with repositioning and heel elevation. CNA 1 also stated that a pillow was placed under Resident 10's lower legs but both heels continued to touch the bed. CNA 1 stated Resident 10 should be wearing a heel protector, and one should be obtained for Resident 10. CNA 1 further stated that she washes Resident 10's feet on Wednesdays and Saturdays, the resident's designated shower days, but not on a daily basis (not following the Podiatry NP's recommendations). During an interview on 7/15/2026 at 12:26 p.m. with TN 1, TN 1 stated that offloading heels involves placing pillows beneath Resident 10's lower legs so that the heels do not contact the bed surface, thereby preventing pressure or friction. TN 1 stated that it is important to educate staff on the correct technique for heel elevation. During a follow-up concurrent interview and record review on 7/15/2026 at 12:26 p.m. with TN 1, Resident 10's comprehensive skin assessment dated [DATE], Braden scale assessment dated [DATE], progress notes dated 6/26/2026 to 7/9/2026, care plan titled, Risk for skin breakdown, initiated on 5/28/2026, and skin observation tasks dated 6/15/2026 to 6/28/2026 and 7/1/2026 to 7/15/2026, were reviewed. TN 1 stated that Resident 10's care plan addressing the resident's risk for skin breakdown was initiated on 5/28/2026 based on Resident 10's Braden scale risk and included interventions to inspect Resident 10's skin during daily care provisions and notify the physician about abnormal findings. TN 1 stated that CNAs assist the licensed nurses by observing and reporting any skin changes and documenting the observations in the skin observation task. TN 1 stated there were no documented evidence that skin observations were done for Resident 10 from 6/15/2026 to 7/15/2026. TN 1 stated that the frequency for skin observations had been set to as necessary rather than of daily, and acknowledged that it should have been corrected to require daily documentation in accordance with the Podiatry NP's recommendations. TN 1 stated that the diabetic foot ulcer on Resident 10's left lateral foot was first identified by the Podiatry NP on 6/26/2026. TN 1 stated that she did not read Resident 10's podiatry progress note, dated 6/26/2026, which included recommendations for daily foot inspection, washing the feet with warm water, and other preventive foot care measures. TN 1 stated that the WCC initially evaluated Resident 10 on 7/9/2026 and identified a new diabetic foot ulcer on the right great toe. TN 1 stated that according to Resident 10's wound evaluation and treatment progress note of the WCC, dated 7/9/2026, the progress note also indicated preventive recommendations including daily inspections for cracks, blisters, and sores; avoiding barefoot walking; proper foot washing and drying; lotion application; and appropriate footwear. TN 1 stated she did not implement additional recommendations made by the Podiatry NP on 6/26/2026 and the WCC on 7/9/2026 for Resident 10. TN 1 stated that Resident 10's care plan report titled, Diabetic Ulcer, initiated on 6/26/2026 and revised on 7/9/2026, should have incorporated the recommendations from both the Podiatry NP and WCC because these measures are important components of diabetic foot care. TN 1 added that timely skin assessment could have prevented the wound from opening or worsening, leading to a better outcome if all recommendations from the Podiatry NP on 6/26/2026 and the WCC on 7/9/2026 had been carried out for Resident 10. TN 1 stated that Resident 10's history of diabetes and polyneuropathy placed Resident 10 at increased risk for skin impairment. TN 1 stated that it is important to perform daily skin inspections to identify new areas of skin breakdown and prevent existing foot ulcers from worsening for Resident 10. TN 1 further stated that delayed healing could place Resident 10 at risk for infection and amputation (removal of a body part, such as a toe, foot, or leg usually because it is severely damaged, infected, or has lost its blood supply). During an interview on 7/15/2026 at 3:14 p.m. with WCC, the WCC stated that today (7/15/2026) he re-evaluated Resident 10's diabetic foot ulcers located on the left lateral foot and the right great toe. The WCC stated that he performed debridement on both diabetic foot ulcers. The WCC stated that Resident 10's diabetic foot care instructions included in the treatment plan are part of standard care and should be implemented alongside the wound care treatment. The WCC stated that residents (including Resident 10) with a history of diabetes are at increased risk for developing wounds, and that conducting regular skin and foot assessments are crucial to identify new wounds early and prevent existing ones from worsening. During an interview on 7/16/2026 at 9:24 a.m. with Registered Nurse (RN) 2, RN 2 stated that for residents with diabetes, management should include regular inspection of the lower extremities (such as toes and feet), wearing of proper footwear, and ensuring wheelchairs are equipped with footrests to prevent dangling resulting in injuries. RN 2 stated that foot care must be incorporated into the care plan as part of diabetes management to avoid complications that could lead to significant consequences, including potential loss of toes or limbs if neglected. RN 2 stated CNAs can assist by conducting daily skin checks during activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care and promptly report any issues or changes to licensed nurses. RN 2 stated that Resident 10's diabetic foot ulcers were avoidable and could have been prevented from worsening had they been identified during assessment. RN 2 stated it is important to conduct assessments to identify new areas of skin breakdown and prevent wound progression. RN 2 further stated that all nursing staff should proactively engage in resident care to help prevent skin breakdown. During a concurrent interview and record review on 7/16/2026 at 3 p.m. with the Director of Nursing (DON), the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, reviewed on 1/20/2026, Resident 10's skin observation task records dated 6/15/2026 to 6/28/2026 and 7/1/2026 to 7/15/2026, podiatry progress notes dated 6/26/2026, and wound evaluation and treatment progress notes dated 6/26/2026, were reviewed. The DON stated that proper management of nutrition and medications, along with consultation with podiatry or wound specialists is crucial for residents (including Resident 10) with a history of diabetes, particularly when wounds are present. The DON stated that according to the P&P, complications related to diabetes can include foot issues such as neuropathy, dry skin, calluses, poor circulation, ulcers, and other skin problems. The DON stated it is important to provide residents with diabetes, proper skin and foot care as indicated in the P&P, including keeping skin clean and dry, applying lotion to dry skin, when necessary (unless contraindicated), using aseptic (free from harmful germs, preventing infection, and keeping an area clean) techniques for treating lacerations (torn, ragged, or jagged wounds in the skin and soft body tissues, usually caused by blunt force impact), abrasions (scrapes, scratches, or the general wearing away of surfaces caused by rubbing or friction), or any breaks in skin integrity (a medical term for the health, wholeness, and normal strength of the skin), and promptly reporting these conditions to a supervisor. The DON stated that additional guidelines include bathing feet in warm water as needed, ensuring feet are dry, particularly between the toes, encouraging the use of non-constricting, well-fitting footwear, keeping feet warm without external heat sources, having toenails trimmed by qualified staff, and referring corn or calluses to professionals. The DON stated that these skin and foot care practices should have been added to Resident 10's care plan to prevent skin impairment or worsening of wounds. The DON stated that CNAs and Licensed Vocational Nurses (LVNs) are responsible for conducting skin assessments and proper documentation during daily care routines. The DON stated it is important to conduct skin checks to identify new areas of skin breakdown and to promptly notify the attending physician if necessary. The DON stated that without timely identification of skin changes, residents may develop wounds, and appropriate care may be delayed. The DON stated that Resident 10's left lateral and right big toe diabetic foot ulcers were avoidable because the Podiatry NP and the WCC's recommendations, as well as the facility's P&P for diabetic foot care, were not implemented. The DON stated that these recommendations, along with the foot care measures outlined in the P&P should also have been incorporated in Resident 10's diabetic foot care plan. The DON further stated that Resident 10 is at risk for potential complications including delayed healing of the foot ulcers, deterioration of condition, or amputation. During a review of the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, reviewed 1/20/2026, the P&P indicated, To provide an overview of diabetes in the older adult, its symptoms and complications. Complications Associated with Diabetes. f. foot complications - neuropathy, dry skin, calluses, poor circulation, ulcers. Skin and Foot Care. 1. Skin should be kept as dry and clean as possible. a. apply lotion to dry skin as needed, unless contraindicated. 2. Use aseptic technique on caring for any lacerations, abrasions, or breaks in skin integrity, and report the condition immediately to your supervisor. 3. Bathe feet in warm (not hot) water as necessary to keep clean. 4. Keep feet dry, especially between toes. 5. Encourage the use of non-constricting, well-fitting shoes, slippers, and hose. 6. Keep feet warm without the use of external heat source (e.g. [exempli gratia - Latin phrase meaning for example]) heating pads). 7. Toenails should only be trimmed by personnel qualified to do so (this can be regular associates and does not have to be a podiatrist). 8. Care of corn and/or calluses should be referred to qualified individuals (which may require health care provider or podiatrist intervention). During a review of the facility's P&P titled, Prevention of Pressure Injuries, last reviewed on 1/20/2026, the P&P indicated a guideline that staff should inspect skin daily during personal care. The P&P also indicated guidelines in preventing heel pressure injuries by elevating the heels of residents at risk so they do not touch the support surface, using a heel off-loading device suited to the person's mobility and activity level. If such a device is unavailable or unsuitable, standard pillows or cushions with enough height can be used to keep heels off the surface. In addition, monitoring requires evaluation, reporting, and documenting any potential skin changes, as well as continuously reviewing interventions and strategies for effectiveness.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Kitchen and storage areas were not free from dirt and food debris. Reach-in freezer vent had dust and dirt buildup. Meat reach-in freezer bottom shelves had dirt, crumbs and other food debris. Walk-in refrigerator floors had food particles, debris and milk spills. Four (4) of 4 vents in the walk-in refrigerator contained dust and dirt buildup. Walk-in refrigerator shelves had food debris Dry storage floor had noodles, oatmeal and dirt debris. Dry foods and condiment container covers had oatmeal, sugar and flour debris. Hot water dispenser spout contained hard water buildup. Trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] roof contained food splatters and was not cleaned before lunch trayline started. Utensil drawer had dirt debris and silverware was wrapped in a dirty paper towel. Two (2) of 2 fans on the trayline area had dust and dirt buildup. Residents' refrigerator by the Director of Nursing's office contained fruit residue and debris. Kitchen equipment and surfaces are not cleanable surface One (1) metal rack was corroded with rust and 1 black rack had paint coming off and had chips. [NAME] chopping board had scratches and knife marks. Mislabeled and expired trays cheese sandwiches dated 6/30/2026, ham and cheese sandwiches labeled 7/7/2026 and 6/25/2026 in the walk-in refrigerator. Sliced lemon was wrapped in a paper towel and prepared food such as hamburger patty and sliced zucchini were stored in a plastic bag. Four (4) of 4 dented cans (a packaged metal food container that have been physically deformed or crushed) were found with non-dented cans. Personal staff beverage containers were on the mixer table and on top of the dishwashing countertops. Dietary staff were wearing bracelets, rings, and a watch during meal preparation and dishwashing. Four (4) of 4 dietary staff did not wash their hands during food preparation, dishwashing and other kitchen tasks. Dietary Aide 1 (DA 1): held a soiled towel and wiped the countertop surfaces then started putting way clean pans in the storage area then proceeded to touch the lid of the trash. moved the gray trash can using his hands, drinking Gatorade (a brand of drink) and touching a clean cart containing residents' beverages and thickener then went back to the storage area to store the thickener. threw the paper liner in the trash, touched the trash can lid then went to handwashing station and washed and rinsed his hands for 5 seconds (timing using a wristwatch). DA 1 placed his hand in his mouth and proceeded to check and held meal trays without handwashing. held the trash lid, [NAME] his gloves away then held the milk carton and went into the walk-in refrigerator. DA 1 touched his face then proceeded to label the beverage cup and placed it back in the walk-in refrigerator. Dietary Aide 2 (DA 2) wiped his hands on his pants then put gloves on and started dishing out corn coleslaw. DA 2 then held the lid of the trash can then went back to dishing out corn coleslaw. dipped and washed his hands in the red sanitizing bucket and touched the clean dishes. Cross-Reference F802 [NAME] 1 washed the green bell pepper, removed her gloves and opened the trash lid with her bare hands then proceeded chopping the green bell pepper and tofu. [NAME] 1 removed her gloves and threw it in the trash can after peeling the onions then proceeded to cook. [NAME] 1 then wiped her hands using a paper towel then changed her gloves. [NAME] 1 did not wash hands after cleaning the preparation area and before touching the onion. [NAME] 1 only rinsed her hands when changing tasks. [NAME] 2 did not wash her hands after cleaning and wiping surfaces and before putting away clean pots and pans. Cross-Reference F802. DA 1 was drinking Gatorade in the dishwashing area and chewing gum during trayline, food preparation and food serving. Trays, pans and plates were not air dried and stacked wet. There was no thermometer in the resident's freezer. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 125 of 126 medically compromised residents who received food and ice from the kitchen. Findings: 1. a. During an initial kitchen tour observation on 7/13/2026 at 8:16 a.m., of the reach-in freezer, observed freezer vent had dust and dirt accumulation and the dust came off when touched. During an interview on 7/13/2026 at 8:24 a.m., with the Dietary Supervisor (DS), the DS stated the vents are cleaned by an outside vendor and they come every week. The DS stated he did not know when the vendor last cleaned the vent. The DS further stated the vent was dusty and dirty, and it was important to maintain its cleanliness to make food safe because the dust could come to the food in the freezer especially if the food is open. During a review of the facility's policies and procedures (P&P) titled, Procedure for Freezer Storage, dated 1/20/2026, the P&P indicated, Food items should be stored on clean surfaces in a manner that protects it from contamination. b. During an initial kitchen tour observation on 7/13/2026 at 8:20 a.m., of the meat reach-in freezer, observed the bottom shelves had food and dirt debris. During an interview on 7/13/2026 at 8:27 a.m., with the DS, the DS stated the meat freezer is cleaned every Wednesday but there were food crumbs on the bottom shelves that needed cleaning. The DS further stated if they do not clean the debris, the debris could get to the food, and the food gets spoiled resulting in residents getting sick of food poisoning. During a review of the facility's policies and procedures (P&P) titled, Refrigerator and Freezers dated 1/20/2026, the P&P indicated, This facility will ensure refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 11. Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis or more often as necessary. c. During an initial kitchen tour observation on 7/13/2026 at 8:34 a.m. of the walk-in refrigerator floor, food debris and milk spills on the floor observed. During an interview on 7/13/2026 at 8:44 a.m., with the DS, the DS stated the walk-in refrigerator floor was cleaned last Wednesday and there were milk spills on the floor. The DS stated it was not okay to have milk spilled on the floor because of cross contamination of food and it could attract roaches and rodents. The DS further stated pests could go to the food and contaminate it and pests could potentially spread germs to the residents. During a review of the facility's P&P titled. Refrigerator and Freezer, dated 1/20/2026, the P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. For the best results, always refer to your owner's manual. 1. Refrigerator and freezer should be on a weekly cleaning schedule. 2. Wipe up spills immediately. d. During an initial kitchen tour observation on 7/13/2026 at 8:34 a.m. of the walk-in refrigerator vents, observed 4 of 4 vents had dust and dirt accumulation. During an interview on 7/13/2026 at 8:51 a.m. with the DS, the DS stated the staff cleaned the vent two weeks ago and there are 4 vents with dirt accumulation. The DS further stated that it was not okay to have dirt accumulation on the vents as it could blow air in the food and dust could go to the food causing cross-contamination. During a review of the facility's policy and procedure (P&P) titled, Hood, Filters, and Vents, dated 1/20/2026, the P&P indicated, Vents must be free of dust and dirt. e. During an observation on 7/13/2026 at 8:34 a.m., of the walk-in refrigerator shelves, observed food debris on the shelves. During an interview on 7/13/2026 at 8:40 a.m., with the DS, the DS stated the racks and shelves should be cleaned to prevent cross contamination and make sure the food is safe. During a review of the facility's P&P titled, Shelves, Counters, and Other Surfaces including Sinks (Handwashing, Food Preparation, etc.) dated 1/20/2026, the P&P indicated, Cleaning procedure: 1. Remove any large debris and wash surface with a warm detergent solution following manufacturer's instructions. f. During a concurrent observation and interview on 7/13/2026 at 9:18 a.m., of the dry storage room with the DS, the floor had oatmeal and dirt debris. The DS stated the floor has spaghetti pasta and food particles, and it was important to maintain the cleanliness of the floor to prevent pest, rodents and cockroaches as they could spread germs to the residents. During a review of the facility's P&P titled, Storage of Food and Supplies dated 1/20/2026, the P&P indicated, 1. The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. During a review of the facility's P&P titled, Storeroom, dated 1/20/2026, the P&P indicated, The general cleanliness and care of the storeroom and supplies are important to ensure safe wholesome food. 1. The floor, walls, ceiling, lights, shelves and equipment must be kept clean by setting up, maintaining, and monitoring a regular cleaning schedule. Routine inspection must be made to ensure cleanliness and high standards of sanitation. g. During a concurrent observation and interview on 7/13/2026 at 9:22 a.m. of the condiment containers with the DS, the oatmeal, sugar and flour cover had food debris observed. The DS stated the food debris on the cover of the condiment containers was not okay as it could attract pets resulting in possible cross-contamination. During a review of the facility's P&P titled, Storage of Food and Supplies, dated 1/20/2026, the P&P indicated, Food and supplies will be stored properly and in a safe manner. 5. Routine cleaning and pest control procedures should be developed and followed. 6. Dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. During a review of the facility's P&P titled, Ingredient Bins, dated 1/20/2026, the P&P indicated, Ingredient bins must be kept clean and covered to prevent food contamination. h. During an observation on 7/13/2026 at 11:24 a.m., of the hot water beverage dispenser, the spout had hard water buildup and dirt debris was observed. During a concurrent observation and interview on 7/13/2026 at 2:24 p.m., of the hot water dispenser with the DS, observed the spout contained white buildup. The DS stated the hot water dispenser was cleaned last Wednesday (7/8/2026) and it had some crusting from the water. The DS further stated the spout had a hard water buildup, and it was not okay because the debris could come off and contaminate the hot water. During a review of the facility's P&P titled, Coffee and Brewing Equipment, dated 1/20/2026, the P&P indicated, Coffee urns and coffee service equipment must be free from stains and foreign film buildup. I. During an observation on 7/13/2026 at 11:26 a.m., of the trayline roof, food splatters on the trayline roof observed. During an interview on 7/13/2026 at 1:40 p.m., with the DS, the DS stated the trayline is cleaned every after meal between 10 a.m.-12 noon. The DS stated the trayline roof was not cleaned as there were food spills. The DS further stated it was important to clean the food spill before the start of each meal because the food spill could go to the food resulting in cross-contamination. During a review of the facility's P&P titled, Steam Table, dated 1/20/2026, the P&P indicated, The following procedure should be used to clean the steamtable. 1. Clean after each meal. j. During an observation on 7/13/2026 at 11:32 a.m., of the utensil drawer, observed dirt debris where there were kitchen utensils. During a concurrent observation and interview on 7/13/2026 at 2:21 p.m., of the kitchen utensil drawer with the DS, observed dirt debris where kitchen utensils were stored. The DS stated inside the drawer was silverwares wrapped in a dirty paper towel and there was dirt debris in the drawer. The DS stated it was not okay to have dirt debris in the utensil drawer and dirty paper towel because of cross-contamination. During a review of the facility's P&P titled, Cabinets and Drawers, dated 1/20/2026, the P&P indicated, Clean cabinets and drawers on a weekly basis. k. During an observation on 7/14/2026 at 9:45 a.m., of the fans by the trayline, observed 2 of 2 fans contained dust buildup. During an interview on 7/14/2026 at 9:46 a.m., with the DS, the DS stated he was not sure when the last time the fans by the trayline were cleaned by staff however, it had dust buildup. The DS further stated the fans can blow dust to the plates by the trayline and could potentially cause cross-contamination of food. During a review of the facility's P&P titled, Sanitation dated 1/20/2026, the P&P indicated, The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures, and the hood over stove, which will be cleaned by the maintenance staff. l. During a concurrent observation and interview on 7/15/2026 at 11:30 a.m., of the residents' refrigerator with the DS and Registered Nurse 2 (RN 2), observed dirt debris on the refrigerator surfaces. RN 2 stated it was important to maintain the cleanliness of the refrigerator to prevent rotten foods. RN 2 stated the residue in the refrigerator is from the fruits and it was important to clean it to prevent bacterial growth and unnecessary foreign microbes. The DS stated residents could potentially get sick of food poisoning because of cross contamination. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. 2. a. During an initial kitchen tour observation on 7/13/2026 at 8:34a.m., of the walk-in refrigerator, observed one metal rack was corroded with amber discoloration and the black racks had chips and paint was coming off. During an interview on 7/13/2026 at 8:40 a.m., with the DS, the DS stated the walk-in refrigerator should be cleaned and free from rust however he was aware that there are some racks that are rusted and requested for them to be replaced two (2) months ago. The DS stated he did not follow up with maintenance department about the replacement; the administrator was not aware of it hence he did not know what was taking them so long to replace the metal racks. The DS further stated the racks in the walk-in refrigerator were corroded and the paint was peeling off and it was not okay because of cross contamination of food. During a review of the facility's P&P titled, Refrigerator and Freezer, dated 1/20/2026, the P&P indicated, Periodically inspect shelves and replace if coating is chipped away exposing metal shelves. b. During an observation on 7/13/2026 at 11:30 a.m., of the white chopping board in the preparation area, observed visible knife marks and scratches on the white chopping board. During a concurrent observation and interview on 7/13/2026 at 2:17 p.m., of the preparation area with the DS, observed the white chopping board with scratches. The DS stated dietary staff prepare sandwiches in the area, and they needed to buy a new chopping board because the current chopping board contained knife markings. The DS stated the white chopping board is not a cleanable surface because they would not be able to clean in the marks and scratches. The DS further stated there would be bacterial growth if surface is not a cleanable surface potentially causing cross-contamination. During a review of the facility's P&P titled, Sanitation dated 1/20/2026, the P&P indicated, All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 3. During an observation on 7/13/2026 at 8:40 a.m. of the walk-inrefrigerator, observed tray of sandwiches not labeled. During a concurrent observation and interview on 7/13/2026 at 9:06 a.m., of the tray of sandwiches with the DS, observed the trays of sandwiches labeled and dated as follows: A tray of cheese sandwiches 6/30/2026 A tray of ham and cheese sandwiches 7/7/2026 A tray of ham and cheese sandwiches 6/25/2026. The DS stated the dietary staff did not put the correct date, and the sandwiches might be too old. The DS further stated it was important to date food correctly so they do not serve expired food to the residents that could cause foodborne illnesses. During a review of the facility's P&P titled, Refrigerator and Freezers dated 1/20/2026, the P&P indicated, 7. All foods are appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened. 9. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. During a review of the facility's P&P titled, Labeling and Dating of Foods, dated 1/20/2026, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. All prepared foods need to be covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray with masking tape if going to be used for meal service (i.e. salads, drinks, and other miscellaneous items for trayline). During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. 4. During an observation on 7/13/2026 at 8:53 a.m., of the walk-in refrigerator shelves, observed a lemon cut into halves wrapped in paper towel and the eggs were in plastic. Observed the DS transferred the lemon and eggs to a disposable container. The DS stated the hash brown, egg and lemon were left over foods, and staff were supposed to keep leftovers in a different container or disposable container. The DS further stated the lemon wrapped with paper towel is not okay because paper towel was open and the food should be in a sealed container and it was not labeled. The DS stated the hamburger and sliced zucchini were stored in plastic. The DS stated they have enough pans and containers in the kitchen to store food and make the food safe. The DS stated he needed to provide an in-service for labeling and dating to prevent serving spoiled and contaminated foods to the residents. During a review of the facility's P&P titled, Storing Produce dated 1/20/2026, the P&P indicated, 7. Keeping fresh vegetables tightly wrapped with as little air in the bag/container as possible will keep them fresh longer. During a review of the facility's P&P titled, Leftover Foods, dated 1/20/2026, the P&P indicated, Leftover foods will be stored and served in a safe manner. During a review of the facility's P&P titled, Labeling and Dating of Foods, dated 1/20/2026, the P&P indicated, leftovers will be covered, labeled and dated. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 5. During a concurrent observation and interview on 7/13/2026 at 9:30a.m., of the dry storage area with the DS, observed 4 dented cans stored with non-dented cans. The DS stated they keep the dented cans separately from non-dented cans at bottom of the racks but there was no label of dented cans section. The DS stated they need to separate dented cans from non-dented cans because there may be little pieces of cans that could contaminate the food and if it's not separated staff might use them. During a review of the facility's P&P titled, Storage of Food and Supplies, dated 1/20/2026, the P&P indicated, Food in unlabeled rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used. During a review of the facility's P&P titled, Food Storage-Dented Cans, dated 1/20/2026, the P&P indicated, food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used by the facility. All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed of immediately. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 6. During an observation on 7/13/2026 at 11:28 a.m., of the mixer table,observed water bottle on the mixer table. During an observation on 7/13/2026 at 11:33 a.m., of the dishwashing area countertops, observed Gatorade bottle, water bottle and a tumbler on top of the shelves. During an interview on 7/13/2026 at 1:46 p.m., of the DS and Registered Dietitian (RD), the DS stated the dietary staff were not supposed to drink in the kitchen. The RD stated the only time they could eat in the kitchen is when they are tasting and testing food for the residents. The RD stated the drinks should be kept in the office, so it is away from food preparation. The RD stated the bottled water on the mixer table and the tumbler, and Gatorade belong to dietary staff. The RD stated the staff are not allowed to store personal belongings in the kitchen and preparation area because of sanitation, especially if they do not wash their hands. The DS stated cross contamination and saliva could get in the food if the staff are drinking and talking. During a review of the facility's P&P titled, Handwashing Procedure dated 1/20/2026, the P&P indicated, Food and Nutrition Service staff personal items such as coats, purses, etc. will be stored in a designated place. These items are not stored with food or in the kitchen. 7. During an observation on 7/13/2026 at 11:34 a.m. of the dishwashing process, observed DA 1 wearing a ring on his middle finger, a silver bracelet and a leather bracelet while dishwashing and cleaning surfaces. During an observation on 7/13/2026 at 12:14 a.m., of trayline lunch service, observed DA 2 was wearing a wristwatch while scooping corn coleslaw from the pan to the disposable wares. During an interview on 7/13/2026 at 1:53 p.m. with the DS and the RD, the RD stated dietary staff should not wear big hoops earrings, but small stud earrings are okay and minimal jewelry if possible. The DS stated dietary staff should not wear studs, rings with stones, watches and bracelets but plain bracelets are allowed and matrimonial rings with no diamonds. The DS further stated diamonds could go to the resident's food and could cause choking, and the watches and bracelet could touch the food causing cross-contamination. During a review of the facility's P&P titled, Dress Code dated 1/20/2026, the P&P indicated, 9. No excessive jewelry, just wedding ring on hand, non-dangling earrings on ears, and wristwatch. Wristwatch and wedding rings needed to be covered with gloves when food handling. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. 8. a. i. During an observation on 7/13/2026 at 11:34 a.m., of thedishwashing area, observed DA 1 went from dirty to clean area, held a towel and wiped the countertop surfaces. Observed DA 1 proceeded to put away the clean pans and touched the lid of the trash without washing his hands. Ii. During an observation on 7/13/2026 at 11:48 a.m., of the dishwashing area, observed DA 1 moved and pushed the grey trash can, drank Gatorade then proceeded to push the cart with resident's drinks and thickener and placed the thickener back in the storage area without washing his hands. During an observation on 7/13/2026 at 11:53 a.m., of DA 1 assisting in trayline, observed DA 1 supplied milk on the residents' trays and scooped ice from the ice machine. iii. During an observation on 7/13/2026 at 12:45 p.m., of DA 1 working in trayline, observed DA 1 held the trash can, threw the paper liner in the trash then proceeded to the handwashing station. Observed DA 1 washed his hands and rinse it for five (5) seconds then proceeded to trayline and held a meal tray. During an observation on 7/13/2026 at 12:48 p.m., of DA 1 working in trayline, observed DA 1 placed his hand in his mouth and then continued handling food trays without washing his hands. iv. During an observation on 7/13/2026 1:05 p.m. of DA 1 working in trayline, observed DA 1 held the trash can lid, threw away his gloves then proceeded to hold the milk and went to the walk-in refrigerator without washing his hands. Observed DA 1 touched his face then proceeded to label the beverage cups and placed it in the walk-in refrigerator without washing his hands. During an interview on 7/13/2026 at 2:07 p.m., with the RD, the RD stated DA 1 should wash his hands when putting his hand in his mouth due to because of saliva contamination. b. i. During an observation on 7/13/2026 at 12:14 a.m., of trayline lunch service, observed DA 2 wiped his hands on his pants and wore gloves and started dishing out corn coleslaw without washing his hands. During an observation on 7/13/2026 at 12:21 p.m., of DA 2 working in trayline, observed DA 2 held the lid of the trash then proceeded to dish out corn coleslaw without washing his hands. ii. During an observation on 7/14/2026 at 9:20 a.m., of the dishwashing process, observed DA 2 in the clean area dipped his hands in the red bucket containing sanitizer and water then put away clean dishes. During an observation on 7/14/2026 at 9:22 a.m., of the dishwashing process, observed DA 2 dipped his hands in the red bucket then put away clean dishes. During a concurrent observation and interview on 7/14/2026 at 9:41 a.m., of DA 2 dishwashing with the DS and DA 2, observed the DS dip his hands in the red bucket. The DS stated DA 2 placed his hands in the sanitizer bucket. DA 2 stated he dipped his hands in the sanitizer bucket because his co-worker told him to do so but he does not know the reason why. The DS stated DA 2 was not supposed to dip his hands in the sanitizer because it is used to clean surfaces and carts and not used to clean hands. The DS further stated cleaning of hands is done by going to the handwashing sink and handwash to prevent cross-contamination. c. i. During an observation on 7/13/2026 at 12:55 p.m., of food preparation, observed [NAME] 1 washed the green bell pepper, removed her gloves, touched the trash lid then threw the gloves in the trash. [NAME] 1 proceeded to cut and chopped the green bell peppers and tofu without washing her hands. ii. During an observation on 7/13/2026 at 1:03 p.m., of the food preparation, observed [NAME] 1 peeled an onion, removed her gloves then threw it in the trash can then wiped her hands with a paper towel then proceeded to cook without handwashing. During an interview on 7/13/2026 at 1:59 p.m., with the DS and the RD, the DS stated dietary staff should wash their hands when going outside and returning to the kitchen, after touching their face, hair and clothes. The RD stated dietary staff should wash their hands when touching the phone, in between tasks, when they pick up something on the floor, when something spills, handling dirty trays from outside, after cleaning, touching the trash and before starting to work. The RD further stated dietary staff should wash their hands for 20 seconds to make sure all the germs come out of their hands. During an interview on 7/13/2026 at 2:09 p.m., with the RD, the RD stated [NAME] 1 should have washed hands after washing the bell pepper, after throwing her gloves

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (menu tickets) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. This failure had the potential to violate 125 of 126 residents' rights for privacy and confidentiality of personal and medical records. Findings: During an observation on 7/14/2026 at 9:25 a.m., of the dishwashing process in the dishmachine area, observed Dietary Aide 3 (DA 3) throwing the leftover foods, plastic and menu tickets into the grey trash can. During an observation on 7/14/2026 at 9:27 a.m., of DA 3 dishwashing, observed DA 3 threw the meal ticket in the trash can. During a concurrent observation on 7/14/2026 at 9:28 a.m., of DA 3 dishwashing with the Dietary Supervisor (DS), observed DA 3 continue to throw meal tickets in the trash from the soiled trays. The DS stated their process of dishwashing starts by throwing all the trash in the garbage can including the meal tickets. The DS stated DA 3 came from the sister facility and he did not provide training before starting to work and help in their facility. During an interview on 7/14/2026 at 9:34 a.m., with the DS, the DS stated after dishwashing is done, the staff take the trash to the outside dumpster. The DS further stated the first step of dishwashing is to dispose of the meal tickets in the trash during stripping of the trays (removing trays from the cart and clearing from the solid waste and food leftovers). The DS stated the meal tickets contained residents' food likes and dislikes, food allergies, name of the residents, ID number (medical record), diet order, and room number. The DS stated throwing meal tickets in the trash is not good practice because the meal tickets contained PHI, including name and picture of the resident. The DS further stated they needed to separate the menu tickets and shred it before disposing due to Health Insurance Portability and Accountability Act (HIPPA, a federal law designed to protect sensitive patient health information from being disclosed without the resident's consent). The DS stated throwing the meal tickets in the trash is not protecting residents' health information and other people could get the residents information and use them as a potential outcome. During an interview on 7/14/2026 at 3:48 p.m., with the Director of Nursing (DON), the DON stated the menu ticket contained name, room number, age, gender, allergies, diet preferences, diet order, diet order, ID number which is the residents medical record number, and the picture of the residents. The DON stated they should have shredded the menu tickets before throwing it in the trash because it contained PHI and needed to be protected. The DON stated they violated HIPPA by throwing it in trash and the information was exposed to other people. During a review of the facility's policy and procedure (P&P) titled, Protected Health Information (PHI) Management and Protection of, dated 1/20/2026, the P&P indicated, Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws. 1. It is the responsibility of all personnel who have access to resident and facility information to ensure such information is managed and protected to prevent unauthorized release or disclosure.10. Health information may be considered not to be individually identifiable in the following circumstances: a. A person with appropriate knowledge and experience with generally acceptable statistical and scientific principles and methods determines that the risk is very small that the information could be used, alone, or with other reasonably available information, to identify the resident who is the subject of the information; or b. The following identifiers of the resident (and relatives, employers or household members) are removed: Names Medical record numbers Full face photographic images Any other unique identifying number, or characteristic code. During a review of the facility's P&P titled, HIPPA Training Program, dated 1/20/2026, the P&P indicated, All facility personnel, including business associates, are required to attend our facility's HIPPA compliance training program. 1. To ensure the confidentiality of our resident's protected health information (PHI) and facility information, a HIPPA and data security training program will be provided for all employees and business associates who have access to protected health information.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when: 1. One (1) of two (2) dumpsters (a movable waste container designed to be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) was not closed when not actively being used. 2. Two of two trash cans in the kitchen were not properly covered and closed while not actively being used during lunch trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). 3. The dumpster body had dirt and food debris. 4. The surrounding area of the dumpster contained soiled gloves These failures had the potential to attract pests such as rats, cockroaches, flies, and ants, which may spread diseases to 126 of 126 residents living in the facility. Findings: 1. During an observation on 7/13/2026 at 8:10 a.m., observed one of two dumpsters were open and was not actively being used. During an interview on 7/14/2026 at 10:44 a.m., with the Maintenance Supervisor (MS), the MS stated the dumpster needed to be covered all the time to prevent birds from picking up the trash and spreading infections to the residents. 2. During an observation on 7/13/2026 at 12:02 p.m., of the grey trash can by the preparation area, observed the grey trash can was not completely closed. During an observation on 7/13/2026 at 12:52 p.m., of the grey trash can by the preparation area, observed one grey trash not completely closed and it was not being used. During an observation on 7/13/2026 at 1:01 p.m., of the grey trash cans by the preparation area and dishwashing area, observed two trash cans not completely closed and they were not being used. During a concurrent observation and interview 7/13/2026 at 2:14 p.m., of the trash cans in the kitchen with the Dietary Supervisor (DS) and the Registered Dietitian (RD), observed the trash cans by the preparation area and dishwashing area were not completely closed and they were not actively being used. The DS stated trash cans should be covered when not in use. The RD stated it was important to cover the trash, and it should be securely closed but it was not closed. The DS stated pests could cause cross contamination and spread germs to the residents. 3. During a concurrent observation and interview on 7/14/2026 at 10:37 a.m., with the DS, observed the dumpster surrounding and dumpster body. The DS stated they throw food in the outside dumpster. The DS stated there were food debris on the body of the dumpster and it was not okay and the trash needed to be clean because flies can go to it and spread germs to the residents as a potential outcome. 4. During a concurrent observation and interview on 7/14/2026 at 10:37 a.m., of the outside dumpster with the MS, observed soiled gloves on the floor of the dumpsters. The MS stated he was the one maintaining the dumpster area and the truck picks up trash five days a week, but they do not have a particular day of pickups. The MS stated the dumpster needs to be clean to make sure there are no birds to pick up the trash and spread infections to residents. The MS stated the janitor cleans the dumpster, but it was not clean due to visible debris. The MS stated there were only two (2) soiled dishes on the floor and the debris on the dumpster body was new. During a review of the facility's policy and procedure (P&P) titled, Miscellaneous Areas, dated 1/20/2026, the P&P indicated Garbage and trash can must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean.The area must be swept and washed down by maintenance with a detergent on a regular basis. During a review of Food Code 2022, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents' (Resident 5 and Resident 4) drug regimen were free from the use of unnecessary (any medication with excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind emotions, and behavior) medications in accordance with the facility policies and procedures (P&P) by failing to: 1. Implement the physician's order to obtain orthostatic blood pressures (taking blood pressure measurements when lying, sitting, and standing to detect for significant drop in blood pressure during each position change) for Resident 5, who was receiving risperidone (an antipsychotic [medication that works by changing the effects of chemicals in the brain] medication). 2. a. Ensure the target behavior (specific, observable, and measurable behavioral symptom) for Resident 4 receiving quetiapine (an antipsychotic medication used to treat certain mental/mood conditions) was specific to allow for effective monitoring and evaluation by the licensed nurses. b. Ensure Resident 4's alprazolam (an anti-anxiety medication) daily dosage parameters were followed. These failures had the potential to place Resident 4 and 5 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic medications, resulting in impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.Findings: a. During a review of Resident 5's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 5 on 5/15/2026 with diagnoses that included psychosis, dementia (a progressive state of decline in mental abilities) and hypertension (high blood pressure). During a review of Resident 5's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 5/24/2026, the MDS indicated Resident 5 usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated Resident 5's had severe cognitive (ability to learn, think, remember and make decisions) impairment. The MDS indicated Resident 5 was dependent (helper does all of the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility. The MDS indicated Resident 5's active diagnosis included psychotic disorder (a condition characterized by delusions and/or hallucinations, often resulting in a loss of contact with reality), depression, and dementia. The MDS indicated Resident 5 is taking antipsychotic. During review of Resident 5's History and Physical (H&P), dated 5/20/2026, the H&P indicated Resident 5 does not have the capacity to make decisions or make needs known. During a review of Resident 5's physician orders, the physician orders indicated the following orders dated 5/19/2026: -Risperidone oral tablet 1 milligram (mg-unit of measurement used for medication dosage and/or amount) by mouth two times a day for psychosis manifested by agitation as evidence by (AEB) trying to hit staff during ADLs. -Risperidone oral tablet 1 mg by at bedtime for psychosis manifested by AEB trying to hit staff during ADLs. -Orthostatic blood pressure (B/P) every Saturday. Take B/P while lying in bed then repeat upon sitting (Lying) every day shift every Saturday for Risperdal (brand name of Risperdone) use. -Orthostatic B/P every Saturday. Take B/P while lying in bed then repeat upon sitting (Sitting) every day shift for Risperdal use. During a review of Resident 14's care plan titled, [Resident] uses psychotropic medication Risperdal last revised on 6/14/2026, date initiated 5/25/2026, the care plan indicated the goal as The resident will be/remain free of psychotropic drug related complications, including.hypotension. The care plan indicated an intervention to monitor the resident for side effects (unintended response to a medication or medical intervention). During a concurrent interview and record review on 7/16/2026 at 12:28 p.m. with the Assistant Director of Nursing (ADON), Resident 5's physician orders and Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 06/2026 and 07/2026 were reviewed. The ADON stated that there was supposed to be two separate BP blood pressures taken for Resident 5 every Saturday; while lying in bed and while sitting in bed. The ADON stated that the MAR should have two distinct sections for documenting Resident 5's BP to reflect that the blood pressure was done per the physician orders. The ADON stated that the MAR should have one section for recording the BP value and another specifying Resident 5's position, if lying or sitting. The ADON stated that it is important that Resident 5's BP was measured as per the physician orders. The ADON stated that Resident 5 was receiving antipsychotics and that one of the side effects of antipsychotics was a drop in BP. The ADON stated that if Resident 5's BP is not measured properly, a drop in BP could be missed which may result in Resident 5 having a fall. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use Residents last reviewed 1/20/2026, the P&P indicated, Residents receiving psychotropic medication are monitored and the response to treatment is documented. Monitoring may include lab results, vital signs, progress notes, behavior flow sheets, medication administration records, and the drug regimen review from the consultant pharmacist. In addition, residents are monitored for adverse consequences associated with psychotropic medications, including cardiovascular effects - .increased blood pressure, orthostatic hypotension. During a review of the facility's policy and procedure (P&P) titled, Blood Pressure. Monitoring last reviewed 1/20/2026, the P&P indicated that to measure orthostatic blood pressure, repeat the same steps taken with how to take blood pressure after helping the resident to a standing position. b. During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included psychosis, anxiety (feelings of uneasiness) and history of fall. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 4 required substantial/maximal assistance (helper does more than half the effort) with eating. The MDS indicated Resident 4 takes an antipsychotic and anti-anxiety medication. b.1.During a review of Resident 4's Physician's Orders, dated 6/12/2026, the order indicated: Seroquel 100 mg, give one tablet by mouth two times a day for psychosis manifested by sudden anger outburst of anger. During a review of Resident 4's Medication Regimen Review (MRR-a process when the facility's pharmacist consultant conducts a comprehensive review of the facility residents' medications) covering the dates 6/15/2026 to 6/16/2026, the MRR indicated the pharmacist recommended the following: Seroquel for sudden outburst of anger may be seen as too vague and subjective and thus make this medication be considered inappropriate by surveyors. Clarify behaviors and be specific. During a review of Resident 4's Care Plan for Psychotropic Medication, initiated 6/19/2026, the care plan indicated Resident 4 is on Seroquel. The care plan indicated a goal that the resident will not suffer from any adverse effects from the medication use. The care plan indicated an intervention to monitor resident behaviors and report ineffectiveness of medication to provider if needed. During a concurrent interview and record review with Licensed Vocational Nurse 4 (LVN 4) on 7/15/2026 at 4:16 p.m., LVN 4 reviewed Resident 4's Physician's Orders which included the medication, Seroquel. LVN 4 stated there should be specific behaviors in the order, so that licensed nurses can be specific in their assessment. LVN 4 stated the licensed nurses may not know if the medication is effective if the behaviors are not specific to the resident. During a concurrent interview and record review with the ADON on 7/16/2026 at 9:13 a.m., the ADON reviewed Resident 4's Physician's Orders which included the medication Seroquel. The ADON stated outburst of anger is too vague. The ADON stated the order should have been clarified. The ADON stated it is important to monitor for specific behavior to see if it is improving or worsening and notify Resident 4's psychiatrist. The ADON stated this is important, ensuring Resident 4 is free from unnecessary medication and free from side effects such as sedation, drowsiness and risk for fall. During an interview with LVN 3 on 7/16/2026 at 12:13 p.m., LVN 3 stated she observed Resident 4's behaviors of yelling and screaming for no reason. b.2. During a review of Resident 4's Physician's Orders, the orders indicated the following: Alprazolam tablet 0.5 mg, give one tablet by mouth every eight hours as needed for anxiety for 14 days, manifested by increase restlessness. Not to exceed (NTE) 0.75 mg in 24 hours, dated 6/12/2026 and discontinued 6/28/2026. During a review of Resident 4's MAR covering the dates 6/12/2026 to 6/30/2026, the MAR indicated Resident 4 was given two doses of alprazolam on 6/25/2026. During a concurrent interview and record review with LVN 4 on 7/16/2026 at 9:20 a.m., Resident 4's Physician's Orders which included the medication, alprazolam were reviewed. LVN 4 stated that NTE 0.75 mg meant alprazolam administered to Resident was not to exceed 0.75 mg in 24 hours period. LVN 4 stated the dosing parameters should have been clarified with Resident 4's psychiatrist to see if they wanted the 0.75 mg daily limit. Two doses given in a day would be 1 mg given, which is over the 0.75 mg daily limit. During a concurrent interview and record review with the Director of Nursing (DON) on 7/16/2026 at 11:33 a.m., the DON reviewed Resident 4's Alprazolam physician order and 6/2026 MAR. The DON stated if the Alprazolam was ordered not to exceed 0.75 mg, then there should not be two doses given on 6/25/2026, which would be over the daily limit. The DON stated Resident 4's psychiatrist should be called to see if they want the daily limit to be 0.75 mg. The DON stated it is important to follow the physician's orders so that Resident 4 would not be at risk for impaired coordination and sedation. During a review of the facility's P&P titled, Psychoactive/ Psychotropic Medication Use, last reviewed 1/20/2026, the P&P indicated the following: -A psychotropic medication is any drug that affects brain activities associated with mental processes and behavior which includes antipsychotic medications. -Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes: determining adequate indications for use, adequate monitoring for efficacy and adverse consequences, and preventing, identifying, and responding to adverse consequences. -Adequate indication for use refers to the identified, documented clinical rationale for administering medication that is based on an assessment of the resident's condition and therapeutic goals. During a review of the facility's P&P titled, Administering Medications, last reviewed 1/20/2026, the P&P indicated the following: -Medications are administered in accordance with prescriber orders, including any required time frame. -If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity and respect by failing to: 1. Ensure residents were not served side dishes in paperware during lunch time. 2. Ensure Certified Nursing Assistant 3 (CNA 3) was not standing over one of one sampled resident (Resident 101) while assisting with eating. This deficient practice had the potential to affect 70 of 126, including Resident 39 and Resident 101, residents' self-esteem and self-worth. Findings: 1. During a review of Resident 39's admission Record, the admission Record indicated the facility initially admitted Resident 39 on 2/1/2023 and readmitted the resident on 1/8/2026 with diagnosis including, but not limited to essential hypertension (HTN, high blood pressure), type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with hyperglycemia (high blood sugar), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) with acute exacerbation (a sudden, significant worsening). During a review of Resident 39's Minimum Data Sheet (MDS- a resident assessment tool) dated 4/10/2026, the MDS indicated Resident 39 understood others and was able to make self-understood. The MDS indicated Resident 39 is independent (resident completes the activity by themself with no assistance from a helper) when eating. During a review of Resident 39's Order Summary Report, dated 4/10/2026, the Order Summary Report indicated Resident 139 had an order for consistent carbohydrate diet (CCHO, a diet used to manage blood sugar levels by providing the same amount of carbohydrates each meals), International Dysphagia Diet Standardization Initiative (IDDSI, globally standardized framework used to describe and classify texture of food and thickness of liquids for individual with swallowing difficulties) level six (6) texture (soft and bite size, consist of soft, moist, and tender foods require chewing before swallowing. Food must be cut into bite-sized pieces less than or equal to 1.5 centimeter x 1.5 centimeter) with thin consistency for liquids. During an observation on 7/13/2026 at 12:12 p.m., observed dietary staff serving corn coleslaw on paperware bowls. During an observation on 7/13/2026 at 12:14 p.m., observed Dietary Aide 2 (DA 2), serving corn coleslaw on paperware bowls in trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). During an observation on 7/13/2026 at 12:21 p.m., observed DA 2 serve corn coleslaw on paperware bowls. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 7/13/2026 at 1:16 p.m., of the regular diet with the Dietary Supervisor (DS), the DS stated paperwares are being used since he started his employment because of Coronavirus disease (COVID-19 a highly contagious respiratory illness) and they had to buy every two weeks because the residents throw them away. The DS stated residents did not request their dishes to be placed on paperware and it was not okay and good practice due to residents' dignity. During an interview on 7/13/2026 at 1:21 p.m., with the Registered Dietitian (RD), the RD stated the reason why they use paperware is because the side dishes were thrown away and they tried educating nurses not to throw them. The RD stated the residents may not eat the food and lose weight as a potential outcome of food served on paperwares. During an interview on 7/14/2026 at 12:54 p.m., with Resident 39, Resident 39 stated it would be better if cups, spoons and forks, and side dishes are not in disposable or plasticwares. During an interview on 7/15/2026 at 11:54 a.m., with Resident 39, Resident 39 stated it was discussed in the resident council that the facility will start using plasticwares instead of silverware because residents could use it as weapon to cut themselves, however with the use of disposable beverage container, and side dishes, he did not agree with it. Resident 39 stated it did not bother him; however, it would be nice to serve in regular beverage containers and silverwares at it helped them eat the meat and vegetables because it is sturdy (not easily broken) compared to plastic. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 1/20/2026, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. During a review of the facility's meeting minutes titled, Quarterly Quality Assurance/Utilization Review Committee Meeting, dated 4/16/2026, the minutes indicated, the facility will limit and eliminate standard silverwares and plastic cups during meals to best preserve the odds of preventing unwanted accidents or incidents. The minutes did not specify the use of disposable side dishes being disposable. 2. During a review of Resident 101's admission Record, the admission Record indicated the facility admitted the resident on 5/4/2026 with diagnoses that included dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). During a review of Resident 101's MDS dated [DATE], the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 101 required partial/moderate assistance (helper does less than half the effort) with eating. During a review of Resident 101's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) for Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) initiated 5/6/2026, the care plan indicated a goal that Resident 101 will have needs anticipated and met by staff. The care plan indicated an intervention, initiated 7/15/2026, that Resident 101 requires extensive assistance with eating. During a concurrent observation and interview on 7/16/2026 at 8:18 a.m., with CNA 3, observed CNA 3 feeding Resident 101 in his wheelchair by his bed. CNA 3 was standing and not at eye level while feeding Resident 101. When asked how she feeds a resident, CNA 3 stated she should be sitting in a chair, left the room, returned with a chair, and started feeding Resident 101 while sitting in the chair. During an interview on 7/16/2026 at 8:30 a.m., with CNA 3, CNA 3 stated the practice is to feed a resident sitting in a chair at eye level with a resident. CNA 3 stated this was important because it is comfortable for the resident and for her, and to explain what she is feeding the resident. During an interview on 7/16/2026 at 8:58 a.m., with the Director of Nursing (DON), the DON stated residents that need assistance with eating are to be fed at eye level to provide dignity for the residents. During a review of the facility's policy and procedure titled, Assistance with Meals, last reviewed 1/20/2026, indicated residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals.

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when dietary staff did not follow the portion size of three (3) ounces (oz, unit of measurement) and served two (2) oz and four (4) oz of roast beef for regular and therapeutic diets (a personalized meal plan prescribed by a doctor to treat medical condition or manage symptoms). This failure had the potential to result in decrease in food flavor, decrease and increase in food and nutrient intake to 70 of 126 residents on regular, therapeutic diets, resulting in unplanned weight loss or unplanned weight gain. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Summer Menus, dated 7/13/2026, the spreadsheet indicated residents on regular texture would include the following foods on the tray: French dip-roast beef 3 oz Soft sandwich roll one (1) piece Au Jus 2 oz Sweet potato fries 1/2 cup (c, a household measurement) Ketchup 1 Tablespoon (tbsp, a household measurement) Corn coleslaw 1/2 c Cappuccino mousse 1/3 c Milk 4 oz During an observation on 7/13/2026 at 12:02 p.m., observed a pan of roast beef containing different portion sizes, some looked big and some looked small in trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). During a concurrent observation and interview on 7/13/2026 at 12:21 p.m., of the roast beef portion sizes with the Dietary Supervisor (DS), observed the DS weighing a serving of the roast beef using a facility scale. The DS stated one serving is one piece of roast beef. The DS stated the following pieces of meat weighed: 1st roast beef (1 pc) 2 oz 2nd beef (2 pcs) 3.8 oz 3rd beef (1 pc) 2 oz 4th beef (2 pcs) 4 oz 5th beef (1 pc) 2 oz 6th beef (2 pcs) 3.2 oz 7th beef 3 oz 8th beef 3 oz The DS stated he would serve 2 pcs of roast beef moving forward. During an observation on 7/13/2026 at 12:33 p.m., observed the DS serving one piece of roast beef to the trays. During an interview on 7/13/2026 at 1:25 p.m., with the DS, the DS stated [NAME] 1 left this morning and she was the one who sliced the roast beef and [NAME] 2 cooked the roast beef yesterday. The DS stated the roast beef portion size is 3 oz and they need to serve the right portion to make sure the residents would get their whole protein. The DS stated residents could get hungry if their food is under portioned causing weight loss and weight gain if it's over portioned as a potential outcome of not getting the roast beef portion correct. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 1/20/2026, the P&P indicated, The facility will use approved recipes, standardized to meet the resident census.Recipes are specific as to portion yield, method of preparation, quantities of ingredients , and time and temperature guidelines. During a review of the facility's P&P titled, Menu Planning, dated 1/20/2026, the P&P indicated, This menu service which provides the seasonal menus with corresponding recipes.4. The menus are planned to meet nutritional needs of the residents in accordance with established national guidelines, physician's orders and, to extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutritional Board of the National Research Council National Academy of Sciences.Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. During a review of the facility's P&P titled, Portion Sizes, dated 1/20/2026, the P&P indicated, Various portion sizes of the food served will be available to better meet the needs of the residents. During a review of the facility's standardized recipe titled, Recipe: French Dip Sandwich, dated 1/20/2026, the recipe indicated that roast beef portion size is 3 oz.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. Dietary Aide 3 (DA 3) from Skilled Nursing Facility 2 (SNF 2, a sister facility [a building or location that shares the same parent organization or owner as another place]) did not have facility training and competency verification from the Dietary Supervisor (DS) from SNF 1 before performing the dishwashing job. 2. Dietary Aide 2 (DA 2) did not know the reason why he should not dip his hands in the sanitizer bucket when doing hand hygiene. 3. [NAME] 2 is unable to verbalize when to perform handwashing and identify clean and dirty areas. These failures had potential to result in harmful bacterial growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food and drinks that are contaminated with germs or chemicals) and violate resident's rights for privacy and confidentiality and medical records in 125 of 126 residents. Findings: 1. During an observation on 7/14/2026 at 9:25 a.m., of the dishwashing process in the dishmachine area, observed DA 3 throwing the leftover foods, plastic and menu tickets into the grey trash can. During an observation on 7/14/2026 at 9:27 a.m., of DA 3 dishwashing, observed DA 3 threw the meal ticket in the trash can. During a concurrent observation and interview on 7/14/2026 at 9:28 a.m., of DA 3 dishwashing with the DS, observed DA 3 continue to throw meal tickets in the trash from the soiled trays. The DS stated their process of dishwashing starts by throwing all the trash in the garbage can including the meal tickets. The DS stated DA 3 came from SNF 2 and he did not provide training before starting to work and help in their facility. During an interview on 7/14/2026 at 9:34 a.m., with the DS, the DS stated after dishwashing is done, the staff take the trash to the outside dumpster (a movable waste container designed to be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts). The DS further stated the first step of dishwashing is to dispose of the meal tickets in the trash during stripping of the trays (removing trays from the cart and clearing them from the solid waste and food leftovers). The DS stated the meal tickets contained residents' food likes and dislikes, food allergies, name of the residents, ID number (medical record), diet order and room number. The DS stated throwing meal tickets on the trash is not good practice because the meal tickets contained Protected Health Information (PHI), including name and picture of the resident. The DS further stated they needed to separate the menu tickets and shred them before disposing due to Health Insurance Portability and Accountability Act (HIPPA, a federal law designed to protect sensitive patient health information from being disclosed without the residents' consent). The DS stated throwing the meal tickets on the trash is not protecting residents' health information and other people could get the residents information and use them as a potential outcome. During an interview on 7/14/2026 at 11:53 a.m., with the DS, the DS stated he asked the Administrator (ADM) for help because he was short of people in the kitchen and they borrowed DA 3 for only today. The DS stated he did not provide any training for DA 3 and he was not sure what training DA 3 had with SNF 2. The DS stated their process of onboarding staff is to train them first and identify if they could do the job alone, however, when he asked DA 3, DA 3 told him that he dishwash and did trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving]) task in their sister company. The DS further stated he did not know what kind of training DA 3 received from their sister facility and he did not evaluate DA 3's training before having him dishwash. The DS stated DA 3 may not be competent by not washing the dishes right and he did not know if DA 3 knows how to do dishwashing tasks. The DS stated if the dishes were not washed properly residents could potentially get sick from food poisoning. During an interview on 7/14/2026 at 2:17 p.m., with the ADM, the ADM stated he was aware that the DS from SNF 2 was here to observe survey process but not to do regular job. The ADM stated DA 3 was here not to do anything day to day or regular tasks that they are responsible for. The ADM stated he had not spoken to them yet, so he was not aware of what DA 3 was assisting with. The ADM stated both facilities (SNF 1 and SNF 2) can share employees if they are part-time in the other facilities and want full-time hours. The ADM further stated SNF 2 and them have the same job description, and it was acceptable they work in their facility. The ADM stated DA 3 was not employed in their facility (SNF 1) and the expectation is for DA 3 to help for a day and not to do a regular job. The ADM stated he has to check what DA 3 was exactly doing in the kitchen. During an interview on 7/14/2026 at 3:48 p.m., with the Director of Nursing (DON), the DON stated the menu ticket contained name, room number, age, gender, allergies, diet preferences, diet order, diet order, ID number which is the residents medical record number and the picture of the residents. The DON stated they should have shredded the menu tickets before throwing it in the trash because it contained PHI and needed to be protected. The DON stated they violated HIPPA by throwing it in trash and the information was exposed to other people. During an interview on 7/14/2026 at 3:57 a.m., with the DON, the DON stated they have shared employees in the past with their sister company during the pandemic because their practice was streamlined, they are under one umbrella and their policies and procedures are the same so she would assume that it is safe that they could share employees. The DON further stated before they have an employee start working in their facility, they checked their recent competency, records, checked their credentials, and gave task that were not too complex. The DON stated it was important to check records of the employees to ensure that the staff are competent before starting the job. The DON stated in emergency cases they needed to borrow an employee from their sister company, she would do a huddle so that the expectation would be set forth and would tell the supervisor to watch the employee closely. The DON stated if competency of staff were not verified and no training was given to them before starting the job, the employee would not know what to expect, and the standards of care would not be up to par with what is expected in the building. The DON stated the process of having a new staff start is to do their own orientation and onboarding and set up expectations. During an interview on 7/15/2026 at 9:11 a.m., with the Director of Staff Development (DSD), the DSD stated she does the onboarding for new hires by checking their credentials, training, clearance and background checks and provide tour of the facility and introduction to the department heads. The DSD stated she also follows a training calendar for all the mandatory training like HIPPA, infection control, and hand hygiene but she has not done HIPPA in-service yet this year. The DSD stated she was not aware that their sister facility was bringing an employee into their facility. The DSD stated she did not provide handwashing or HIPPA training to DA 3. The DSD stated if the employees did not receive training prior to starting the job in their facility, the employee could commit mistakes because their layout is completely different and it is a safety issue and infection control issue for the residents. During an interview on 7/15/2026 at 9:27 a.m., with the DON, the DON stated there was no signed job description, competency, and training for DA 3 their facility completed before working in the kitchen. During a review of the facility's policies and procedures (P&P) titled, Protected Health Information (PHI) Management and Protection of, dated 1/20/2026, the P&P indicated, Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws. 1. It is the responsibility of all personnel who have access to resident and facility information to ensure such information is managed and protected to prevent unauthorized release or disclosure.10. Health information may be considered not to be individually identifiable in the following circumstances: a. A person with appropriate knowledge and experience with generally acceptable statistical and scientific principles and methods determines that the risk is very small that the information could be used, alone, or with other reasonably available information, to identify the resident who is the subject of the information; or b. The following identifiers of the resident (and relatives, employers or household members) are removed: Names Medical record numbers Full face photographic images Any other unique identifying number, or characteristic code. During a review of the facility's P&P titled, HIPPA Training Program, dated 1/20/2026, the P&P indicated, All facility personnel, including business associates, are required to attend our facility's HIPPA compliance training program. 1. To ensure the confidentiality of our resident's protected health information (PHI) and facility information, a HIPPA and data security training program will be provided for all employees and business associates who have access to protected health information. 2. During an observation on 7/14/2026 at 9:20 a.m., of the dishwashing process, observed DA 2 in the clean area dipping his hands in the red bucket containing sanitizer and water and then put away clean dishes. During an observation on 7/14/2026 at 9:22 a.m., of the dishwashing process, observed DA 2 dipping his hands in the red bucket and then put away clean dishes. During a concurrent observation and interview on 7/14/2026 at 9:41 a.m., of DA 2's dishwashing with the DS and DA 2, observed DA 2 dipping his hands in the red bucket. The DS stated DA 2 placed his hands in the sanitizer bucket. DA 2 stated he dipped his hands in the sanitizer bucket because his co-worker told him to do so but he does not know the reason why. The DS stated DA 2 was not supposed to dip his hands in the sanitizer because it is used to clean surfaces and carts and not used to clean hands. The DS further stated cleaning of hands is done by going to the handwashing sink and handwash to prevent cross-contamination. During a review of the facility's P&P titled, Handwashing Procedure, dated 1/20/2026, the P&P indicated, Handwashing is important to prevent the spread of infection. Procedure: - Use warm water (100 F - 108 F) and soap, preferably from a dispenser. Wet hands and forearms first. Add soap and rub hands together foaming a lather. Rub the palms, back of the hands, the fingers, between the fingers, and the fingernail area, and above the wrist area for 20 seconds. Rinse thoroughly and dry hands. If wrist blades or food pedals do not control faucet, protect clean hands by turning faucets off with paper towels. - When hands need to be washed: Before starting work in the kitchen After handling soiled dishes and utensils. Before and after doing housekeeping procedures Before and after handling foods with the hands (cutting, peeling, mixing, etc.) After going to the toilet, after sneezing, after using a handkerchief or tissue or after touching your hair or face. Before and after eating or smoking After leaving a resident's room. Touching trash can and lid. During a review of the facility's job description (JD) titled, Dietary Assistant, dated and signed by DA 2 on 7/8/2026, the JD indicated, To leave the kitchen in a clean and sanitary manner and be of assistance when called upon by the cook or dietary supervisor. Participate in the orientation and on-going training of dietary staff. During a review of the facility's checklist, titled Dietary Aide Competency Skills Checklist, dated and signed by DA 2 on 7/8/2026, the checklist indicated, DA 2 satisfactory performed following established infection control precautions policies and procedures when performing daily task. The checklist did not indicate specific to handwashing competencies. 3. During an observation on 7/15/2026 at 10:30 a.m., of the food preparation, observed [NAME] 2 wiping the countertops and surfaces using a blue towel. During a concurrent observation and interview on 7/15/2026 at 10:35 a.m., of [NAME] 2's food preparation with the DS, observed [NAME] 2 put away pots and pans after wiping the countertops without washing her hands. The DS stated pans are clean and it was not acceptable practice for [NAME] 2 to hold a soiled towel and start putting away clean pans. The DS further stated [NAME] 2 needed to wash hands to prevent cross-contamination. During an interview on 7/15/2026 at 10:40 a.m., with [NAME] 2 and the DS, [NAME] 2 stated she got an in-service about handwashing and learned to wash hands when touching dirty items. [NAME] 2 stated the towel she used to wipe the countertop was clean then she then rinsed the towel with sanitizer. [NAME] 2 stated the countertops were clean and she wiped them for no reason. [NAME] 2 stated it was okay not to wash her hands because the areas she touched were clean and she just put away clean pans. The DS stated when [NAME] 2 started cleaning, the blue towel was clean then [NAME] 2 rinsed the towel and placed it in the red bucket hence the towel was not dirty. During an interview on 7/15/2026 at 10:48 a.m., with the DS, the DS stated the blue towel got dirty after cleaning the surfaces hence [NAME] 2 needed to wash her hands to prevent cross-contamination. During an interview on 7/15/2026 at 9:49 a.m., with Infection Preventionist Nurse (IPN), the IPN stated the training she gave the facility staff including the dietary staff were as follows: - Perform hand hygiene before and after wearing gloves, exiting and entering resident's room for at least 20 seconds if their hands were not soiled but if their hands were soiled, they need to wash for 1 minute. Hand hygiene includes handwashing in the handwashing sink and the use of the sanitizer. - Wearing jewelry is not allowed and bracelet that could cause possible cross contamination. - Long nails were not allowed because it might contaminate the food during preparation and the long nails could puncture and break the gloves that could contaminate the food. - Wearing nail polish is not allowed because you would not know if nail polish was clean or not for possible cross-contamination. The IPN stated she went to the kitchen last month and every month to observe hand hygiene and have the dietary staff demonstrate handwashing to her. The IPN stated she would do her rounds at 2pm before the dietary staff end their shift. The IPN stated she would go and do her observation during busy times to assess issues with handwashing and the reason why she does it at 2pm was not to disrupt kitchen operation. During an interview on 7/15/2026 at 10:05 a.m., with the IPN, the IPN stated dietary staff should wash their hands when going from dirty area to clean, after touching dirty lids and before pushing a clean cart, before touching food, after placing their hands in their mouth, and after touching their clothes. The IPN stated dietary staff should wash their hands for 20 seconds and not five (5) seconds because it's not enough time to clean their hands and there would be a risk of contaminating food. During a review of the facility's P&P titled, Sanitation, dated 1/20/2026, the P&P indicated, All food and Nutrition Services staff shall know the proper handwashing technique. The FNS director is responsible for the proper training of this.If an employee does need to go from soiled end to clean end, a strict handwashing routine must be followed. During a review of the facility's job description (JD) titled, Dietary Aide, dated and signed by [NAME] 2 on 5/21/2019, the JD indicated, Practice infection control policies and procedures of the department and facility. Attend in-service education and staff meetings as required. During a review of the facility's checklist, titled Dietary [NAME] Competency Skills Checklist, dated and signed by [NAME] 2 on 5/21/2026, the checklist indicated, [NAME] 2 satisfactory performed following established infection control precautions policies and procedures when performing daily task. The checklist did not indicate specific handwashing competencies. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. Food employee shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to perform and document an assessment of edema (swelling) of the hands for one of one residents (Resident 14), who has 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 was receiving Lasix (a medication that helps remove extra fluid from the body). This failure had the potential for delay of necessary care and services that places Resident 14's at increased risk of complications, such as shortness of breath that results in hospitalization. Findings: During a review of Resident 14's admission Sheet (the front page of the chart that contains a summary of basic information about the resident), the admission sheet indicated the facility originally admitted Resident 14 on 7/27/2022 and re-admitted on [DATE] with diagnoses that included CHF, acute respiratory failure (the lungs rapidly stop functioning properly), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 7/1/2026, the MDS indicated Resident 14 usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated Resident 14 had moderate cognitive (ability to learn, think, remember and make decisions) impairment. The MDS indicated Resident 14 was dependent (helper does all of the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility. The MDS indicated Resident 14's active diagnosis included heart failure, respiratory failure, and COPD. The MDS indicated Resident 14 was taking diuretic (water pill - a medication that helps remove extra fluid from the body). During review of Resident 14's History and Physical (H&P), dated 7/22/2027, the H&P indicated Resident 14 cannot make own medical decisions and was conserved (a judge has legally appointed another person or agency to make financial, medical, or personal decisions on their behalf). During an observation on 7/13/2026 at 3:36 p.m., observed Resident 14 lying in bed on his back with left arm resting on a pillow and right arm placed under a blanket. Resident 14's left hand was observed to have edema. During a concurrent observation and interview on 7/15/2026 at 9:38 a.m. with Licensed Vocational Nurse (LVN) 2 at Resident 14's bedside, observed Resident 14 lying in bed with hands under the blanket. LVN 2 folded Resident 14's blanket to expose resident's arms that were resting on his upper abdomen. LVN 2 stated that Resident 14 had edema on both hands. LVN 2 applied pressure to Resident 14's edema and stated that it was pitting edema (a type of swelling where pressure on the affected area leaves dents on the skin that takes time to refill) measured at 2+ (indication of moderate fluid swelling caused by excess fluid on the tissues). LVN 2 stated that Resident 14 is on Lasix. LVN 2 stated that she observed Resident 14's edema off and on since residents return from hospitalization. LVN 2 stated she did not report any of her observations of Resident 14's edema to a Registered Nurse (RN) or the physician since the swelling decreases when the arms are elevated on a pillow. During a concurrent interview and record review on 7/15/2026 at 9:55 a.m. with RN 2, the Admission/readmission Evaluation/Assessment dated 6/23/2026, Nursing Comprehensive Skin Evaluation/Assessment dated 6/24/2026 and Nursing Weekly Summary dated 7/3/2026 and 7/10/2026 were reviewed. The Admission/readmission Evaluation/Assessment indicated Resident 14 had no edema. The remaining documents reviewed did not indicate Resident 14 had edema. RN 2 stated Resident 14's edema should have been documented. RN 2 stated LVN 2 should have documented Resident 14's edema when first observed and reported it to the RN to conduct further assessment. During a subsequent interview on 7/15/2026 with LVN 2 at 2:05 p.m., LVN 2 stated she was incorrect in her initial statement that she observed Resident 14's edema off and on since Resident 14's last return from hospitalization. LVN 2 stated she observed the edema yesterday (7/14/2026) in the morning during her rounds while doing medication pass. LVN 2 stated Resident 14's edema on the previous day was at + 1 on both hands. LVN 2 stated she did not document her findings of Resident 14's edema of the hands because she forgot. LVN 2 stated she did not report Resident 14's edema to the RN or physician since the edema decreased with repositioning. During an interview on 7/16/2026 at 1:56 p.m., with the Director of Nursing (DON), the DON stated that Resident 14's edema was a change of condition which required an assessment. The DON stated that Resident 14's edema should have been documented by LVN 2, escalated to the RN for assessment and evaluation. The DON emphasized that it is especially important in Resident 14's case, as Resident 14's co-morbidities (when a person has two or more medical conditions at the same time) places Resident 14 at higher risk for complications that could potentially lead to hospitalization. During a review of the facility's policy and procedure (P&P) titled, Resident Examination and Assessment last reviewed 1/20/2026, the P&P indicated, purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Physical exam: 1. Vital Signs. 2. Cardiovascular. 3. Respiratory. 4. Neurological. 5. Musculoskeletal. 6. Gastrointestinal. 7. Genitourinary. 8. Skin. 9. Activity Level. 10. Eyes, Ears, Nose, Throat. 11. Head and Neck. 12. Teeth and Gums. 13. Psychiatric/Behavioral 14. Pain The following information should be recorded in the resident's medical record. During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status last reviewed 1/20/2026, the P&P indicated, Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to ensure a resident unable to carry out activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) to maintain grooming and personal hygiene was free off yellow/white discharge on her bilateral eyes and cheeks for one of one sampled resident (Resident 54) investigated under the ADL care area. This deficient practice had the potential to negatively affect Resident 113's dignity and placed Resident 113 at risk for eye infections.Findings: During a review of Resident 54's admission Record, the admission Record indicated the facility admitted Resident 54 on 5/6/2024 with diagnoses that included dysphagia (swallowing difficulties), unspecified dementia (a progressive state of decline in mental abilities) and limitation in activities due to disability. During a review of Resident 54's Minimum Data Set (MDS, a resident assessment tool), dated 6/16/2026, the MDS indicated Resident 54 was never/rarely understood, and required substantial assistance (when helper does more than half the effort) from facility staff for showering/bathing. During a review of Resident 54's Activities of Daily Living Care Plan (CP), the CP indicated an intervention to provide Resident 54 assistance with ADLs as indicated. During a concurrent observation and interview on 7/13/2026 at 8:47 a.m., with Certified Nursing Assistant 2 (CNA 2) in the hallway right outside of Resident 54's room, CNA 2 looked at Resident 54's face and stated the resident had yellow/white discharge coming down both of her cheeks from her eyes. CNA 2 stated Resident 54 is unable to wash her own face, and she provided morning care about 15 minutes prior. CNA 2 stated she thought she washed Resident 54's face but was not certain. CNA 2 stated that she should have paid more attention because the discharge can feel uncomfortable or affect the residents' dignity. During an interview 7/16/2026 at 1:02 p.m., with the Director of Nursing (DON), the DON stated residents have the right to have a clean face. The DON stated Resdeint 54's face should be cleaned daily and as needed for good hygiene and dignity. During a review of the facility's policy and procedure (P&P) titled, Resident Rights last reviewed on 1/20/2026, the P&P indicated residents have a right to a dignified existence. During a review of the facility's P&P titled, Activities of Daily Living (ADLS), Supporting last reviewed on 1/20/2026, the P&P indicated residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, dressing, and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure a resident who had a Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level 1 positive received Level II (a resident is assessed on a Level I first which is a determination if a resident is suspected of having a serious mental illness. If a resident is positive for Level 1, then they are referred to Level II; a Level II Contractor from California Department of Health Services [DHCS, a government agency that provides health care to low-income individuals, children, older adults, and people with disabilities] comes to evaluate further) evaluation by the state-designated authority for one (Resident 7) of six sampled resident reviewed under PASARR. This failure had the potential for Resident 7, who has a diagnosis of Post-Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) to not receive specialized mental health services to manage the resident's behaviors. Findings: During a review of Resident 7's admission Record, the document indicated the resident was admitted to the facility on [DATE] with diagnoses that included PTSD. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 4/02/2026, the MDS indicated Resident 7 was moderately impaired in cognition with skills required for daily decision making. The MDS indicated Resident 7 has a diagnosis of PTSD. During a review of Resident 7's Trauma-informed Care Care Plan, initiated 3/27/2026, the care plan indicated Resident 7 is at risk for decreased psychosocial well-being and adjustment issues, emotional distress related to combat or exposure to a warzone in the military. The care plan indicated a goal that Resident 7 will demonstrate effective coping strategies as evidenced by active participation in health care decisions and activities of choice. The care plan indicated an intervention to encourage the resident to verbalize feelings. During a review of Resident 7's PASARR, dated 3/26/2026, the document indicated Resident 7 was positive for Level 1. Resident 7's PASARR indicated positive for serious mental illness (SMI). During a review of Resident 7's DHCS letter, dated 4/12/2026, the DHCS letter indicated the following: -SUBJECT: NOTICE OF ATTEMPTED EVALUATION -Information: If a Level I Screening returns a positive result for possible ID (Intellectual Disability)/DD (Developmental Disability)/RC (Related Condition), the Department of Developmental Services (DDS) determines if a Level II Evaluation is necessary and a representative from a DDS Regional Center will contact the facility for further action. -The letter indicated: Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level 1 screening. During a concurrent interview and record review with the Minimum Data Set Nurse (MDSN) on 7/16/2026 at 1:02 p.m., the MDSN reviewed Resident 7's 3/26/2026 PASARR and the DDS letter dated 4/12/2026. The MDSN stated the process is that if a resident is positive for Level 1, then the DHCS will contact the facility about conducting a Level II assessment. When asked about facility being unresponsive to two or more separate attempts of communication, the MDSN stated the facility has not spoken to any DHCS staff, and no attempts were made to communicate with them. The MDSN stated he should have followed up with DHCS. The MDSN stated it was important to follow-up with the DHCS so that Resident 7 would get a proper Level II assessment and possibly require specialized services. THE MDSN stated he would submit another PASARR on the computer so that the DHCS could contact him again. During a review of the facility's policy and procedure titled, PASARR, last reviewed 1/20/2026, indicated if a level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.

Based on observation, interview, and record review the facility failed to ensure resident were free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of one sampled residents (Resident 121) by failing to ensure that a wedge pillow (special triangle-shaped pillows that raise the top half of the body while sleeping) was not placed under the mattress on the right side at the foot of the bed. This failure had the potential to result in the restriction of Resident 121's freedom of movement, a decline in physical functioning, injuries related to entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from, or death.Findings: During a review of Resident 121's admission Record, the admission Record indicated that the facility originally admitted Resident 121 on 4/30/2026 with diagnoses including history of falling, right femur displaced comminuted fracture (shattered injury of the thigh bone), bilateral (both side) artificial hip joint (a procedure in which a surgeon removes a damaged joint and replaces it with a new, artificial part), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and metabolic encephalopathy (a chemical imbalance in the blood affecting the brain). During a review of Resident 121's Minimum Data Set (MDS-a resident assessment tool), dated 5/7/2026, the MDS indicated Resident 121 had the ability to understand others and makes self-understood. The MDS indicated that Resident 121 had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 121 was dependent (helper does all the effort) for bed mobility. The MDS also indicated that there were no physical restraints or alarms used for Resident 121. During a review of Resident 121's History and Physical (H&P), dated 5/1/2026, the H&P indicated that Resident 121 did have the capacity to understand and make decisions. During an observation on 7/13/2026 at 9:56 a.m. with Resident 121, Resident 121 was observed with a wedge pillow placed under the mattress on the right side at the foot of the bed. During an interview on 7/13/2026 at 11:01 a.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated that Resident 121 required two-person assistance for bed mobility and the wedge pillow was used for repositioning to prevent the development of wounds. During an interview on 7/13/2026 at 11:11 a.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated that Resident 121 was at risk of falling and needs assistance from two people for bed mobility. LVN 3 stated that the wedge pillow should be placed underneath the resident but on top of the mattress, not beneath the mattress, as putting it under the mattress turns it into a physical restraint. LVN 3 explained that when a wedge pillow is tucked under the mattress, the wedge pillow becomes immovable and prevents the resident from getting out of bed. During an interview on 7/16/2026 at 3:00 p.m. with Director of Nursing (DON), the DON stated that a wedge pillow should be used to help prevent wounds in residents who have mobility issues and require assistance with repositioning to reduce pressure. The DON explained that the pillow should be placed beneath the sheet, along the mid-lateral part of the body, not under the mattress, as placing it there would be ineffective. The DON stated that if a resident cannot freely remove an adaptive device such a wedge pillow, it may act as a restraint and in such cases, nursing staff are required to perform an entrapment evaluation. During a review of facility's Policy and Procedure (P&P) titled Physical Restraint Application, reviewed 1/20/2026, the P&P indicated that physical restraints are defined as any manual method or physical or mechanical device, material, or equipment affixed to or near the resident's body that cannot be easily removed by the individual, thereby restricting freedom of movement or normal access to their body. The P&P further clarifies that residents must be physically and cognitively able to self-release devices such as Velcro lap trays or tables, seat belts with Velcro, or easy snap seat belts; if the resident is unable to do so, the device is classified as a restraint. Under preparation for using physical restraints, the P&P requires verification of the physician's order, a review of the resident's care plan to assess for any special needs, and assembly of necessary equipment and supplies. Additionally, the P&P directs staff to adhere to the manufacturer's instructions for the proper use of restraints.

Based on observation, interview, and record review, the facility failed to notify the physician of a change in condition for one of one residents (Resident 14) investigated under edema (swelling), by failing to notify the physician of Resident 14's left and right hand edema. This deficient practice had the potential for delay of necessary care and services and worsening of Resident 14's condition. Findings: During a review of Resident 14's admission Sheet (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted Resident 14 on 7/27/2022, and re-admitted on [DATE] with diagnoses that included congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) , acute respiratory failure (the lungs rapidly stop functioning properly), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 14's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/1/2026, the MDS indicated Resident 14 usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversations). The MDS indicated Resident 14 had moderate cognitive (ability to learn, think, remember and make decisions) impairment. The MDS indicated Resident 14 was dependent (helper does all of the effort) for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility. The MDS indicated Resident 14's active diagnosis included heart failure, respiratory failure, and COPD. The MDS indicated Resident 14 was taking a diuretic (water pill - a medication that helps remove extra fluid from the body) medication. During review of Resident 14's History and Physical (H&P), dated 7/22/2027, the H&P indicated Resident 14 cannot make own medical decisions and was conserved (a judge has legally appointed another person or agency to make financial, medical, or personal decisions on their behalf). During an observation on 7/13/2026 at 3:36 p.m., observed Resident 14 lying in bed on his back with left arm resting on a pillow and right arm placed under a blanket. Resident 14's left hand was observed to have edema. During a concurrent observation and interview on 7/15/2026 at 9:38 a.m. with Licensed Vocational Nurse 2 (LVN 2) at Resident 14's bedside, observed Resident 14 lying in bed with hands under the blanket. LVN 2 folded Resident 14's blanket to expose the resident's arms that were resting on his upper abdomen. LVN 2 stated that Resident 14 had edema on both hands. LVN 2 applied pressure to Resident 14's edema and stated that it was pitting edema (a type of swelling where pressure on the affected area leaves dents on the skin that takes time to refill) measured at 2+ (indication of moderate fluid swelling caused by excess fluid on the tissues). LVN 2 stated that Resident 14 is receiving Lasix (a medication that helps remove extra fluid from the body). LVN 2 stated that she observed Resident 14's edema off and on since the resident's return from hospitalization. LVN 2 stated she did not report any of her observations of Resident 14's edema to a Registered Nurse (RN) or the physician since the swelling decreases when the resident's arms are elevated on a pillow. During a concurrent interview and record review on 7/15/2026 at 9:55 a.m. with RN 2, the Admission/readmission Evaluation/Assessment dated 6/23/2026, Nursing Comprehensive Skin Evaluation Assessment dated 6/24/2026, 6/30/2026, 7/8/2026 and Nursing Weekly Summary dated 7/3/2026 and 7/10/2026 were reviewed. The Admission/readmission Evaluation/Assessment indicated no presence of edema. The remaining documents reviewed did not indicate Resident 14 had edema. RN 2 stated that an assessment of Resident 14's edema should have been done when first observed and the physician should have been notified of Resident 14's change of condition. RN 2 stated she did not find documentation of a change of condition for Resident 14's edema. RN 2 stated that it was important to notify the physician of Resident 14's edema so the physician can place necessary orders, such as laboratory or diagnostic tests, to further assess Resident 14's condition and provide appropriate care and treatment. During an interview on 7/16/2026 at 1:56 p.m. with the Director of Nursing (DON), the DON stated that Resident 14's edema is a change in condition and should have been reported to the RN for assessment and evaluation, who (RN) would then have notified the physician. The DON stated that not notifying the physician of Resident 14's edema resulted in Resident 14 not having orders for addressing the change of condition. During a follow-up interview on 7/15/2026 with LVN 2 at 2:05 p.m., LVN 2 stated she was incorrect in her initial statement that she observed Resident 14's edema off and on since Resident 14's last return from hospitalization. LVN 2 stated she observed the edema yesterday (7/14/2026) in the morning during her rounds while doing medication pass. LVN 2 stated Resident 14's edema on the previous day was at + 1 on both hands. LVN 2 stated she did not document her findings of Resident 14's edema of the hands because she forgot. LVN 2 stated she did not report Resident 14's edema to the RN or physician since the edema decreased with repositioning. The DON stated that not notifying the physician caused a delay in the appropriate monitoring and treatment of Resident 14's edema. The DON stated that Resident 14's had co-morbidities (when a person has two or more medical conditions at the same time) that places him at even higher risk for hospitalization when a change of condition is not reported and addressed promptly. During a review of the facility's policy and procedure (P&P) titled, Change in Resident's Condition or Status last reviewed 1/20/2026, the P&P indicated, The nurse will notify the resident's attending physician, provider, or physician on call when there has been a significant change of condition.A significant change of condition is a major decline or improvement in the residents status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). During a review of the facility's policy and procedure (P&P) titled, Resident Examination and Assessment last reviewed 1/20/2026, the P&P indicated, purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan.The following information should be recorded in the resident's medical record.Notify the physician of any abnormalities.Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of five sampled residents (Resident 2) when on 7/3/2024 Resident 1 hit Resident 2's face. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility. Resident 2 sustained a cut (a break in skin due to injury) on the left eye area of Resident 2's face, redness (red discoloration [a change in natural skin tone] to the skin) on the left eye area of Resident 2's face and swelling (accumulation of fluid in the skin tissues due to injury) on the left eye area of Resident 2's face. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 2's severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 5/6/2022 with diagnoses that included seizures (a sudden, uncontrolled burst of electrical activity in the brain that causes temporary abnormalities in muscle tone or movements) and schizophrenia (a serious mental health condition that affects how people think, feel, and behave). A review of Resident 1's Initial History and Physical, dated 5/14/2024, indicated Resident 1 did not have the ability to understand or make his (Resident 1) own decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 4/30/2024 indicated Resident 1 had severely impaired cognition. A review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident's health) Evaluation Form, dated 7/3/2024, timed at 1:30 p.m., indicated that Resident 1 had physical aggression (behavior causing or threatening physical harm towards others) with another resident (Resident 2). The COC form further indicated that Resident 1 hit Resident 2. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 1/26/2021 with diagnoses that included dementia (the loss of the ability to think, remember and reason to levels that affect daily life) and schizophrenia. A review of Resident 2's MDS dated [DATE] indicated Resident 2 had severely impaired cognition. A review of Resident 2's COC Evaluation Form, dated 7/3/2024, timed at 1:30 p.m., indicated that Resident 2 was hit by Resident 1 and sustained a cut on the left eye area with minimal bleeding, skin discoloration, and swelling to the left periorbital (the area around the left eye). The COC form further indicated that Resident 2 required ice packs to the left eye to decrease the swelling. A review of Resident 2's Comprehensive Skin Assessment Report dated 7/23/2024, indicated Resident 2 sustained a cut on the left eye area with a width of 1.5 centimeters (cm- a unit of measurement) with bleeding noted on Resident 2's left eye area. A review of Resident 2's Physician Order dated 7/3/2024 indicated to cleanse the cut on the left eye area with Normal Saline Solution (NSS - a wound cleansing solution), pat dry, then apply antibiotic (a medication applied topically [to the skin surface] to prevent wound infection) and leave the area open to air daily for 14 days. During a concurrent observation and interview on 7/19/2024 at 12:35 p.m., with Director 1 (DIR 1), observed Resident 2 lying in his bed with visible purplish discoloration and swelling around Resident 2's left eye. DIR 1 stated that Resident 2's left eye had purplish discoloration and swelling. During an interview on 7/19/2024 at 1:50 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that on 7/3/2024 (unable to recall specific time) she (LVN 1) saw Resident 1 walk past Resident 2 while in front of the nursing station. LVN 1 stated that she (LVN 1) then turned away when LVN 1 suddenly heard a disruption. LVN 1 stated that she (LVN 1) turned and saw Resident 1 and Resident 2 struggling and grabbing each other's arms. LVN 1 stated that she (LVN 1) ran and separated Resident 1 and Resident 2. LVN 1 stated that upon separating Resident 1 and Resident 2, LVN 1 noticed discoloration to Resident 2's left eye. LVN 1 stated that Resident 1 likely hit Resident 2 during the altercation because Resident 2 did not have discoloration to the left eye prior to the incident. During a concurrent interview and record review on 7/19/2024 at 2:30 p.m. with the Director of Nursing (DON), the DON reviewed Resident 2's COC Evaluation Form dated 7/3/2024. The DON stated Resident 2's injury (cut and swelling with discoloration to the left periorbital area) that was sustained on 7/3/2024, after Resident 2's altercation with Resident 1, was consistent with someone being hit. The DON stated that Resident 1 hitting Resident 2 was physical abuse which should not have been allowed to happen. During an interview on 7/19/2024 at 2:55 p.m., with the Administrator in Training (AIT), the AIT stated that he (AIT) is the facility's abuse coordinator (the person that investigates allegations of abuse in the facility). The AIT stated that the altercation that occurred between Resident 1 and Resident 2 on 7/3/2024 was physical abuse. The AIT stated that Resident 2 sustained physical injuries (cut and swelling with discoloration to the left periorbital area) from the altercation. During a concurrent interview and record review on 7/19/2024 at 3:05 p.m., with the DON, the DON reviewed the facility's policy titled Abuse Prevention Program, dated 12/2016. The DON stated that the facility failed to ensure that Resident 2 was free and protected from abuse when on 7/3/2024, Resident 1 hit Resident 2, causing Resident 2 to sustain a cut, discoloration and swelling to the left periorbital area. The DON stated that this failure indicated that the facility did not follow the facility's policy for the prevention of abuse. A review of the facility's policy titled, Abuse Prevention Program, dated 12/2016, last reviewed on 1/16/2024 indicated that the facility's residents have the right to be free from abuse . this includes physical abuse.

Based on interview and record review, the facility failed to: 1. Develop and implement a policy and procedure to evaluate a resident ' s capacity to consent and engage in sexual acts prior to them having sexual contact for one of three sampled residents (Resident 1). 2. Ensure ability to consent to engage in a sexual act was established for one of three sampled residents (Resident 1) prior to Resident 1 and Resident 2 partaking in oral sex (sexual activity in which the sexual organ of one partner is stimulated by the mouth). As a result, Resident 1 who had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was subjected to a sexual act by Resident 2 while under the care of the facility and prior to the facility evaluating whether Resident 1 had the capacity to consent to a sexual act. An individual who has been a victim of sexual abuse has the potential for lifelong physical pain and psychological effects including feelings of hopelessness, helplessness and humiliation. On 7/21/22 at 4:21 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), the Director of Nursing (DON), and the Administrator-in-Training (AIT) due to the facility's failure to prevent resident-to-resident sexual abuse. On 7/23/22 at 1:14 p.m., the ADM provided an IJ Removal Plan which included the following summarized actions: 1. Resident 1 was assessed on 7/19/22 by a Registered Nurse (RN) with no signs of injury and no evidence of psychosocial distress. Resident 1 ' s primary care physician (PCP), psychiatrist/psychologist for consult and Responsible Party (RP) were notified. Every 30 minutes monitoring was initiated immediately and terminated at the end of the 7:00 to 3:00 p.m. shift on 7/21/22 after the Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the resident) reviewed the resident ' s plan of care, to ensure Resident 1 was monitored closely for untoward effects such as emotional and psychological distress. Psychiatrist came and evaluated Resident 1 on 7/22/22. 2. Resident 2 was assessed on 7/19/22 by an RN with no signs of injury and no evidence of psychosocial distress. PCP and Conservator (court appointed individual who manages the medical and physical care of a person with limited capacity) were notified. One-on-one monitoring (one staff to care for one resident) was initiated until Resident 2 was transferred to General Acute Care Hospital 1 (GACH 1). Psychiatrist/ psychologist will assess Resident 2 upon return from GACH 1. 3. On 7/19/22, the Director of Staff Development (DSD) started conducting in-services to facility staff regarding Abuse Prevention and Reporting to be completed by 7/25/22. 4. On 7/21/22, Resident 1 was again assessed by a RN, and found with no signs of injury, and no evidence of psychosocial distress resulted from sexual activity by another resident. One-on-one monitoring was initiated, and RP and PCP were notified to ensure any adverse consequences were immediately identified, addressed and a safe environment was provided to Resident 1. 5. The IDT on 7/19/22, determined interventions to protect Resident 1 from unsafe sexual advances of other residents and revised his plan of care. 6. On 7/21/22, the IDT met, and the following areas were addressed: increased supervision of Resident 1 by assigning one to one staff monitoring starting 7/21/22 3:00-11:00 p.m. shift and ongoing. IDT to review on 7/25/22 if one to one monitoring is still needed. Mental health evaluation and psychotherapy (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued RN assessment of Resident 1 for any visible signs of injury or psychosocial distress, PCP and RP were notified. IDT requested PCP to conduct an additional review of resident ' s mental capacity. PCP reached the same determination of resident ' s mental incompetence and indicated Resident 1 did not have mental capacity, and the most recent sexual activity did not affect Resident 1 ' s medical condition. 7. Resident 1 was scheduled to be evaluated by a psychologist on 7/22/22 and a follow up visit was scheduled on 7/29/22. Psychologist will communicate with IDT results of evaluation and any additional recommendations. 8. Policy and procedure on Abuse Prevention and Reporting was reviewed. Administrator, DON, Medical Director, Regional Director of Clinical Services, Assistant Regional Director of Clinical Services, and Director of Staff Development agreed on policy and procedure on residents ' sexual rights to consent, sexual consent with other residents while protecting unconsenting or incompetent residents from unwanted or unsafe sexual advances from other residents. Quality Assessment and Assurance (QAA) Committee met on 7/22/22 and reviewed the policy with Medical Director and it was approved. In-services started on 7/22/22 by DSD and DON regarding policy and procedures for resident supervision, residents that do not have capacity engaging in sexual activity and keeping residents free from sexual abuse by providing a safe environment. 9. An extra staff monitor is assigned starting 7/21/22 to check residents ' whereabouts on the outside premises or patio area to ensure residents requiring supervision are monitored closely to prevent any abuse. 10. Medical records checked all current residents ' History and Physicals on 7/21/22 and found 28 residents have capacity, 69 residents do not have capacity, 32 residents with fluctuating capacity. 11. Social Service Director (SSD) interviewed random alert residents on 7/22/22 to determine if anyone observed any resident showing any inappropriate sexual behaviors and/or residents asking other residents sexual favors. No residents were identified. 12. On 7/21/22 reviewed current residents ' incidents and progress notes from last 30 days to identify any resident that does not have capacity engaging in sexual activity or has history of inappropriate sexual behaviors. No other residents were identified. 13. Orientation for new hire and annual staff competency evaluation will include education and training regarding policy and procedure on sexuality among residents, how to deal with residents ' sexual behaviors especially those deemed not having capacity, residents requiring supervision with ADLs, and how to prevent any resident from any form of abuse. 14. For new admissions, IDT will review initial baseline care plan and history and physical, residents with history of sexual contact or sexual behaviors providing safe expression of sexuality that does not infringe (violate) rights of other residents. Ongoing assessment will be done as follows -IDT will update plan of care quarterly and PCP to review annually and as necessary. 15. Department Heads, during daily rounds, and Manager on Duty on weekends, will randomly check residents that do not have capacity for any indications of behaviors that are sexual in nature. Any issues identified will be discussed during stand-up meeting, one-on-one supervision will be immediately initiated to protect resident/s involved, IDT will review plan of care, and additional interventions will be in place to ensure resident/s involved are free from sexual abuse. Any allegations of abuse will be reported to authorities, California Department of Public Health (CDPH) , and Ombudsman within two-hour requirement. On 7/23/22 at 5:47 p.m., while onsite and after verifying the facility ' s full implementation of the IJ removal plan, the Department accepted the IJ removal plan and removed the IJ in the presence of the ADM, the DON, and the AIT. Findings: A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 6/17/22 indicated Resident 1 had severely impaired cognition. A review of Resident 1 ' s History and Physical dated 5/3/22 indicated Resident 1 did not have capacity to understand and make decisions. A review of Resident 1 ' s Change in Condition Evaluation dated 7/19/22 indicated facility staff witnessed a female resident (Resident 2) performing an inappropriate sexual act on Resident 1 on the outside patio. A review of Resident 2 ' s Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2 ' s History and Physical dated 7/14/22 indicated Resident 2 did not have capacity to understand and make decisions. A review of Resident 2 ' s Change in Condition Evaluation dated 7/19/22 indicated staff witnessed Resident 2 on the ground of the patio, exhibiting inappropriate sexual behavior with another resident (Resident 1). During an interview with Licensed Vocational Nurse 1 (LVN 1) on 7/20/22 at 9:19 a.m., LVN 1 stated on 7/18/22 at around 9:30 a.m., he saw Resident 1 and Resident 2 seated on the outside patio floor. LVN 1 stated he saw Resident 2 performing oral sex on Resident 1. LVN 1 stated he instructed Resident 1 and Resident 2 to stop and separated the two residents. During an interview with Nurse Practitioner 1 (NP 1) on 7/21/22 at 2:33 p.m. , NP 1 stated that Resident 1 and Resident 2 did not have capacity and therefore could not consent. During an interview with the DON on 7/21/22 at 3:20 p.m., the DON stated the facility did not have a policy in place to establish a resident ' s ability to consent to sexual acts when first arriving to the facility. During an interview with Resident 1 on 7/22/22 at 3:46 p.m., Resident 1 could not recall the 7/19/22 incident that occurred between him and Resident 2, where Resident 2 was found performing a sexual act on him. Resident 1 further stated that he did not know who Resident 2 was. During an interview with the DON on 7/20/22 at 12:36 p.m., the DON stated that Resident 1 was a confused resident with severely impaired cognition. During an interview with the ADM on 7/21/22 at 12:21 p.m., the ADM stated he did not believe the incident that took place between Resident 1 and Resident 2 was consensual because the residents did not have capacity. The ADM stated because the residents could not give consent, the inappropriate sexual incident was non-consensual. During a concurrent interview and record review with the AIT on 8/2/22 at 4:26 p.m., the State Operation Manual (SOM - contains the primary survey and certification regulations and guidance for Long Term Care [LTC] providers) was reviewed. After reviewing the definition of sexual abuse which was defined as the non-consensual sexual contact of any type, the AIT stated that the incident that took place between Resident 1 and Resident 2 would be considered sexual abuse because neither Resident 1 nor Resident 2 had the ability to consent to the sexual act due to their cognition level and capacity. During a follow up interview with NP 1 on 8/3/22 at 11:09 a.m., NP 1 stated that while Resident 1 may not have the capacity to consent to medical treatment, NP 1 stated that he believed Resident 1 had the capacity to make needs known, one of which included sex. NP 1 stated that he did not formally establish Resident 1 ' s capacity to consent to sexual acts until three days (7/22/22) after the incident where Resident 2 was found performing a sexual act on Resident 1. A review of the policy and procedure titled, Abuse Prevention Program, revised 12/2016, indicated the residents of the facility have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident ' s symptoms. The policy and procedure further indicated that it is the policy of the facility to protect their residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors or any other individual.

Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 1), who had severely impaired cognition (the person is unable to remember, learn, understand the meaning or importance of things and situations, communicate needs and wants, and make decisions), had the right to be free from sexual abuse (non-consensual sexual contact of any type) from Resident 2. On 1/1/2021, at 6 a.m. Resident 1's body was exposed, and Resident 2, a male, was touching Resident 1's vagina. As a result, Resident 1 was sexually abused and based on the Reasonable Person Concept, due to Resident 1's severely impaired cognition and medical condition, an individual subjected to sexual abuse has lifetime physical pain and psychological effects including feelings of hopelessness, helplessness and humiliation. Findings: A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 1/7/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical (H&P) exam completed by the attending physician on 1/10/2020 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-planning tool) dated 10/9/2020 indicated Resident 1 could not communicate needs and wants and required extensive to total assistance with activities of daily living (ADLs, such us transfers, eating, dressing, personal hygiene, and bathing). Resident 1 was incontinent (unable to control) of bowel and bladder functions. A review of Residents 1's Progress Note dated 1/1/2021, timed at 6:25 a.m., indicated Licensed Vocational Nurse 1 (LVN 1) received report that a staff member (Housekeeper 1) found a male resident touching Resident 1's vaginal area. Resident 1 was lying in bed on her back, with her disposable incontinent brief off and her night gown pulled up. Resident 2 was standing near Resident 1's bed, touching her vaginal area. A review of Resident 1's Safety Event Report completed 1/6/2021 indicated Resident 1 was the alleged/suspected abuse victim of sexual abuse that occurred on 1/1/2021. Resident 1 did not have mental capacity to interviewed. The alleged perpetrator was another resident (Resident 2). A review of Resident 1's Initial Psychological Evaluation dated 1/1/2021 indicated the reason for evaluation was suspected abuse and during the evaluation, Resident 1 appeared to be sad with low energy. A Review of Resident 2's Admission Record indicated the facility admitted the resident on 10/8/2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's (H&P) exam completed by the attending physician on 8/21/2020 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE] indicated the resident had unclear speech, was able to walk in the room and corridor with steady balance and without the use of a mobility device. A review of Residents 2's Progress Note dated 1/1/2021, timed at 6:30 a.m., indicated LVN 2 received report from a staff that Resident 2 was found touching Resident 1's vaginal area. Resident 2 was removed from Resident 1's room. A review of Resident 2's Psychological Progress Report dated 1/1/2021 indicated Resident 2 was found in Resident 1's room, touching her vaginal area. Resident 2 had poor concentration and impaired judgement. The recommendation was to provide Resident 2 with 1 to 1 (1:1 one staff with the resident always) monitoring as needed. On 1/8/2021 at 4:20 p.m., during an interview, Director of Nursing 1 (DON 1) stated during early morning of 1/1/2021 around 6 a.m., Housekeeper 1 was going past Resident 1's room and saw Resident 2 standing near Resident 1's bed, fully dressed and touching Resident 1's vaginal area. Housekeeper 1 told Resident 2 to get out of the room. DON stated Resident 2 had history of going into other residents' rooms. On 5/9/2022 at 10:00 a.m., during an interview, Housekeeper 1 stated she remembered the incident she witnessed on 1/1/2021. Housekeeper 1 stated it was early morning, around 6 a.m. and she was starting her shift, when she saw Resident 2 standing over Resident 1 with his hand on her vaginal area. Housekeeper 1 stated she told Resident 2 to get out of the room and brought him to Registered Nurse Supervisor 1 (RNS 1) and told him what she saw. On 5/9/2022 at 11:15 a.m., during an interview, RNS 1 stated he no longer worked at the facility but remembered the incident with Resident 2. On 5/10/2022 at11:30 a.m., during an interview, the Administrator (ADM) stated he was unaware of Resident 2's history of sexually inappropriate behavior. The ADM stated it was the responsibility of the staff to supervise and protect the residents and the facility failed to do that with regards to the 1/1/2021 incident that occurred between Residents 1 and 2. A review of the policy and procedure titled, Abuse Prevention Program, revised 12/2016, indicated it is the policy of the facility to protect its residents from abuse by anyone.

Based on interview and record review, the facility failed to ensure that four of five sampled residents (Resident 2, 3, 4, and 5) maintained acceptable parameters of nutritional status (desirable body weight range) and did not experience unplanned severe weight loss (a loss of greater than 5% of weight in one months' time) by: 1. Failing to ensure the facility did not limit the residents to primarily cold foods such as salads and sandwiches for a period of two (2) months after the range/stove was deemed inoperable due to a fire on 7/22/2021. 2. Failing to ensure the facility attempted to provide other sources of food items that included but were not limited to hot foods items after residents verbalized that they were tired of being served primarily salads and sandwiches for two months starting from 7/22/2021. 3. Failing to ensure the facility had an administrator (Admin 2) who was actively at the facility to oversee the day-to-day operations and ensure the issue with the limitation of cold foods and the lack of an operable range/stove was managed effectively. 4. Failing to ensure Admin 2 informed the corporation of the ongoing limitation of food due to not having an operable range/ stove to obtain additional resources to find alternative food items such as hot foods. 5. Failing to ensure the facility staff followed therapeutic (meal plan that controls the intake of certain foods or nutrients, part of the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices resulted in residents being forced to endure a prolonged limited cold food menu, causing residents to not like the food due to a lack of variety and leading to residents experiencing unplanned severe weight loss. Resident 2 experiencing a severe unplanned weight loss of 19 pounds (lbs.-unit of measure) from 07/27/2021 to 08/31/2021, which was 17.4% of their body weight. Resident 3 had severe unplanned weight loss of 9 lbs. from 08/01/2021 to 08/31/2021 which was 5.6% of their body weight. Resident 4 experienced a severe weight loss of 12 lbs. from 7/20/2021 to 8/31/2021, which was 5.6% of their body weight. Resident 5's food preferences were not met, forcing the resident to purchase their own food from outside facility. On 09/23/2021 at 4:32 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Director of Nursing (DON) with regards to the failure to maintain acceptable parameters of nutritional status for Resident 2, Resident 3 Resident 4, and Resident 5. On 9/29/2021 at 4:31 p.m., the DON provided the Department with a Plan of Action (POA) which was accepted and included the following summarized actions: 1. Residents 2's nutritional needs were reevaluated on 09/24/2021 by RD 1 and the current plan of care was continued with appetite stimulant also ordered as of 09/24/2021. 2. Resident 3 has been out to General Acute Care Hospital (GACH) as of 09/19/2021. Resident 3 was readmitted on [DATE] with their nutritional needs reevaluated by RD 1 as of 09/29/2021. 3. Resident 4's nutritional needs were reevaluated on 09/24/2021, current plan of care meets nutritional needs as of 09/25/2021. 4. Gas Grill has been purchased for supplementation and to offer a varied menu to Residents and a protocol for it's safe use has been created. Kitchen Staff has been in serviced on Protocol for Requirements as of 09/29/2021 by Dietary Supervisor (DS) and RD 1. 5. Resident 2, 4, and 5 nutritional re-evaluations were done and completed on 09/25/2021 by RD 1. 6. A new policy and procedure were developed and implemented as of 09/25/2021. The policy and procedure for kitchen major equipment failure will be submitted to the Quality Assessment and Assurance (QAA) Committee on 09/29/2021 for Final Approval by DON. 7. Audit of the last three (3) months of RD recommendations for sample residents has been completed by Medical Records Designee (MRD) on 09/24/2021. Two dietary recommendations were not carried out and have been ordered as of 9/24/2021 by Registered Nurse Supervisor. Licensed Staff have been in-serviced regarding requirements associated with timely follow up with Medical Doctor (MD) and orders of RD recommendations (within 72 hours) by DON as of 09/25/2021 and continuing until 100 % of licensed staff have been in serviced by 9/28/2021. 8. Instituted holding temperature Log (Log created to ensure that food that is awaiting to be served maintains a temperature that prevents the growth of bacteria that can cause foodborne illness) as of 09/24/2021. 9. Alternative Menu was updated to include meal delivery from local restaurant who will be providing catered meals three (3) times (x) a week for the next three (3) weeks. Delivered meals will be evaluated, arranged, supplemented, or modified to meet our Residents with therapeutic dietary needs as of 09/27/2021 by RD 1. 10. A total of six crock pots that were 10 quartz (unit of measure) were purchased as well as a one 60 cup (unit of measure) rice cooker for use as of 09/28/2021 by the kitchen. 11. Kitchen Staff have been in serviced regarding compliance with Therapeutic meals (preparing, holding & serving the therapeutic diets with holding temperature log) from 09/22/21 to 09/25/2021 by DS and RD. 12. Chief of Specialized Food Services was contacted and provided conditions for usage of Grill: a. Nothing Overhead. b. protect public three feet away - create a barrier if needed. c. Must ONLY cook food outside and bring inside to distribute to Residents d. Always use food safety temperature logs, red buckets 09/28/2021 by Corp RD. On 09/30/2021 at 3:09 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department removed the Immediate Jeopardy, in the presence of the DON and Administrator (Admin 1) present over the phone. Findings: During an interview, on 08/26/2021, at 12:45 p.m., with DS, DS stated the facility's stove was removed on 07/22/2021 due to a fire on a wooden platform in which the stove was sitting directly on top of. DS stated that the facility has not had a stove since 07/22/2021 and has been serving meals from the temporary menu that was created as a response to the fire. The DS further stated the temporary menu which consist of primarily cold foods such as salads and sandwiches was only intended to be used for three days but has been in use since 7/22/2021. The DS stated he is surprised that the facility has served food from only the temporary food menu for so long and that residents have been verbalizing wanting to eat hot foods again. During a record review of the temporary menus dated 07/25/2021 through 09/25/2021, the temporary menu indicated a sandwich or salad was served as the main dish to the residents of the facility for the following: 1. Out of 63 lunches, 45 lunches consisted of sandwiches, and 12 lunches consisted of salads. 2. Out of 63 dinners, 37 dinners consisted of salads, and 15 dinners consisted of sandwiches. During an interview on 08/26/2021, at 2:15 p.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated that almost daily since the range/stove became inoperable on 7/22/2021, that the residents are served primarily salads, sandwiches, and hard-boiled eggs. CNA 1 stated that when the issue was brought to the attention of management, they were informed that nothing could be done regarding the food because the range/stove is broken. During an interview, on 08/26/2021, at 3:00 p.m. with Registered Nurse 2 (RN 2), RN 2 stated that the facility is not giving the residents hot meals and has been serving mainly cold meals. RN 2 further stated certified nurse assistants have been instructed to explain to residents that the facility is waiting on permits to be approved for the installation of a new range/stove. RN 2 further stated residents are offered a limited number of substitutes which also includes sandwiches. During an interview and concurrent record review on 09/22/2021, at 3:30 p.m., with RD 1, the facility's temporary menu for residents from 07/2021 to 08/2021 was reviewed. RD 1 stated after reviewing the menu, that the facility did not begin including hot foods to the residents until 8/29/2021 which was 34 days after the range/stove first being inoperable. RD 1 confirmed that the menu for the residents consisted primarily of salads and sandwiches. RD 1 stated that they are unable to ensure residents therapeutic diets are being followed due to the limitations of foods being made available to the residents. RD 1 stated that an example would be residents prescribed a fortified diet (food that has extra nutrients added to it or has nutrients added that are not normally there), RD 1 stated that salads and sandwiches cannot be fortified. During an interview with the DON on 09/24/2021, at 4:30 p.m., the DON stated that Admin 2 was not often present in the facility and was currently suspended. During an interview, on 09/28/2021, at 4:18 p.m., with the DON stated for the past two months since 7/22/2021, primarily salads and sandwiches have been served to the residents. DON stated he did not expect for the temporary menus to be used for this long. DON stated serving primarily sandwiches and salads is not enough variety for the residents. When the DON was asked what was being done to ensure that additional resources were being obtained to provide hot foods to its residents, the DON stated he does not report to corporate, and it is the administrator's duty to communicate with corporate. During an interview on 9/29/2021, at 10:41 a.m. with RD 1, RD 1 was asked about Admin 2's involvement during the fire that occurred in the facility's kitchen on 7/22/2021. RD 1 stated Admin 2 was at the facility when the fire occurred but left the facility and went home at around 2:00 to 3:00 p.m. RD 1 stated DS and kitchen staff stayed at the facility until about 11:00 p.m. trying to clean up the kitchen. RD 1 stated she does not remember the last time she saw Admin 2 at the facility, but it has been at least two months. RD 1 stated she had conversations with Admin 2 over the phone, but it did not involve the kitchen menu and nothing about what is happening at the facility regarding the absence of the kitchen range. RD 1 stated no one notified corporate to get help. RD 1 stated she thought Admin 2 would have reached out to corporate for additional resources to help with the ongoing issue of not having a range/stove to provide a variety and hot foods to residents. RD 1 stated they did not have a credit card when the fire happened and as a result, was not able to buy needed supplies. RD 1 stated it was only until a couple of days ago that Food Service Efficiency Consultant (FSEC) was made aware about the facility's ongoing problem of not being able to serve hot foods to its residents, at which point they provided them with funding to buy additional needed kitchen supplies. RD 1 stated he has since spent around $10,000 dollars buying needed supplies to add more varieties and hot foods to the residents. During an interview on 9/29/2021 at 2:59 p.m. with the Area President (AP), the AP stated that they were informed only that there was a fire that occurred in the facility's kitchen. AP stated being told they were using an alternative menu that did not require an oven, but no other details. During an interview on 9/30/2021 at 10:55 a.m., with the FSEC, the FSEC stated there was a lack of communication of what was happening at the facility. FSEC stated he was just made aware of the situation about the residents being limited to primary cold foods such as salads and sandwiches about six (6) days ago. The FSEC stated the DON reached out to the Senior Registered Dietician (SRD ) and that's how he was notified. During a follow-up interview on 09/30/2021, at 2:30 p.m., with FSEC, the FSEC stated the administrator would be the person responsible to contact corporate about informing them of any pertinent on-going issues at the facility. FSEC stated that had they been notified sooner of the limited food choices of the residents, they could have provided the facility with a dietary consultant to help the facility. During an interview on 10/1/2021 at 12:05 p.m., with the DS, DS stated he does not feel like he had support from Admin 2 during the time after the fire and the kitchen range becoming inoperable. During an interview, on 10/01/2021, at 12:56 p.m., with the DON, the DON stated they could have had better resources such as a company credit, or consultants to assist them with the on-going food issue, if only corporate had been made fully aware of the situation. The DON stated that he questioned why the SRD from corporate was not made aware of the situation at the facility. The DON stated that Admin 2 could have done a better job of obtaining additional resources from the facility. A review of Resident 2's Admission Record indicated the facility originally admitted resident on 05/24/2021 and readmitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) with behavior disturbance, Alzheimer's disease (type of dementia that affects memory, thinking and behavior) with early onset. A review of Resident 2's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 06/01/2021 indicated that the resident usually makes self-understood and usually understands others. The MDS further indicated that Resident 2 requires one-person physical assist with eating. A review of Resident 2's care plan for food preferences, dated 07/20/2021, the plan indicated a goal for resident to eat/drink 50 to 100% of meals provided and to maintain a goal weight range of 110 to 120 pounds. A review of Resident 2 physician orders, dated 07/21/2021, indicated a diet order of general fortified regular diet with mechanical texture (food is made easier to chew and swallow through the use of machines) and thin liquids. During a concurrent interview and record review on 09/22/2021, at 11:30 a.m., RD 1 reviewed Resident 2's weekly weights. The weekly weight report indicated the following weights: 05/25/2021 = 113 lbs. (initial weight on admission) 07/27/2021 = 109 lbs. 08/03/2021 = 100 lbs. 08/10/2021 = 96 lbs. 08/17/2021 = 94 lbs. 08/24/2021 = 93 lbs. 08/31/2021 = 90 lbs. RD 1 stated based on the weight history, Resident 2 had a severe weight loss of 19 lbs. (17 .4%) from 07/27/2021 to 8/31/2021. During a concurrent interview and record review on 09/22/2021, at 11:30 a.m. with RD 1, Resident 2's nutrition notes, dated 08/18/21, was reviewed. RD 1 stated that the following recommendations were not carried out (being provided) for Resident 2: 1. Increase Med Pass 2.0 (nutritional supplement shake that has high calories and high protein) to 240 milliliter (ml-unit of measure) four times a day for 1440 calories and 57 grams (g-unit of measure) of protein. 2. Consider Appetite Stimulant (medication to increase appetite), if medically appropriate. RD 1 states recommendations for appetite stimulant and supplement were not carried out by nursing staff and they should have been implemented within three days. RD 1 further states Resident 2 has varying levels of intake, but her food intake was poor overall. RD 1 stated salad and sandwiches cannot be fortified and confirmed that Resident 2 is on fortified regular diet. RD 1 states the facility should have provided the resident with the prescribed fortified diet. A review of Resident 3's Admission Record indicated that the facility admitted the resident on 04/29/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS dated [DATE], indicated the resident rarely or never makes self understood and rarely or never understands others. The MDS further indicated Resident 3 requires one-person physical assist with eating. A review of Resident 3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the temporary menu for 09/2021, indicated 09/21/2021 residents would be served grilled ham and cheese sandwich for lunch. During a concurrent interview and record review, 09/22/2021, at 12:00 p.m. with RD 1, Resident 3's weekly weights were reviewed. The report indicated the following weights : 05/01/2021 = 165 lbs. (initial weight on admission) 08/01/2021 = 160 lbs. 08/10/2021 = 158 lbs. 08/17/2021 = 153 lbs. 08/24/2021 = 153 lbs. 08/31/2021 = 151 lbs. RD 1 stated based on the weight history, Resident 3 had a severe weight loss of nine (9) lbs. (5.6%) from 08/01/2021 to 8/31/2021. During a concurrent interview and record review on 09/22/2021, at 12:00 p.m., of Resident 3's interdisciplinary team meeting (IDT- a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) note dated 08/18/2021 with RD 1 was reviewed. The record indicated that RD 1 made the following recommendations: 1. Fortify Diet (A food that has extra nutrients added to it or has nutrients added that are not normally there.) change to fortify regular, regular texture, thin liquid diet. 2. Increase Med Pass 2.0 (nutritional supplement shake that has high calories and high protein) to 120 milliliters (ml-unit of measure) three times per day (TID) at medication pass for a total of 720 calories and 30 grams (g-unit of measure) of protein) RD 1 stated Resident 3 was below their usual body weight (160-170 lbs.) and further states resident had severe weight loss related to underlying medical condition and variable intake. RD 1 stated her recommendations for Resident 3's fortified diet and supplement, dated 08/18/2021, were not implemented until 09/16/2021 and should have been communicated with the primary care physician and implemented within three days of her recommendations because of Resident 3's recent weight loss. A review of Resident 4's Admission Record indicated the facility admitted Resident 4 on 06/29/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated the resident has the ability to make self understood and understand others. A review of Resident 4's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review, 09/22/2021, at 2:45 p.m., of Resident 4's weekly weights with RD 1, the report indicated the following weights : 07/20/2021 = 214 lbs. 08/01/2021 = 203 lbs. 08/10/2021 = 205 lbs. 08/17/2021 = 203 lbs. 08/24/2021 = 204 lbs. 08/31/2021 = 202 lbs. RD 1 stated based on the weight history, Resident 4 had a severe weight loss of 12 lbs. (5.6%) from 07/20/2021 to 8/31/2021. During a concurrent interview and record review on 09/22/2021, at 2:45 p.m. of Resident 4's IDT notes dated 08/04/2021 with RD 1, the record indicated that RD 1 made the recommendations to increase Med Pass 2.0 to 120 ml Three times a day (TID) to provide an additional 720 calories and 30 grams protein. RD 1 stated that the recommendations was not implemented, and further stated nursing should have communicated recommendations to Resident 4's primary care physician to obtain orders and implement recommendations. During an interview with Resident 4, on 09/27/2021 at 11:00 a.m., Resident 4 stated she does not want to have to eat sandwiches every day. Resident 4 stated she feels mad about getting cold sandwiches and salads all the time. Resident 4 states she knows she is losing weight, and she has to order outside food because she gets tired of eating sandwiches every day. Resident 4 stated she does not like eating salads. A review of Resident 5's Admission Record indicated the facility admitted Resident 5 on 07/03/2021. A review of Resident 5's MDS, dated [DATE], indicated the resident has the ability to make self understood and understand others. The MDS also indicated that Resident 5 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ., and Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 5's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the temporary menu for 09/2021, indicated that on 09/21/2021 residents would be served grilled ham and cheese sandwich for lunch. During an interview with Cook 1, on 09/21/2021, at 11:30 a.m., when asked how sandwiches are prepared, Cook 1 stated all sandwiches are prepared the same with two slices of american cheese (type of processed cheese) and one slice of processed ham. During an interview, on 09/21/2021, at 2:55 p.m., with Resident 5, Resident 5 stated she orders from restaurants and pays for her own food. Resident 5 states it angers her that she has to resort to buying her own food. Resident 5 stated she is on [CONDITION(S)] (a process in which a machine filters the toxin from a person's blood because the kidneys are no longer functioning) and she refuses the facility's food because they serve processed foods. Resident 5 stated she can't have processed foods as a renal patient. Resident 5 further stated she's tired of hard-boiled eggs for breakfast, egg salad sandwich for lunch, and salads for dinner. A review of the facility's policy and procedure titled Food and Nutrition Services dated 10/2017, indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each diet

Based on interview, and record review, the facility failed to ensure four of five sampled residents (Resident 2, 3, 4, and 5) were free of neglect (fail to care for) by: 1. Failing to ensure the facility did not limit the residents to primarily cold foods such as salads and sandwiches for a period of two (2) months after the range/stove was deemed inoperable due to a fire on 7/22/2021. 2. Failing to ensure the facility attempted to provide other sources of food items that included but were not limited to hot foods items after residents verbalized that they were tired of being served primarily salads and sandwiches for two months starting from 7/22/2021. 3. Failing to ensure the facility had an administrator (Admin 2) who was actively at the facility to oversee the day-to-day operations and ensure the issue with the limitation of cold foods and the lack of an operable range/stove was managed effectively. 4. Failing to ensure Admin 2 informed the corporation of the ongoing limitation of food due to not having an operable range/ stove to obtain additional resources to find alternative food items such as hot foods. 5. Failing to ensure the facility staff followed therapeutic (meal plan that controls the intake of certain foods or nutrients, part of the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices resulted in residents being forced to endure a prolonged limited cold food menu, causing residents to not like the food due to a lack of variety and leading to residents experiencing unplanned severe weight loss (a loss of greater than 5% of weight in one months' time). Resident 2 experiencing a severe unplanned weight loss of 19 pounds (lbs.-unit of measure) from 07/27/2021 to 08/31/2021, which was 17.4% of their body weight. Resident 3 had severe unplanned weight loss of 9 lbs. from 08/01/2021 to 08/31/2021 which was 5.6% of their body weight. Resident 4 experienced a severe weight loss of 12 lbs. from 7/20/2021 to 8/31/2021, which was 5.6% of their body weight. Resident 5's food preferences were not met, forcing the resident to purchase their own food from outside facility. On 09/23/2021 at 4:32 p.m., the State Survey Agency (the Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Director of Nursing (DON) with regards to the failure to ensure Resident 2, Resident 3 Resident 4, and Resident 5 were free from neglect. On 9/29/2021 at 4:31 p.m., the DON provided the Department with a Plan of Action (POA) which was accepted and included the following summarized actions: 1. Residents 2's nutritional needs were reevaluated on 09/24/2021 by RD 1 and the current plan of care was continued with appetite stimulant also ordered as of 09/24/2021. 2. Resident 3 has been out to General Acute Care Hospital (GACH) as of 09/19/2021. Resident 3 was readmitted on [DATE] with their nutritional needs reevaluated by RD 1 as of 09/29/2021. 3. Resident 4's nutritional needs were reevaluated on 09/24/2021, current plan of care meets nutritional needs as of 09/25/2021. 4. Gas Grill has been purchased for supplementation and to offer a varied menu to Residents and a protocol for it's safe use has been created. Kitchen Staff has been in serviced on Protocol for Requirements as of 09/29/2021 by Dietary Supervisor (DS) and RD 1. 5. Resident 2, 4, and 5 nutritional re-evaluations were done and completed on 09/25/2021 by RD 1. 6. A new policy and procedure were developed and implemented as of 09/25/2021. The policy and procedure for kitchen major equipment failure will be submitted to the Quality Assessment and Assurance (QAA) Committee on 09/29/2021 for Final Approval by DON. 7. Audit of the last three (3) months of RD recommendations for sample residents has been completed by Medical Records Designee (MRD) on 09/24/2021. Two dietary recommendations were not carried out and have been ordered as of 9/24/2021 by Registered Nurse Supervisor. Licensed Staff have been in-serviced regarding requirements associated with timely follow up with Medical Doctor (MD) and orders of RD recommendations (within 72 hours) by DON as of 09/25/2021 and continuing until 100 % of licensed staff have been in serviced by 9/28/2021. 8. Instituted holding temperature Log (Log created to ensure that food that is awaiting to be served maintains a temperature that prevents the growth of bacteria that can cause foodborne illness) as of 09/24/2021. 9. Alternative Menu was updated to include meal delivery from local restaurant who will be providing catered meals three (3) times (x) a week for the next three (3) weeks. Delivered meals will be evaluated, arranged, supplemented, or modified to meet our Residents with therapeutic dietary needs as of 09/27/2021 by RD 1. 10. A total of six crock pots that were 10 quartz (unit of measure) were purchased as well as a one 60 cup (unit of measure) rice cooker for use as of 09/28/2021 by the kitchen. 11. Kitchen Staff have been in serviced regarding compliance with Therapeutic meals (preparing, holding & serving the therapeutic diets with holding temperature log) from 09/22/21 to 09/25/2021 by DS and RD. 12. Chief of Specialized Food Services was contacted and provided conditions for usage of Grill: a. Nothing Overhead. b. protect public three feet away - create a barrier if needed. c. Must ONLY cook food outside and bring inside to distribute to Residents d. Always use food safety temperature logs, red buckets 09/28/2021 by Corp RD. On 09/30/2021 at 3:09 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department removed the Immediate Jeopardy, in the presence of the DON and Administrator (Admin 1) present over the phone. Findings: During an interview, on 08/26/2021, at 12:45 p.m., with DS, DS stated the facility's stove was removed on 07/22/2021 due to a fire on a wooden platform in which the stove was sitting directly on top of. DS stated that the facility has not had a stove since 07/22/2021 and has been serving meals from the temporary menu that was created as a response to the fire. The DS further stated the temporary menu which consist of primarily cold foods such as salads and sandwiches was only intended to be used for three days but has been in use since 7/22/2021. The DS stated he is surprised that the facility has served food from only the temporary food menu for so long and that residents have been verbalizing wanting to eat hot foods again. During a record review of the temporary menus dated 07/25/2021 through 09/25/2021, the temporary menu indicated a sandwich or salad was served as the main dish to the residents of the facility for the following: 1. Out of 63 lunches, 45 lunches consisted of sandwiches, and 12 lunches consisted of salads. 2. Out of 63 dinners, 37 dinners consisted of salads, and 15 dinners consisted of sandwiches. During an interview on 08/26/2021, at 2:15 p.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated that almost daily since the range/stove became inoperable on 7/22/2021, that the residents are served primarily salads, sandwiches, and hard-boiled eggs. CNA 1 stated that when the issue was brought to the attention of management, they were informed that nothing could be done regarding the food because the range/stove is broken. During an interview, on 08/26/2021, at 3:00 p.m. with Registered Nurse 2 (RN 2), RN 2 stated that the facility is not giving the residents hot meals and has been serving mainly cold meals. RN 2 further stated certified nurse assistants have been instructed to explain to residents that the facility is waiting on permits to be approved for the installation of a new range/stove. RN 2 further stated residents are offered a limited number of substitutes which also includes sandwiches. During an interview and concurrent record review on 09/22/2021, at 3:30 p.m., with RD 1, the facility's temporary menu for residents from 07/2021 to 08/2021 was reviewed. RD 1 stated after reviewing the menu, that the facility did not begin including hot foods to the residents until 8/29/2021 which was 34 days after the range/stove first being inoperable. RD 1 confirmed that the menu for the residents consisted primarily of salads and sandwiches. RD 1 stated that they are unable to ensure residents therapeutic diets are being followed due to the limitations of foods being made available to the residents. RD 1 stated that an example would be residents prescribed a fortified diet (food that has extra nutrients added to it or has nutrients added that are not normally there), RD 1 stated that salads and sandwiches cannot be fortified. During an interview with the DON on 09/24/2021, at 4:30 p.m., the DON stated that Admin 2 was not often present in the facility and was currently suspended. During an interview, on 09/28/2021, at 4:18 p.m., with the DON stated for the past two months since 7/22/2021, primarily salads and sandwiches have been served to the residents. DON stated he did not expect for the temporary menus to be used for this long. DON stated serving primarily sandwiches and salads is not enough variety for the residents. When the DON was asked what was being done to ensure that additional resources were being obtained to provide hot foods to its residents, the DON stated he does not report to corporate, and it is the administrator's duty to communicate with corporate. During an interview on 9/29/2021, at 10:41 a.m. with RD 1, RD 1 was asked about Admin 2's involvement during the fire that occurred in the facility's kitchen on 7/22/2021. RD 1 stated Admin 2 was at the facility when the fire occurred but left the facility and went home at around 2:00 to 3:00 p.m. RD 1 stated DS and kitchen staff stayed at the facility until about 11:00 p.m. trying to clean up the kitchen. RD 1 stated she does not remember the last time she saw Admin 2 at the facility, but it has been at least two months. RD 1 stated she had conversations with Admin 2 over the phone, but it did not involve the kitchen menu and nothing about what is happening at the facility regarding the absence of the kitchen range. RD 1 stated no one notified corporate to get help. RD 1 stated she thought Admin 2 would have reached out to corporate for additional resources to help with the ongoing issue of not having a range/stove to provide a variety and hot foods to residents. RD 1 stated they did not have a credit card when the fire happened and as a result, was not able to buy needed supplies. RD 1 stated it was only until a couple of days ago that Food Service Efficiency Consultant (FSEC) was made aware about the facility's ongoing problem of not being able to serve hot foods to its residents, at which point they provided them with funding to buy additional needed kitchen supplies. RD 1 stated he has since spent around $10,000 dollars buying needed supplies to add more varieties and hot foods to the residents. During an interview on 9/29/2021 at 2:59 p.m. with the Area President (AP), the AP stated that they were informed only that there was a fire that occurred in the facility's kitchen. AP stated being told they were using an alternative menu that did not require an oven, but no other details. During an interview on 9/30/2021 at 10:55 a.m., with the FSEC, the FSEC stated there was a lack of communication of what was happening at the facility. FSEC stated he was just made aware of the situation about the residents being limited to primary cold foods such as salads and sandwiches about six (6) days ago. The FSEC stated the DON reached out to the Senior Registered Dietician (SRD ) and that's how he was notified. During a follow-up interview on 09/30/2021, at 2:30 p.m., with FSEC, the FSEC stated the administrator would be the person responsible to contact corporate about informing them of any pertinent on-going issues at the facility. FSEC stated that had they been notified sooner of the limited food choices of the residents, they could have provided the facility with a dietary consultant to help the facility. During an interview on 10/1/2021 at 12:05 p.m., with the DS, DS stated he does not feel like he had support from Admin 2 during the time after the fire and the kitchen range becoming inoperable. During an interview, on 10/01/2021, at 12:56 p.m., with the DON, the DON stated they could have had better resources such as a company credit, or consultants to assist them with the on-going food issue, if only corporate had been made fully aware of the situation. The DON stated that he questioned why the SRD from corporate was not made aware of the situation at the facility. The DON stated that Admin 2 could have done a better job of obtaining additional resources from the facility. A review of Resident 2's Admission Record indicated the facility originally admitted resident on 05/24/2021 and readmitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) with behavior disturbance, Alzheimer's disease (type of dementia that affects memory, thinking and behavior) with early onset. A review of Resident 2's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 06/01/2021 indicated that the resident usually makes self-understood and usually understands others. The MDS further indicated that Resident 2 requires one-person physical assist with eating. A review of Resident 2's care plan for food preferences, dated 07/20/2021, the plan indicated a goal for resident to eat/drink 50 to 100% of meals provided and to maintain a goal weight range of 110 to 120 pounds. A review of Resident 2 physician orders, dated 07/21/2021, indicated a diet order of general fortified regular diet with mechanical texture (food is made easier to chew and swallow through the use of machines) and thin liquids. During a concurrent interview and record review on 09/22/2021, at 11:30 a.m., RD 1 reviewed Resident 2's weekly weights. The weekly weight report indicated the following weights: 05/25/2021 = 113 lbs. (initial weight on admission) 07/27/2021 = 109 lbs. 08/03/2021 = 100 lbs. 08/10/2021 = 96 lbs. 08/17/2021 = 94 lbs. 08/24/2021 = 93 lbs. 08/31/2021 = 90 lbs. RD 1 stated based on the weight history, Resident 2 had a severe weight loss of 19 lbs. (17 .4%) from 07/27/2021 to 8/31/2021. During a concurrent interview and record review on 09/22/2021, at 11:30 a.m. with RD 1, Resident 2's nutrition notes, dated 08/18/21, was reviewed. RD 1 stated that the following recommendations were not carried out (being provided) for Resident 2: 1. Increase Med Pass 2.0 (nutritional supplement shake that has high calories and high protein) to 240 milliliter (ml-unit of measure) four times a day for 1440 calories and 57 grams (g-unit of measure) of protein. 2. Consider Appetite Stimulant (medication to increase appetite), if medically appropriate. RD 1 states recommendations for appetite stimulant and supplement were not carried out by nursing staff and they should have been implemented within three days. RD 1 further states Resident 2 has varying levels of intake, but her food intake was poor overall. RD 1 stated salad and sandwiches cannot be fortified and confirmed that Resident 2 is on fortified regular diet. RD 1 states the facility should have provided the resident with the prescribed fortified diet. A review of Resident 3's Admission Record indicated that the facility admitted the resident on 04/29/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MDS dated [DATE], indicated the resident rarely or never makes self understood and rarely or never understands others. The MDS further indicated Resident 3 requires one-person physical assist with eating. A review of Resident 3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the temporary menu for 09/2021, indicated 09/21/2021 residents would be served grilled ham and cheese sandwich for lunch. During a concurrent interview and record review, 09/22/2021, at 12:00 p.m. with RD 1, Resident 3's weekly weights were reviewed. The report indicated the following weights : 05/01/2021 = 165 lbs. (initial weight on admission) 08/01/2021 = 160 lbs. 08/10/2021 = 158 lbs. 08/17/2021 = 153 lbs. 08/24/2021 = 153 lbs. 08/31/2021 = 151 lbs. RD 1 stated based on the weight history, Resident 3 had a severe weight loss of nine (9) lbs. (5.6%) from 08/01/2021 to 8/31/2021. During a concurrent interview and record review on 09/22/2021, at 12:00 p.m., of Resident 3's interdisciplinary team meeting (IDT- a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) note dated 08/18/2021 with RD 1 was reviewed. The record indicated that RD 1 made the following recommendations: 1. Fortify Diet (A food that has extra nutrients added to it or has nutrients added that are not normally there.) change to fortify regular, regular texture, thin liquid diet. 2. Increase Med Pass 2.0 (nutritional supplement shake that has high calories and high protein) to 120 milliliters (ml-unit of measure) three times per day (TID) at medication pass for a total of 720 calories and 30 grams (g-unit of measure) of protein) RD 1 stated Resident 3 was below their usual body weight (160-170 lbs.) and further states resident had severe weight loss related to underlying medical condition and variable intake. RD 1 stated her recommendations for Resident 3's fortified diet and supplement, dated 08/18/2021, were not implemented until 09/16/2021 and should have been communicated with the primary care physician and implemented within three days of her recommendations because of Resident 3's recent weight loss. A review of Resident 4's Admission Record indicated the facility admitted Resident 4 on 06/29/2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated the resident has the ability to make self understood and understand others. A review of Resident 4's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review, 09/22/2021, at 2:45 p.m., of Resident 4's weekly weights with RD 1, the report indicated the following weights : 07/20/2021 = 214 lbs. 08/01/2021 = 203 lbs. 08/10/2021 = 205 lbs. 08/17/2021 = 203 lbs. 08/24/2021 = 204 lbs. 08/31/2021 = 202 lbs. RD 1 stated based on the weight history, Resident 4 had a severe weight loss of 12 lbs. (5.6%) from 07/20/2021 to 8/31/2021. During a concurrent interview and record review on 09/22/2021, at 2:45 p.m. of Resident 4's IDT notes dated 08/04/2021 with RD 1, the record indicated that RD 1 made the recommendations to increase Med Pass 2.0 to 120 ml Three times a day (TID) to provide an additional 720 calories and 30 grams protein. RD 1 stated that the recommendations was not implemented, and further stated nursing should have communicated recommendations to Resident 4's primary care physician to obtain orders and implement recommendations. During an interview with Resident 4, on 09/27/2021 at 11:00 a.m., Resident 4 stated she does not want to have to eat sandwiches every day. Resident 4 stated she feels mad about getting cold sandwiches and salads all the time. Resident 4 states she knows she is losing weight, and she has to order outside food because she gets tired of eating sandwiches every day. Resident 4 stated she does not like eating salads. A review of Resident 5's Admission Record indicated the facility admitted Resident 5 on 07/03/2021. A review of Resident 5's MDS, dated [DATE], indicated the resident has the ability to make self understood and understand others. The MDS also indicated that Resident 5 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ., and Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 5's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the temporary menu for 09/2021, indicated that on 09/21/2021 residents would be served grilled ham and cheese sandwich for lunch. During an interview with Cook 1, on 09/21/2021, at 11:30 a.m., when asked how sandwiches are prepared, Cook 1 stated all sandwiches are prepared the same with two slices of american cheese (type of processed cheese) and one slice of processed ham. During an interview, on 09/21/2021, at 2:55 p.m., with Resident 5, Resident 5 stated she orders from restaurants and pays for her own food. Resident 5 states it angers her that she has to resort to buying her own food. Resident 5 stated she is on [CONDITION(S)] (a process in which a machine filters the toxin from a person's blood because the kidneys are no longer functioning) and she refuses the facility's food because they serve processed foods. Resident 5 stated she can't have processed foods as a renal patient. Resident 5 further stated she's tired of hard-boiled eggs for breakfast, egg salad sandwich for lunch, and salads for dinner. A review of the facility's policy, titled abuse prevention program, dated 12/2019, indicated residents have the right to be free from neglect.

Based on interview and record review, facility failed to ensure one of three sampled residents (Resident 1) received adequate supervision and assistance to prevent accidents and injuries. Resident 1, who was assessed at risk for falls and was on isolation precautions (creation of barriers between people and germs. These types of precautions help prevent the spread of germs in facilities) for Coronavirus Disease 2019 (COVID 19 - a highly contagious [CONDITION(S)] infection that spreads from person to person through the air causing mild to severe respiratory illness), was not monitored to prevent her from leaving the room and the unit unattended. As a result, on 12/15/2020 at 2:30 p.m., Resident 1 wheeled herself out of the isolation room, went to the patio, where there was no staff present, attempted to stand up and fell on to the floor. Resident 1 sustained a left [CONDITION(S)] (broken bone) requiring transfer to General Acute Care Hospital 1 (GACH 1), where on 12/16/2020 she underwent a left hip open reduction and internal fixation (ORIF - a surgical procedure that involves putting pieces of bone into place using screws or rods to hold the broken bone together). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident on 9/11/2020 with diagnosis including Alzheimer's Disease (s the most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life), [CONDITION(S)] (inflammation of joints causing pain, swelling and redness) of knees, and difficulty with walking and lack of coordination (imbalance). A review of Resident 1's History and Physical dated 9/15/2020, indicated the resident did not have capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 9/17/2020 indicated the resident needed extensive assistance from staff for personal hygiene, bed mobility, dressing, and transfers). Resident 1 needed limited assistance with one-person physical assist with walking. Resident 1 used a wheelchair as a mobility device. Resident 1's balance when moving from seated to standing position and when walking was not steady and only able to stabilize with staff assistance. A review of Resident 1's Comprehensive Care Plan Review with Interdisciplinary Team dated 9/18/2020, indicated Resident 1 was at risk for falls related to visual impairment, unsteady gait, altered balance while standing and / or walking. Fall prevention plan included providing safe and hazard free environment, frequent visual checks, and safety precaution always observed. A review of Resident 1's Physician's Orders for the month of 12/2020 indicated the resident's medications included the anti-psychotic (a type of psychiatric medication which are available on prescription to treat [CONDITION(S)] [a severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality]) [MEDICATION(S)] 12.5 milligrams (mg) twice a day, for uncontrollable extreme mood swings causing anger manifested by hitting staff. Resident 1's had an order for restorative nursing assistant (RNA - trained certified nursing assistant [CNA] to provide exercises to residents to maintain the functional gains made in therapy [physical, occupational or speech]) to provide safe ambulation using a front wheeled walker (FWW) as tolerated five times a week in the morning. Resident 1 was on contact/droplet (drops from talking, coughing, sneezing) isolation precaution since 12/3/2020 through 1/26/2021 due to possible COVID-19 exposure. A review of Resident 1's Event Report dated 12/15/2020, indicated at 2:30 p.m., Resident 1 fell on the floor on the side patio, after attempting self-transfer, and was complaining of severe pain (rated 7-8 on a pain scale from zero to 10, zero indicating no pain and 10, the worst possible pain) on both knees. The note indicated that a staff saw the resident through a window and noticed Resident 1 was trying to stand up. Physician was notified and ordered x-rays. The x-ray results on the same day showed a left [CONDITION(S)] (broken bone). Physician was notified and at 11 p.m., ordered transfer to GACH 1 for evaluation and treatment. A review of Resident 1's GACH 1's Surgical Information indicated Resident 1 had a left hip osteoporotic (bone becomes fragile/weak due to low bone mass) fracture and on 12/16/2020 the orthopedist (doctor that specializes in treating bones and joints) surgeon performed a left hip ORIF. On 5/17/2021 at 10:07 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had history of getting up from the bed and wheelchair without waiting for assistance and fall precautions included frequent visual monitoring. LVN 1 stated the Medical Records Assistant (MRA) saw resident wheeling herself to the patio on 12/15/2020, at 2:30 p.m., stood up before staff could intervene and fell on her right side. MRA called LVN 2 to the patio. On 5/17/2021 at 11:45 a.m., during an interview, Registered Nurse 1 (RN 1) stated Resident 1 should be monitored frequently and supervised because she gets up unassisted and was likely to fall if unattended. On 6/3/2021 at 4:11p.m., during an interview, MRA stated on 12/15/2020 at around 2:30 p.m., he was at his office when he saw Resident 1 wheeling in the patio without assistance. MRA stated he saw her trying to stand up from her wheelchair, so he immediately ran to help her, but she was already on the floor when he reached her. MRA stated he called LVN 2 for assistance immediately. On 7/6/2021 at 10:29 a.m., during an interview, LVN 2 stated on 12/15/2020, at around 2:30 p.m., she was notified that Resident 1 fell in the patio. Resident 1 was on isolation for COVID 19 and was not allowed to leave her room to prevent the spread of infection. LVN 2 stated Resident 1 should have been supervised but no one was around her during that time. A review of facility's policy and procedure, titled Dementia - Clinical Protocol dated 11/2018 indicated direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. A review of facility's policy and procedure, titled Supporting Activities of Daily Living (ADL's) dated 3/2018 indicated, appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: c. Mobility (transfer, and ambulation including walking). A review of facility's policy and procedure, titled Safety and Supervision of Residents dated 7/2017 indicated: 1.Our individualized, resident-centered approach to safety addressed safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessment and observations to identify any specific accident hazards or risk for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on observation, interview and record review, the facility's nursing staff failed to ensure a resident who was impaired in cognition, required extensive assistance on staff with grooming and had episodes of scratching has trimmed fingernails to prevent skin injury for one out of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 developing multiple open [MEDICAL CONDITION] on (MONTH) 6, 2019 on his right arm. Resident 1 was transferred to General Acute Care Hospital (GACH) on (MONTH) 11, 2019 and was diagnosed with [REDACTED]. It happens when bacteria enter a break in the skin and spread. The result is infection, which may cause swelling, redness, pain, or warmth). Resident 1 was admitted to GACH for intravenous (administered into, a vein) antibiotic and returned to facility on (MONTH) 20, 2019 Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. activities), gastro [MEDICAL CONDITION] reflux disease (occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach), and [MEDICAL CONDITION] (a disease that affects brain structure or function). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated (MONTH) 27, 2019, indicated that Resident 1's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making is impaired. The MDS also indicated that the resident required extensive assistance on staff for dressing, toilet use, personal hygiene, and bathing. On (MONTH) 26, 2019 at 10:52 a.m., during an observation and room visit, Resident 1 was observed lying in bed, awake, alert and oriented to his name. It was observed that Resident 1 had a gauze bandage wrapped around his upper right arm. The resident's fingernails were observed long on both hands. When Resident 1 was asked how he got his wound on his right upper arm, Resident 1`s reply was incoherent and would go off tangent and unable to focus on the conversation and instead would repeatedly ask the same question without replying to the question. On (MONTH) 26, 2019 at 1:20 p.m., during an interview with Director of Nursing (DON), with concurrent observation of Resident 1's wound on his right upper arm, which at this time was covered with gauze, DON stated that Resident 1 developed [MEDICAL CONDITION] on his right arm caused by scratching. When Resident 1 was asked to show his fingernails, Resident 1 stated that it is long and needs to be cut. DON stated that indeed Resident 1's nails were long and the appearance and length of the nails must have been several weeks for it to grow this long. A review of Resident 1`s progress notes on the following dates indicated that on: 1. (MONTH) 6, 2019 at 12:15 p.m., Resident 1 was noted with episodes of scratching and itchiness on right upper arm during the shift. Skin assessment was done by the registered nurse supervisor and charge nurse and was noted with [MEDICAL CONDITION] on right arm area. The note indicated there was no discharges and bleeding from the [MEDICAL CONDITION] on the right arm. According to the progress notes, Resident 1 has episodes of refusing and resisting activities of daily living including showers. Physician was notified of the skin condition and order was received on (MONTH) 6, 2019 by the nursing staff to apply [MEDICATION NAME] (antifungal medication) cream 1% and apply to affected area for 14 days. 2. (MONTH) 8, 2019 at 8:30 p.m., Resident 1's lesion on the right upper arm was noted with yellowish drainage that measures 4 cm (centimeter) by 4 cm with redness surrounding the wound, and treatment was provided and physician was notified. 3. (MONTH) 11, 2019 at 12:58 p.m. Resident 1's lesion on the right upper arm became an open wound measuring 15 cm by 15 cm with minimal bleeding, physician was notified and the resident was referred for wound consult and evaluation. At 7:30 p.m., physician assessed and examined Resident 1's right upper arm wound and ordered resident to be transferred to GACH for further evaluation and treatment. A review of Resident 1's GACH Consultation record dated (MONTH) 12, 2019, indicated the patient (resident) was admitted with acute medical problem, [MEDICAL CONDITIONS] (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), and [MEDICAL CONDITION]. A review of Resident 1's Cardiology Consultation dated (MONTH) 12, 2019 indicated the resident comes in with cut in the right arm that resulted in [MEDICAL CONDITION]. The note indicated the resident has history of bilateral lower extremity [MEDICAL CONDITION]. The assessment indicated [MEDICAL CONDITION] and new onset [MEDICAL CONDITION]. The recommendation included continue antibiotic and transferred to intensive care unit for [MEDICATION NAME] drip. A review of Resident 1's GACH physician's orders [REDACTED]. Wound care: Cleanse right upper arm and right lateral arm with Dakins solution pat dry apply santyl ointment cover with xeroform dressing and abdominal pad then wrap with kerlix daily as tolerated. The resident was discharged back to facility on (MONTH) 20, 2019. A review of Resident 1's Wound Care Surgeons dated (MONTH) 26, 2019 indicated present with right arm ulceration that has been present for approximately two weeks that has exacerbated due to the patient (resident) scratching and picking at the wound site. A review of Resident 1's care plan dated (MONTH) 6, 2019 for the right arm multiple [MEDICAL CONDITION], did not indicate in the interventions/approaches about nail care and trimming. On (MONTH) 26, 2019 at 2:27 p.m., during an interview and concurrent record review of Resident 1, DON stated that for the (MONTH) 6, 2019 care plan for multiple [MEDICAL CONDITION] on the right arm, nail trimming should have been included in the intervention. DON stated since it was identified that Resident 1 has episodes of scratching his right arm with multiple [MEDICAL CONDITION] his fingernails should have been checked and ensure it is trimmed. On (MONTH) 5, 2019, at 8:35 a.m., during a telephone interview with the DON she stated the facility has no documented evidence on when Resident 1 fingernails were trimmed. A review of the facility's revised policy and procedure (revised (MONTH) 2010), titled Care of Fingernails/Toenails, indicated that the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy and procedure further outlined in the guidelines, that trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin and that the date and time nail care is given should be recorded in the resident`s medical record. A review of the facility`s policy and procedure dated (MONTH) (YEAR), titled Care Plans, Comprehensive Person-Centered, indicated that the comprehensive, person centered care plan will describe the services that are to be furnished to attain the resident`s highest practicable physical, mental, and psychosocial well- being.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1). For Resident 1, who had a physician's orders [REDACTED]. As a result, Resident 1 became unconscious and expired on the same day. Findings: According to the Admission Face Sheet, Resident 1 was admitted to the facility, on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. The POST form indicated if Resident 1 was found with a pulse and/or was breathing, the facility was to provide full treatment (primary goal of prolonging life by all medically effective means). A review of the care plan, initiated on [DATE], for Resident 1 rummaging through the trash cans and laundry bins indicated the goal was that the resident would not rummage through the trash cans and laundry bins by [DATE], however, the care plan was not revised and no new interventions were added since the initiation date (5 months prior). A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated [DATE], indicated Resident 1's cognitive skills in daily decision making was severely impaired and he had unclear speech. A review of the nursing progress notes indicated, on [DATE], at 3:45 p.m., Resident 1 was taken to the shower by a Certified Nurse's Aide (CNA 1). At 3:50 p.m., CNA 1 noted the resident was unresponsive and took the resident back to his room. There was no documented evidence of vital signs or a pulse check at that time. A review of a nursing progress note, dated [DATE], at 3:58 p.m., eight minutes after Resident 1 was found unconscious, a registered nurse was notified and was unable to obtain a pulse. The nursing progress note indicated CPR was initiated. During a phone interview, on [DATE], at 10:40 a.m., CNA 1 stated he arrived to the facility at 3:40 p.m. on [DATE]. The administrator called CNA 1 to the courtyard where Resident 1 was. CNA 1 stated the resident had a brown substance all over the hands, face, and mouth. The resident appeared to be eating the brown substance, as it was found on the lips as well. At that time, the resident's eyes were open, however, did not verbally communicate with CNA 1. At 3:45 p.m., CNA 1 placed the resident into the shower room. CNA 1 noted the resident's eyes were closed and was unresponsive when he attempted to get the resident into the shower chair. Resident 1's skin was cold as well. CNA 1 stated he called for help without assessing for resident's airway, breathing and pulse. When the licensed staff arrived, they did not check the resident's vital signs including the airway, breathing or pulse while the resident was in the shower room. During an interview and record review, on [DATE], at 11 a.m., the Director of Nurses (DON), stated there was no documented evidence Resident 1's airway, breathing, and pulse were assessed while the resident was in the shower room. The DON stated Resident 1 became unresponsive at 3:50 p.m. and the vital signs and pulses were not assessed until 3:58 p.m. During an interview and record review, on [DATE], at 11:15 a.m., Licensed Vocational Nurse 1 (LVN 1) stated she went into the shower room when CNA 1 asked for help. There was no documented evidence of a pulse check or vital signs being taken at that time, while in the shower room. Resident 1 was taken back to his room at 3:58 p.m. (8 minutes after the resident was found unconscious), and was assessed and vital signs were taken at that time. During a phone interview on [DATE], at 12:20 p.m., Registered Nurse Supervisor 1 (RN 1) stated on [DATE], at 3:50 p.m., CNA 1 came out of the shower room and asked for help because Resident 1 was slumped over and unresponsive. RN 1 did not go into the shower room to assess the resident. She further stated no licensed staff assessed the resident in the shower, however, the resident was assessed and vital signs were taken once the resident was back in his room at 3:58 p.m. During a phone interview, on [DATE], at 9:25 a.m., the Administrator stated on [DATE] while doing rounds, Resident 1 was seen in the courtyard with a dark brown substance on his hands, mouth, and face. The resident was awake and attempting to talk at that time. The administrator asked CNA 1 to clean the resident up. The administrator stated the residents were not constantly supervised in the courtyard. A review of the nursing progress notes, dated [DATE], at 4 p.m., indicated 911 was called and CPR was performed continuously until arrival of paramedics. A review of the nursing progress notes, dated [DATE], at 4:15 p.m., indicated the paramedics arrived at that time and declared Resident 1 expired at 4:16 p.m. A review of the Certificate of Death, dated [DATE], indicated Resident 1's cause of death was asphyxia (a lack of oxygen in the body that results in unconsciousness and often death, and is usually caused by interruption of breathing or inadequate oxygen supply due to a foreign body obstruction. A foreign body airway obstruction causes asphyxia and is a terrifying condition, occurring very acutely, with the patient often unable to explain what is happening to them. If severe, it can result in rapid loss of consciousness and death if first aid is not undertaken quickly and successfully. Immediate recognition and response are of the utmost importance). A review of the autopsy report, dated [DATE], indicated the resident's stomach was noted to contain foreign material alone with semisoft, brown material. Foreign material was found in the trachea and lung airways. During a phone interview, on [DATE], at 9:37 a.m., the Assistant Nursing Director stated Resident 1 had a tendency to rummage through the trash cans and the residents were not supervised on the courtyard. During a phone interview and record review, on [DATE], at 8:40 a.m., the medical records director stated Resident 1's care plan for rummaging through the trash cans and laundry bins should have been revised on [DATE] and new interventions should have been added since the resident continued to this behavior. The facility's policy and procedure titled, Emergency Procedure-Cardiopulmonary Resuscitation, dated ,[DATE] indicated if an individual was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR shall initiate CPR. CPR was to be initiated if a victim was unresponsive and not breathing normally without assessing the victim's pulse. The facility's policy and procedure titled, Behavioral Assessment, Intervention, and Monitoring, dated ,[DATE] indicated as part of the initial assessment, the nursing staff and Attending Physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness (i.e. [MEDICAL CONDITION]). As part of the comprehensive assessment, staff will evaluate the resident's usual patterns of cognition, mood, and behavior, the residents' usual method of communicating things like hunger. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's behavior. The interdisciplinary team will evaluate the behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. The policy indicated safety strategies will be implemented immediately if necessary to protect the resident and others from harm. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as potential situational and environmental reasons for behavior. The care plan will include a description of the behavioral symptoms including frequency, locations, environment, and precipitating factors. It is to include specific and measurable goals and how the staff will monitor for effectiveness of the interventions. The DON, or designee, will evaluate whether the staffing needs have changed based on the acuity of the residents and their plan of care. Additional staff and/or staff training will be provided if it determined the needs of the residents cannot be met with the current level of staff or staff training.

Based on observation, interview, and record review, the facility failed to ensure its resident receives adequate supervision to prevent falls and minimize injuries for one of three sample residents (Resident 1), including: 1. Failure to ensure Resident 1, who was assessed as requiring two-person physical assist with bed mobility and personal hygiene, was provided with the necessary assistance. 2. Failure to indicate in the Care Plan Resident 1 needed two-staff assistance with bed mobility and personal hygiene as indicated in comprehensive assessment. 3. Failure to implement the facility's policy on Assessing Falls and Their Causes, by not following the procedures after the fall, identifying the cause(s) of fall, documenting and reporting. As a result, on 4/4/18, Resident 1 fell when Certified Nursing Assistant 1 (CNA 1), without another staff, carried Resident 1 from bed to wheelchair causing Resident 1 a broken right femur (thigh bone) and patellar (knee) dislocation. Resident 1 post fall assessment was delayed. Findings: A review of the Admission Record, Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - an assessment and care screening tool), dated 3/16/18, indicated Resident 1 was alert and able to answer some questions and was totally dependent and required at least two-person assist from staff for transfers to and from the bed to the wheelchair/chair. A review of the Falls Risk Assessment, dated 3/15/18, indicated Resident 1 had intermittent confusion, was unable to perform any gait, balance or ambulation, was confined to chair, and received antipsychotic (drug used to treat [MEDICAL CONDITION]) and antihypertensive medication (drug used to lower high blood pressure). The fall risk assessment indicated Resident 1 scored a 22, which was a high risk for falls. A review of Resident 1's clinical record, Resident 1 had a care plan for high fall risk, initiated on 3/16/18, due to poor safety judgement, medications, episodes of bending forward while in the wheelchair, and a history of falls. The care plan interventions did not include at least two-person assist from staff for transfers to and from the bed to the wheelchair/chair. The goal of the care plan was to attempt to prevent falls everyday through the next review. During an interview, on 4/24/18, at 11 a.m., the Assistant Director of Nursing (ADON) stated Resident 1 required extensive assist using at least two people for transfers in and out of bed. The ADON stated on 4/4/18, Certified Nursing Assistant (CNA 1) transferred Resident 1 by herself, not realizing the resident was heavy. The ADON stated the CNA 1 should not have transferred Resident 1 on her own. During a phone interview, on 4/24/18, at 11:27 a.m., CNA 1 stated on 4/4/18, she was putting Resident 1 into a wheelchair. The resident was unable to stand up without assistance. The CNA carried the resident on her own in an attempt to put the resident in the wheelchair, however, the wheelchair moved back. CNA 1 further stated, I assisted the resident's fall onto the ground because she was too heavy. During a phone interview, on 4/24/18, at 11:47 a.m., CNA 2 stated she was walking in the hallway when CNA 1 called for help. She observed Resident 1 on the floor, laying on her left side. CNA 2 then called a Licensed Vocational Nurse (LVN 1) for help. CNA 2 further stated Resident 1 required two people to assist with transfers and should never be carried by one person. A review of Resident 1's clinical record indicated there was no documented evidence about the fall, the post fall assessment, or that the physician was notified after the incident on 4/4/18. On 4/24/18, at 12:02 p.m., during a phone interview, LVN 1 stated a post fall assessment was not done and the physician was not notified of Resident 1's fall on the same date (4/418). LVN 1 stated Resident 1 was totally dependent on staff and required two or more person assist. During a phone interview, on 5/24/18, at 10:20 a.m., the ADON stated and verified there was no documentation of Resident 1's fall, a post fall assessment was not done and an incident report was not done on 4/4/18. A review of the Change of Condition (C[NAME]), dated 4/5/18, at 10:55 p.m., (the day after the fall) indicated Resident 1 had swelling to the left knee and was experiencing mild pain at a level of 3 - 4 (0 being no pain at all and 10 being the worst pain). The resident had limited range of motion to the left knee due to the pain. The C[NAME] for swelling of the left knee, indicated the physician was notified and an x-ray and Tylenol (pain medication) was ordered. A review of the radiology report done at the facility, dated 4/6/18, at 12:58 a.m., indicated Resident 1 had a fracture involving the left femur (thigh bone). A review of the Medication Administration Record [REDACTED] A review of the Nursing Progress Note, dated 4/7/18, at 9:33 a.m., indicated Resident 1 was transferred to the general acute care facility with a left femur fracture and a right patellar dislocation. A review of to the general acute care facility's computerized tomography (CT) scan (combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images of the bones. CT scan images provide more-detailed information than plain X-rays do), dated 4/7/18, indicated Resident 1 had a comminuted [MEDICAL CONDITION] distal femur (a break or splinter of the thigh bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma). A review of the general acute care facility's x-ray report, dated 4/7/18, indicated Resident 1 had a patellar (knee) dislocation. A review of the general acute care facility's discharge summary, dated 4/12/18, indicated Resident 1 was started on [MEDICATION NAME] (a narcotic medication used for pain), received physical therapy, and an immobilizer to the left lower extremity. A review of the facility's policy and procedure titled, Assessing Falls and Their Causes, dated 10/2010 indicated the purposes of the procedure were to provide guidelines for assessing a resident after a fall to assist staff in identifying causes of the fall. The care plan was to be reviewed to assess for any special needs of the resident. If a resident had just fallen, nursing staff would record vital signs and evaluate for possible injuries. Once an assessment rules out significant injury such as a fracture, nursing staff would help a resident to a comfortable position and then document relevant details. The nursing staff would notify the resident's attending physician and family in an appropriate time frame. The policy indicated nursing staff would observe for delayed complications of a fall for approximately 48 hours after an observed fall and would document findings in the medical record. Documentation would include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility. An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the director of nursing (DON) no later than 24 hours after the fall occurs. After an observed fall, the staff would clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred. Within 24 hours of a fall, the nursing staff would begin to try to identify possible or likely causes of the incident.