Every finding on record at Sunnyvale Post-Acute Center

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement fall prevention interventions for one of three sampled residents (Resident 1), when facility staff failed to monitor Resident 1 after lunch/activity and did not observe Resident 1 leave the dining/activity area. This failure resulted in Resident 1 having an unwitnessed fall in another resident's bathroom and placed Resident 1 at risk for potential injury. Findings: Review of Resident 1's face sheet (summary page of a patient's important information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit (problem with communication due to disruption in cognitive (thinking) processes), dementia with behavioral disturbance (includes agitation, aggression, anxiety, wandering, sleep disturbances, and psychosis (hallucinations or delusions), generalized muscle weakness, other reduced mobility (loss of ability to move freely or independently) and fall on same level.Review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool), Section C, dated 5/22/26, indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment.Review of Resident 1's MDS Section GG (function and mobility assessment) dated 6/8/26 indicated Resident 1 required substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toilet transfers, sit-to-stand, and chair/bed-to-chair transfers. The MDS also indicated Resident 1 used a manual wheelchair and required assistance with mobility. Review of Resident 1's Fall risk Observation/assessment dated [DATE] indicated Resident 1 as high risk for falls with a score of 26 (high risk). The assessment also indicated Resident 1 had 1 to 2 prior falls, was dependent and incontinent.Review of Resident 1's Interdisciplinary Team (IDT, staff from different disciplines who work together to plan and provide care) note dated 5/28/26 indicated Resident 1 had an unwitnessed fall on 5/24/26 at 5:20 a.m. The IDT identified interventions including intermittent checking and safety protocol, frequent checks for bathroom assistance, and increased visual checks by CNAs (Certified Nursing Assistants) and nurses for safety. Review of Resident 1's Fall care plan, initiated on 5/24/26, indicated Resident 1 had an unwitnessed fall. The fall care plan included interventions for intermittent checking and safety protocol, frequent checks for bathroom assistance, and increased frequency of visual checks for safety by CNAs and nurses.Review of Resident 1's Change of Condition note dated 6/12/26 indicated Resident 1 had an unwitnessed fall in the bathroom and was found lying on his buttocks at approximately 1:00 p.m. The Note indicated vital signs were within normal limits. No visible trauma, wounds, or redness were noted. Resident complained of pain to the left arm/hand and left hip and denied head pain. The Nurse Practitioner (NP) assessed Resident 1, and the physician ordered X-rays (a medical imaging that uses radiation to take pictures of the inside of the body). The note indicated no injury was identified after the fall.During observation on 6/23/26 at approximately 1:30 p.m., Resident 1 was observed sitting in a wheelchair in the hallway in front of Resident 1's room. Resident 1 wore non-skid socks. Resident 1 was able to wheel himself in the hallway and attempted to stand from the wheelchair. Facility staff redirected Resident 1. During an interview with CNA A on 6/23/26 at 2:08 p.m., the CNA assigned to Resident 1 that day. CNA A stated she toileted Resident 1 around 9:00 a.m., before lunch, and after lunch.During an interview with CNA B on 6/23/26 at 2:30 p.m., CNA B was assigned to Resident 1 on 6/12/26, CNA B stated she toileted Resident 1 at approximately 9:30 a.m. and took Resident 1 to the dining/activity room. CNA B stated this was the last time she saw Resident 1 before the fall. CNA B stated Resident 1 would stand up independently even though Resident 1 was unsteady. CNA B stated she was assigned nine residents on that shift. CNA B stated she was providing incontinence care to another resident at the time of the fall. CNA B stated an RNA informed her Resident 1 was on the floor. CNA B stated she believed Resident 1 fell because she had nine assigned residents. Review of the CNA room assignment sheet dated 6/12/26 indicated CNA B was assigned nine residents on the shift.During an interview with the Activity Assistant C (AA C) on 6/30/26 at 2:05 p.m., AA C stated she was in the dining room on 6/12/26. AA C stated Resident 1 was active, kept himself busy with activities, ate slowly, and could wheel himself. AA C stated staff redirected Resident 1 as needed. AA C stated she did not see Resident 1 leave the dining room and did not know what happened at the time of the fall.During an interview with the Restorative Nurse Assistant D (RNA D) on 6/30/26 at 2:15 p.m., RNA D stated Resident 1 comes to the dining room daily, required set-up assistance with meals, and could feed himself. RNA D stated Resident 1 usually finished eating late and was usually one of the last residents to leave the dining room. RNA D stated the last time he saw Resident 1 he was eating in the dining room. RNA D stated he did not see Resident 1 leave the dining room or see Resident 1 in the hallway before the fall.During an interview with the Licensed Vocational Nurse E (LVN E) on 6/30/26 at 3:00 p.m., LVN E stated he was the charge nurse assigned to Resident 1 on 6/12/26. LVN E stated he last saw Resident 1 around noon when giving medications. LVN E stated Resident 1 could not verbalize his needs and could wheel himself. LVN E stated he saw Resident 1 lying on the bathroom floor near the toilet. During a phone interview with RNA F on 7/2/26 at 11:16 a.m., RNA F stated Resident 1's lunch tray was late on 6/12/26 and that everyone else had finished eating except Resident 1. RNA F stated he was pushing other residents back to their rooms. RNA F stated AA C remained in the dining room while Resident 1 was eating. RNA F stated a CNA later told him Resident 1 was on the floor. RNA F stated he went to Room A and saw Resident 1 lying on the bathroom floor near the toilet.During a phone interview with CNA G on 7/2/26 at 2:16 p.m., CNA G stated she was walking in the hallway toward the dining/activity room when she passed Room A and saw a wheelchair outside the bathroom. CNA G stated she went inside to check and observed Resident 1 lying on the bathroom. floor. CNA G stated she immediately called the RNA. Review of the undated facility policy titled Falls - Clinical Protocol indicated .Treatment/Management .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions,based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) .

Based on interview and record review the facility failed to follow their abuse reporting policy and procedure for one of three sampled residents (Resident 1).This failure had the potential to compromise Resident 1's safety.Findings:During an interview with the Director of Nursing (DON) on 7/10/25 at 10:06 a.m., the DON had been notified of an allegation of abuse.During an interview with Resident 2 on 7/10/25 at 10:16 a.m., Resident 2 was sitting on his wheelchair and stated that on 6/25/25 around 3 a.m., to 5 a.m., a male CNA was rough when changing his roommate's (Resident 1) incontinent brief and he reported the incident to the nurse. During an interview with Resident 2 on 7/10/25 at 2:15 p.m., Resident 2 stated that on 6/25/25 he reported the alleged rough handling of Resident 1 to the woman medication charge nurse. Resident 2 further stated he was asked what exactly happened.Review of Resident 2's clinical records he was admitted to the facility on [DATE] with diagnosis including post-traumatic stress disorder (a mental health condition that develops after experiencing or witnessing a traumatic event). Resident 2's minimum data set (MDS, an assessment tool) dated 5/5/25 indicated his brief interview for mental status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (score of 15 indicates cognition [ability to remember, judge and use reason] is intact).During an interview on 7/17/25 at 10:56 a.m., with Certified Nursing Assistant B (CNA B), CNA B acknowledged that he was the CNA assigned for Resident 1 at night shift on 6/25/25. CNA B stated that he did not roughly handle Resident 1 during incontinent brief change. CNA B denied that Resident 2, the roommate of Resident 1, notified the charge nurse about a CNA roughly handling Resident 1 during incontinent brief change. During an interview on 7/23/25 at 2:25 p.m., with Licensed Vocational Nurse A (LVN A), LVN A stated that she was the full-time charge nurse working night shift for Resident 1 and did not observe or there was no report of any suspicious of abuse to Resident 1 on 6/25/25. LVN A denied that Resident 2 the roommate of Resident 1 notified her about a CNA that roughly handle Resident 1 during incontinent brief change. During an interview with the DON on 8/13/25 @ 12:27 p.m., the DON stated that the allegation of abuse was not brought to her attention by LVN A and CNA B that was interviewed by CDPH on 7/17/25 and 7/23/25. The DON further stated if they were notified by anyone other than California Department of Public Health (CDPH) they would have reported it to CDPH, Ombudsman (long term care ombudsman. representatives that assist residents in the long term care facilities with issues related to day to day care, health and safety concerns) and Police.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, dated 2001. The P&P indicated, .1. If Resident Abuse, Neglect, Exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.

Based on observation, interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident1) when Resident 1's ability to hear was not coded on the MDS.Failure to accurately complete the MDS had the potential to compromise the facility's ability to develop and implement care plan interventions.Findings:During a concurrent observation and interview on 7/10/25 at 10:10 a.m., with Resident 1 in his room, surveyor asked Resident 1 a question three times before Resident 1 responded. Resident 1 was observed with no hearing aid.During an interview on 7/17/25 at 10:56 a.m., with Certified Nursing Assistant B (CNA B), he stated that Resident 1 was hard of hearing and does not have hearing aid.During an interview on 7/23/25 at 2:20 p.m., with Licensed Vocational Nurse A (LVN A), she stated that Resident 1 was hard of hearing and does not wear hearing aid.Review of Resident 1's medical record indicated he was admitted to the facility on [DATE] with diagnoses which included muscle weakness, need for assistance with personal care, bilateral (both) sensorineural hearing loss (a condition where there is damage to the inner ear or the auditory nerve. During an interview and concurrent record review with Minimum Data Set Coordinator (MDSC) on 7/10/25, at 2:53 p.m., MDSC reviewed Resident 1's MDS, dated [DATE], and confirmed section B0200 was coded 0, indicating Resident 1's ability to hear was adequate. MDSC confirmed section B0200 should have been coded 3, to indicate Resident 1's highly impaired hearing and with diagnosis of bilateral sensorineural hearing loss.The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2024, indicated for section B0200, Code 3, for highly impaired hearing.

Based on observation, interview, and record review, the facility failed to ensure garbage was disposed properly when one of three facility garbage was overflowing. This failure had the potential to result in the spread of disease from vermin infestation and unsanitary environment for the residents.Findings:During an observation on 7/10/25 at 12:07 p.m., at the back of the parking area, there was an uncovered, blue bin with overflowing garbage positioned at the back door of the facility.During an interview on 7/10/25 at 1:58 p.m. with the infection control preventionist (IP), the IP verified that the garbage was overflowing from the blue bin and not covered. The IP mentioned that the garbage bin must be closed and should not be overflowing.A review of undated facility's policy and procedure (P&P) titled Food- Related Garbage and Rubbish Disposal indicated that All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use.

Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when the facility did not administer medication as ordered by a physician for Resident 1. This failure had the potential to compromise the resident's health and care.Review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted on [DATE] and had diagnoses including essential hypertension (HTN-high blood pressure), hypotension (low blood pressure), and epilepsy (an abnormal activity in the brain causing seizures [uncontrollable jerking movements of the arms and legs, and loss of consciousness]). Review of Resident 1's physician's order, dated 5/7/25, indicated Losartan Potassium (a hypertension medication) 25 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), give 1 tablet by mouth one time a day for hypertension, hold for SBP (systolic blood pressure) less than 100. Review of Resident 1's May 2025 Medication Administration Record (MAR) indicated Losartan Potassium 25 mg tablet was administered from 5/8/25 to 5/15/25. There was no documentation indicating BP was checked and SBP was greater than 100 when administering Losartan Potassium to Resident 1 on the MAR from 5/8/25 to 5/15/25. Review of Resident 1's Change in Condition Evaluation, effective date 5/15/25, indicated the patient began having a seizure and became unresponsive and was staring at the ceiling. The patient had a BP of 80/54. Resident headed to [hospital name] for further evaluation. During an interview and record review with Licensed Vocational Nurse (LVN) A on 5/29/25 at 3:05 p.m., he confirmed the above record review. LVN A confirmed that he administered Losartan Potassium to Resident 1 on 5/12/25 and 5/15/25. LVN A stated there was no documentation indicating BP was checked and SBP was greater than 100 when administering Losartan Potassium to Resident 1 on 5/12/25 and 5/15/25. LVN A acknowledged that Resident 1's BP should have been checked prior to administering Losartan Potassium as ordered and documented. During an interview and record review with the Director of Nursing (DON) on 7/11/25 at 10:45 a.m., she confirmed the above record review. The DON stated Resident 1's BP was checked every shift but there was no evidenced documentation indicating BP was checked and SBP was greater than 100 when administering Losartan Potassium to Resident 1 from 5/8/25 to 5/15/25. The DON acknowledged that Resident 1's BP should have been checked prior to administering Losartan Potassium as ordered and documented. Review of Resident 1's Discharge Summary from the hospital, dated 5/18/25, indicated Principle Diagnosis at discharge: Syncope and collapse (fainting, or a sudden temporary loss of consciousness). During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary.

Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for one of three sampled residents (Resident 1) when: 1. Resident 1 was not accurately assessed for Fall Risk Observation/Assessment and Admission/readmission Evaluation/Assessment; and 2. Staff did not assist Resident 1 during toileting and left Resident 1 unsupervised inside the resident restroom. These failures resulted in Resident 1's unwitnessed fall.Review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted on [DATE] and had diagnoses including essential hypertension (HTN-high blood pressure), hypotension (low blood pressure), epilepsy (an abnormal activity in the brain causing seizures [uncontrollable jerking movements of the arms and legs, and loss of consciousness]), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a symptom that involves the loss of the ability to move on one-side of body) following cerebral infarction (stroke), muscle weakness, and difficulty in walking. Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 5/9/25, indicated a brief interview for mental status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was scored 12 (which indicates moderate cognitive impairment). Resident 1 had an impairment on one side of upper/lower extremity and required partial/moderate assistance (helper does less than half the effort) for toileting hygiene and toilet transfer. Review of Resident 1's Fall Risk Observation/Assessment, dated 5/7/25, indicated Score of 14 (Moderate Risk 9-15). The assessment indicated, 3. Balance and 6. Mobility were marked at 1. Ambulates without problem and with devices. Review of Resident 1's Admission/readmission Evaluation/Assessment, dated 5/7/25, indicated, K. Ambulation: ambulatory with 1 person assist, needs 1 person assist with transfer; M. Other relevant concerns: 4b. seizure precautions was marked at 2. No. Review of Resident 1's Rehab-Functional Abilities, effective date 5/8/25, indicated, Resident 1 required partial/moderate assistance for toileting hygiene and toilet transfer. Review of Resident 1's Occupational Therapy Treatment Encounter Note, dated 5/12/25, indicated, Toileting: toilet/commode transfers = minimum assist; personal hygiene = moderate assist; clothing management = moderate assist. Review of Resident 1's Change in Condition Evaluation, effective date 5/13/25, indicated Heard resident calling out loud 'help me'. found lying down at floor, stated 'I slid down from the commode'. able to ambulate to the bathroom using own FWW (front wheel walker) with one person assist. Review of Resident 1's Intradisciplinary team (IDT, a coordinated group of experts from several different fields who work together toward a common business goal) note, dated 5/15/25, indicated IDT met re: fall, Resident found lying down at floor, stated 'I slid down from the commode'. Noted resident is mod A (moderate assist) for bed mobility, transfer and ambulation . During an interview and record review with the Director of Rehabilitation (DOR) on 5/29/25 at 4 p.m., she confirmed the above record review. The DOR verified licensed nurse did not accurately assess Resident 1 for the Fall Risk Observation/assessment dated [DATE]. The DOR stated Resident 1 was ambulating with problems and with devices, needed one person assistant. During a telephone interview with Registered Nurse (RN) B on 6/2/25 at 8:17 a.m., he confirmed he was Resident 1's nurse on 5/13/25. RN B stated Resident 1's unwitnessed fall was reported by a Certified Nursing Assistant (CNA). RN B stated the CNA assisted Resident 1 to the bathroom and left the room. During a telephone interview with CNA C on 7/11/25 at 10:15 a.m., he confirmed he was Resident 1's CNA on 5/13/25. CNA C stated he assisted Resident 1 into the bathroom, and Resident 1 asked him to close the bathroom door, and wait outside of the bathroom. CNA C stated he left her alone in the bathroom to answer a call light from another resident. CNA C stated Resident 1 was found on the bathroom floor when he came back. During an interview and record review with the Director of Nursing (DON) on 7/11/25 at 11:10 a.m., she confirmed the above record review and stated Resident 1 required one person assistant with her toileting. The DON acknowledged staff should have stayed nearby to provide partial/moderate assistant to Resident 1 during toileting. During an interview and record review with the DON on 7/11/25 at 11:30 a.m., she confirmed the above record review. The DON verified the licensed nurse did not accurately assess Resident 1 for the Fall Risk Observation/assessment dated [DATE]. The DON stated Resident 1 was ambulating with problems and with devices. During an interview and record review with the DON on 7/11/25 at 11:41 a.m., she confirmed the above record review. The DON verified the licensed nurse did not accurately assess Resident 1 for the Admission/readmission Evaluation/assessment dated [DATE]. The DON stated Resident 1 was with seizure precautions. During a review of the facility's policy and procedure (P&P) titled Assisting Activities of Daily Living (ADL); Supervision, dated 2001, the P&P indicated, Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of facility Fall Management dated 8/2014, indicated Purpose, to evaluate risk factors and provide interventions to minimize risk, injury, and occurrences. Assessment guidelines, may include fall risk factors/ fall history .

Based on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: 1. Two bins with thawed, soft mighty health shake cartons were stored in a reach-in refrigerator with expired dates. 2. A 3-door reach-in refrigerator and a walk-in refrigerator did not have internal thermometers to monitor temperature. 3. A large yellow onion with 3 dark grayish green colored spots resembling mold on it was found in case of yellow onions in the dry storage room. 4. A plastic container half full of tuna salad stored was stored inside the walk-in refrigerator and did not have a use by date. 5. The ice machine air filter had black and dark gray debris on it, and the inside ice making parts were not cleaned and maintained according to manufacturer's instructions. 6. A water filter attached to the ice machine, and one attached to the coffee maker machine were expired and not changed according to manufacturer's guidelines. 7. A medium grease trap floor hole space near the food production area was uncovered and had sticky brown dirt and black debris. 8. Ten large plastic bins were stacked wet in the dish machine area. These deficient practices exposed facility residents who consume food from the kitchen to potentially harmful substances which could have led to widespread foodborne illness. Findings: 1. During the initial kitchen tour on [DATE] at 8:30 a.m., an observation and interview was conducted with the Dietary Director (DD). There were two bins containing mighty health shakes stored in the reach-in refrigerator and thawed. One bin contained about 22 chocolate mighty health shakes was labeled In: [DATE], UB (Use By): [DATE]. The second bin contained about five vanilla mighty health shakes and was labeled In: [DATE], UB: [DATE]. On [DATE] at 9:30 a.m., during an interview with the DD, the DD acknowledged the mighty health shakes were thawed and stored in the refrigerator past their use date. She stated the shakes should have been good to use 2 weeks after the date they were placed in the refrigerator. She stated the labels on the bins were incorrect and acknowledged the bin with 22 mighty shakes dated [DATE] were past the 14 days and were not good because their nutritional value was lowered. During an interview with Certified Nursing Assistant (CNA) V on [DATE] at 11:12 a.m., CNA V stated Resident 67 receives mighty shakes three times a day with meals. She stated Resident 67 drank the mighty shake in the morning with his breakfast and typically drinks the entire shake. Review of the health mighty shakes manufacturers label indicated the Store Frozen and to Thaw and serve within 4 days. https://www.hormelhealthlabs.com/wp-content/uploads/ProductFactSheet_26337_[DATE].pdf. 2. During the initial tour of the kitchen on [DATE] at 8:17 a.m., the three-door reach-in refrigerator and walk-in freezer did not have thermometers. During a concurrent interview on [DATE] at 8:59 a.m., the DD verified there were no thermometers in the refrigerator of the walk-in freezer and stated there should be thermometers in both the refrigerator and walk-in freezer to keep the food at an adequate temperature. According to the 2019 California Retail Food Code, section 113928, titled Temperature measuring device, TEMPERATURE MEASURING DEVICE means a thermometer, thermocouple, thermistor, or other device that indicates the temperature of FOOD, air, or water . 3. On [DATE] at 10:59 a.m., an observation and interview were conducted with [NAME] (CK) X and DD. CK X was cutting onions during meal preparation. One onion was discolored inside after it was cut in half. CK X stated he was still going to use the onion even though it had some discoloration. He stated, I'm just going to cut that part off. The DD verified the discoloration on the cut onion and stated, it's rotten. According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section ,d+[DATE].11, Food Products which are damaged, spoiled, or otherwise unfit for .use in a food establishment may become mistaken for safe .and cause contamination of other foods . 4. During an observation on [DATE] at 8:21 a.m. in the main dry storage room, an opened case with six 12-ounce cans each of tuna were on a shelf. During an observation on [DATE] at 8:25 a.m. of the walk-in freezer in the kitchen a container with tuna salad on shelf was labeled [DATE]. On [DATE] at 11:45 a.m. an observation and interview were conducted with the Dietary Aide (DA) Y. DA Y explained the procedure for making tuna salad. DA Y stated she makes tuna salad sandwiches by taking a can of tuna from the dry storage and adding one tablespoon of mayonnaise then mixes it together. She then places it in the refrigerator with a label for the date it was made. She stated the tuna was good for 4 days. She also stated she does not write a cool down temperature on the log before making the tuna sandwiches. According to the 2022 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE].14 titled Cooling, Time/Temperature control for Safety (TCS) Food shall be cooled within 4 hours to .41F or less if prepared from ingredients at ambient temperature, such as .canned tuna . 5. During an observation and interview with the DD and Maintenance Director (MD) L on [DATE] at 3:52 p.m. of the facility's ice machine in the kitchen. The MD L stated he does deep internal cleaning and bin cleaning of the ice machine every month. During a concurrent observation and interview on [DATE] at 3:30 p.m. in the kitchen with DD, and MD L, the ice machine was checked for cleanliness. The MD L opened the ice machine cover and described how he followed the manufacturer's guidelines for cleaning the ice machine. The ice machine's air filter screen was covered with black debris material and had a dead brown bug on it. The DD and MD L acknowledged the black debris on the filter screen and stated it should be clean and without any pest. Review of the ice machine cleaning log schedule indicated the ice machine was last cleaned on [DATE]. According to the 2017 Federal Food Code, section ,d+[DATE].11, Equipment Food-Contact Surfaces and Non-Food Contact Surfaces, .equipment food-contact surfaces shall be clean to sight and touch, effectively washed to remove or completely loosen soils .; Non-Food Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . 6. On [DATE] at 3:40 p.m. an observation and interview were conducted with the DD and MD L in the kitchen. The water filter for the ice machine was dated [DATE] and the water filter for the coffee machine was dated [DATE]. The DD and MD L acknowledged both filters were outdated and should have been changed. Review of the kitchen ice machine manufacturer's cleaning instructions dated [DATE], titled Ice Machine Maintenance and Cleaning Instructions for Filters, indicated The air filter . will capture airborne dust during operation. As the dirt builds up, it begins to restrict air flow and causes the refrigeration system to work less effectively. Clean air filter regularly. 2. Remove dust and dirt by washing the filter . 3. Reinstall filter . 7. During the initial tour of the kitchen on [DATE] at 8:30 a.m., an observation and interview was conducted with the DD. A medium sized grease trap floor hole space near the food production area was uncovered and had sticky brown dirt and black debris. The DD verified the grease trap looked dirty and should be covered with a lid. According to the 2022 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE].16, Nonfood-Contact Surfaces Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. According to the 2022 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE].11, Floors, Walls, and Ceilings floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. 8. An observation and interview were conducted on [DATE] at 9 a.m. with the DD in the kitchen. There were twelve clear plastic bins stored wet on top of a wire shelf. The DD stated the bins should not be stacked and stored wet. According to the Food and Drug Administration (FDA) Food Code 2017, Section ,d+[DATE].11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . On [DATE] at 4:08 p.m. an interview was conducted with the Administrator (ADM) and RD U. Concerns with kitchen findings were discussed. RD U stated she checks on the DD regularly to ensure tasks are carried out correctly and expects the kitchen staff to perform their functions and duties according to standards of practice. The ADM stated he expects the dish washer to always function properly and tasks to be appropriately completed. Review of the facility's policy dated 2023, titled General Cleaning of Food & Nutrition Services Department, indicated Floors and Floor Mats- Floors, floor mats, and walls must be scheduled for routine cleaning and maintained in good condition. 1. Floors must be mopped at least once per day. Review of the facility's policy dated, [DATE] titled Food Receiving and Storage, indicated, Refrigerated/Frozen Storage . 7. Refrigerated foods are labeled, dated, and monitored so they are used by their use -by date, frozen, or discarded. Review of the facility's policy dated [DATE] titled, Sanitization, Filters, indicated All ice machines, water dispensers, and other units containing filters are to be kept clean, free from debris and serviced regularly. Ice machines, water dispensers . are recommended to be changed every six (6) months or as needed. Review of the kitchen ice machine manufacturer's cleaning instructions dated [DATE], titled Ice Machine Maintenance and Cleaning Instructions for Filters, indicated The air filter . will capture airborne dust during operation. As the dirt builds up, it begins to restrict air flow and causes the refrigeration system to work less effectively. Clean air filter regularly. 2. Remove dust and dirt by washing the filter .

Based on observation, interview, and record review, the facility failed to follow infection control practices when: 1. One certified nursing assistant (CNA) did not wash hands after providing care between two residents (Residents 96 and 52) who were on transmission-based precautions (are used to help stop the spread of germs from one person to another); 2. One resident (Resident 149)'s nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) oxygen tubing was not changed after seven days according to facility policy; 3. The facility failed to ensure there was a plan in place to prevent the growth of Legionella (a bacteria that is found in water and can cause illness) in the facility's water supply; 4. One resident (Resident 6)'s oxygen filter was not changed according to facility policy; 5. The Licensed Nurses did not perform hand hygiene before putting on a new pair of gloves and after removing gloves, and wearing double gloves during medication administration; and 6. An unlabeled urinal was found in one resident (Resident 42)'s bathroom that was shared by more than one resident room. These failures had the potential to result in cross-contamination and the spread of infection throughout the facility. Findings: 1. During an observation on 10/14/24, at 10:32 a.m. and 12:52 p.m., Resident 52 and 96's room door showed a sign posted for transmission-based precautions. During an observation on 10/16/24, at 8:43 a.m., in the hallway, Certified Nursing Assistant (CNA) B wore a personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) facemask, gown and gloves entering Resident 52's room to check to check Resident 52's vital signs. After performing the task, CNA B removed her gown and gloves inside the room and then performed hand hygiene using a hand sanitizer outside the room. At 8:45 a.m., CNA B walked to door side of Resident 96's room and put on a gown and new pair of gloves then walked inside of Resident 96's room to check his vital signs. After performing the task, CNA B removed her gown and gloves then she washed her hands at inside of resident's shared restroom. During a follow-up interview on 10/16/24, at 9:22 a.m., with CNA B, CNA B stated she should washed her hands between Resident 52 and 96, because they were on contact precautions. During an interview on 10/17/24, at 2 p.m., with the DON and the registered nurse consultant (RNC), both confirmed staff would need to wash hands between residents' care when residents were on transmission-based precautions. During an interview on 10/18/24, at 10:21 a.m., with the infection preventionist (IP), she stated Residents 52 and 96 were both infected with Methicillin-resistant Staphylococcus aureus (MRSA, a type of bacteria that is resistant to treatment with certain antibiotics). During a review of the facility's undated policy and procedure (P&P) titled, Handwashing/ Hand Hygiene, the P & P indicated, Wash hands with soap and water: when hands are visibly soiled; and after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and Clostridioides difficile (C.difficile). 2. Review of Resident 149's admission record indicated she was admitted to the facility on [DATE] and had diagnoses including shortness of breathing with congestive heart failure (a long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply). Review of Resident 149 physician's orders, dated 9/30/24, indicated she had oxygen 2 liters per minute via nasal cannula continuously and to change nasal cannula every Sunday during night shift. Review of Resident 149's October 2024 medication administration record (MAR) indicated the nasal cannula was marked changed on 10/6/24 and 10/13/24. During an observation on 10/15/24, at 9:58 a.m., with registered nurse (RN) D to check on Resident 149's oxygen filter. Resident 149 sat at bedside chair and with a nasal cannula connected to the oxygen concentrator in use. The nasal cannula oxygen tubing was labeled and dated 10/5/24. During a follow-up observation and interview on 10/16/24, at 8:36 a.m., with RN E, in Resident 149's room, RN E confirmed Resident 149's nasal cannula oxygen tubing was outdated, and it should have been changed. During an interview on 10/17/24, at 2 p.m., with the director of nursing (DON), the DON stated the nasal cannula oxygen tubing should be changed according to physician's orders. During a review of the facility's undated policy and procedure (P&P) titled, Department (Respiratory Therapy)- Prevention of Infection, the P&P indicated, Change the oxygen cannula and tubing every seven (7) days, or as needed. 44583 3. During a concurrent interview with the infection preventionist (IP), maintenance director L (MD L) and maintenance director O (MD O) on 10/18/24 at 10:30 a.m., all three disciplines could not answer about their water management program. MD O stated someone comes in to check their water and took the water sample to the laboratory. MD L stated he checked the water temperature on each resident's bathroom daily. During a follow up interview with MD O on 10/18/24 at 10:58 a.m., MD O provided the daily checks of the water temperature in each resident's bathroom. MD O confirmed they only checked the water temperature in each resident's bathroom. MD O stated maintenance did not do any other checks or assessment in their water system. MD O who was the maintenance consultant for MD L stated he did not know what a water management program was. During a follow up interview with IP on 10/18/24 at 11:05 a.m., the IP confirmed they did not have a water management program. The IP stated, I missed that. The IP confirmed they used to have a water management program when the facility was under a different company. The IP stated, but now, we forgot about it. During a concurrent interview with the IP and record review on 10/18/24 at 11:14 a.m., the IP reviewed the water management program policy and procedure provided by MD O. The IP stated they used to have the program. IP further stated, we should have a system in placed to prevent the water borne infection . During a review of the facility's policy and procedure titled, Water Management Program, dated September 2022, indicated, The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The water management program used by our facility is based on the Centers for Disease Control and Prevention .The water management program includes the following elements .The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria .The identification of situations that can lead to Legionella growth .A system to monitor control limits and the effectiveness of control measures; A plan for when control limits are not met and/or control measures are not effective; and Documentation of the program. 4. Review of Resident 6's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 6 was admitted to the facility with diagnoses including polyneuropathy (a condition that affects many nerves in different parts of the body, causing them to malfunction altogether), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pulmonary fibrosis (a serious lung disease that causes scarring in the lungs, making it difficult to breathe), and unspecified asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath). During an observation on 10/15/24 at 9:16 a.m., inside Resident 6's room, Resident 6 was seated at the edge of bed with oxygen thru nasal cannula (NC, a device used to deliver supplemental oxygen or airflow) at 3 liters per minute (LPM). The oxygen concentrator's filter located at the right side of the machine was observed to have grayish colored substance build up. During a concurrent observation and interview with registered nurse D (RN D) on 10/15/24 at 9:17 a.m., inside Resident 6's room, RN D did not know the location of the oxygen concentrator's filter. RN D did not know when and who should change the oxygen concentrator's filter. During a concurrent observation and interview with the director of nursing (DON) on 10/15/24 at 9:21 a.m., inside Resident 6's room, the DON confirmed there was a grayish substance build up in Resident 6's oxygen concentrator's filter. The DON stated the filter should have been changed weekly. During an interview with MD L on 10/15/24 at 9:31 a.m., MD L stated they changed the oxygen concentrator's filter every Friday. Review of Resident 6's clinical record titled, Order Summary Report, dated 6/3/24, indicated there was an order for oxygen use at 3 LPM with a goal to maintain Resident 6's oxygen saturation (O2 sat, the amount of oxygen circulating in the blood) greater than 90%. Further review indicated, there was an order dated 5/31/24 to change the oxygen filters on concentrator (a medical device that provides a safe source of oxygen-enriched air) every Sunday night. During a review of the facility's undated policy and procedure titled, Departmental (Respiratory Therapy) - Prevention of Infection, indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 46001 5. During a medication pass observation and a concurrent interview with Licensed Vocational Nurse (LVN) Q on 10/16/24 at 9:45 a.m., in front of Resident 15's room, LVN Q was preparing the medication for Resident 15. She did not wash or sanitize her hands before putting gloves on or after removing the gloves and then wearing a new pair of gloves. LVN Q confirmed the above observation and stated that she should have washed or sanitized her hands before and after wearing gloves and between glove changes. During a medication pass observation and a concurrent interview with LVN J on 10/16/24 at 2:01 p.m., in front of Resident 36's room, LVN J was preparing the medication for Resident 36. She did not wash or sanitize her hand before wearing a glove and doubled the gloves before entering Resident 36's room. During an interview with the director of nursing (DON) on 10/18/24 at 1:27 p.m., the DON stated that staff should wash or sanitize their hands before wearing gloves and, after removing gloves, change gloves between tasks to prevent infections. The DON further stated staff should not wear double gloves. A review of the facility's undated policy, Handwashing/Hand Hygiene, indicated, All personnel shall follow the hand washing/ hand hygiene procedures to help prevent the spread of infections to other personal, residents and visitors .use an alcohol-based hand rub containing at least 62% alcohol, or alternatively, soap and water for the following situations: before preparing and handing medications .after removing gloves . 48935 6. During an observation on 10/14/24 at 8:41 a.m., a urinal (a plastic container used to measure urine output) was seen in the resident room bathroom which was shared between two rooms (room [ROOM NUMBER] and 2) with no resident identifier or room or bed identifier. During an interview with CNA H on 10/17/24 at 9:10 a.m., CNA H stated any basins or urinals that were used for residents should be labeled with the room number and either A or B for bed number. CNA H further stated the urinal in room [ROOM NUMBER] was used to empty the urinary catheter (a tube that drains the bladder) bag for Resident 42 and she should have a label now. During an interview with the DON on 10/18/24 at 10:58 a.m., the DON stated urinals and basins should be labeled by resident room number and bed number. Review of facility undated P&P titled Cleaning and Disinfecting Non-Critical Resident-Care Items indicated, Single resident use items are for single resident use only. [NAME] with the resident's room number and discard upon transfer or discharge.

Based on observation, interview, and record review, the facility failed to ensure the dish machine consistently provided accurate temperatures and properly function for cleaning and sanitizing dishes, according to manufacturer's guidelines and standards of practice. This failure had the potential to result in widespread foodborne illness for 97 residents consuming food in the facility. (Cross Reference F802 and F812) Findings: During the initial kitchen tour on 10/14/24 starting at 8:22 a.m., the mechanical dishwashing process was observed. The dish machine did not reach the posted manufacturers' specifications of 120 F (degrees Fahrenheit) for both the wash and rinse cycles. The wash cycle on the machine was 110 F-115 F. Similarly, the rinse cycle was 110 F-115 F. Additional wash cycles revealed similar temperatures including 112 F and 108 F, respectively. During an observation and concurrent interview on 10/14/24, at 8:22 a.m., with Dietary Aide (DA) S in the kitchen, the dish machine's wash water temperature gauge indicated 115 F (Fahrenheit-a unit of measurement). DA S verified the temperature gauge indicated 115 F. DA S stated the dish machine's wash water temperature should be 120 F. DA S ran another load of dirty dishes and the dish machine's wash water temperature continued with readings of 110 F-115 F. DA S verified the dish machine's water temperature only reached 115 F. DA S then stated he has to run the dish machine at least four times before getting a temperature reading of 120 F. DA S stated the dish machine temperature had not been reaching 120 F for the last two months and he notified the dietary manager. He also stated the dish machine was inspected by a technician when low temperature readings were initially noticed but it was still currently not working properly. During a review of the data plate affixed on the dish machine, the manufacturer's instructions indicated, the wash water temperature is to reach a 120 F Minimum. During a concurrent interview on 10/14/24 at 11:06 a.m., with the Dietary Director (DD), the DD verified the dish temperature reading of 115 and confirmed the temperature reading should be at 120 F. She stated she was aware of the low temperature reading of the dish washer and was waiting for the manufacturer to provide an additional mechanical part to raise the water temperature. An interview on 10/14/24 at 11:22 a.m. was conducted with the Maintenance Director (MD) L. MD L stated the dish machine had not been working correctly for the last six weeks. He stated he phoned the dish machine manufacturer and requested placement of a heat booster that would increase the temperature of the water in the dish washer. On 10/14/24 at 11:38 A.M. an interview was conducted with the Administrator (ADM) in the kitchen. The ADM stated he was aware of the dish machine not working properly over the past two months. The ADM stated they were waiting for a heat booster to be installed on the dish machine, which would increase the water temperature. The ADM further stated, We'll use disposable containers and paper goods for meals, and the three compartment sink until the dish machine is fixed. On 10/14/24 at 11:44 a.m., an observation and interview were conducted in the kitchen at the dish machine with the Dish Machine Technician (DMT), ADM, and DD. The DMT stated the manufacturer's operating instructions state the wash temperature needs to reach 120 F to correctly wash dish the dishes. The DMT stated the water temperature tank gauge may need to be repaired before a heater booster could be installed. On 10/16/24 at 4:08 p.m. during an interview with Registered Dietitian (RD) U, RD U stated she noticed the dish machine not working properly one month ago and called the maintenance department for a repair. She stated the maintenance worker turned up the water temperature, but she did not personally check the dishwasher temperature reading afterwards. The RD U stated she expected the dish machine to wash and sanitize correctly according to the dish machine's manufacturer's operation guidelines. According to the 2022 Federal Food and Drug Association (FDA) Food Code section 4-501.11, titled, Good Repair and Proper Adjustment, Part (A) indicated Equipment shall be maintained in a state of repair and condition that meets requirements. Review of the facility's policy dated November 2022 titled, Sanitization indicated Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: b. Low-Temperature Dishwasher (Chemical Sanitization): (1) Wash temperature (120 F).

Based on interview and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis based on Staffing Data Report submitted to Centers for Medicare & Medicaid Services (CMS). This failure had the potential to affect resident's care, health, and psychosocial wellbeing. Findings: During a document review titled, Census and Direct Care Services Hours Per Patient Day (DHPPD), from April through July 2024, indicated the following dates with actual DHPPD were below 3.5 hours: 4/6 - 3.11; 4/13 -3.07; 4/14 - 3.32; 5/5 - 3.43; 5/6 - 3.46; 5/25 - 3.30; 6/16 - 3.48; 6/17: 3.48; 6/29 - 3.29; 6/30 - 3.24; 7/1 - 3.44; and 7/7 - 3.42. Further review indicated the following dates with actual certified nursing assistant (CNA) DHPPD were below 2.4 hours: 4/1 - 2.15; 4/2 - 2.31; 4/3 - 2.38; 4/4 - 2.36; 4/5 - 2.29; 4/6 - 2.05; 4/7 - 2.24; 4/8 - 2.20; 4/9 - 2.40; 4/10 - 2.35; 4/12 - 2.34; 4/13 - 2.03; 4/14 - 2.16; 4/15 - 2.11; 4/16 - 2.25; 4/17 - 2.26; 4/18 - 2.37; 4/19 - 2.30; 4/20 - 2.39; 4/23 - 2.32; 4/24 - 2.22; 4/26 -2.32; 4/27 - 2.37; 4/29 - 2.35; 4/30 - 2.39; 5/3 - 2.37; 5/4 - 2.38; 5/5 - 2.29; 5/6 - 2.33; 5/10 - 2.36; 5/11 - 2.38; 5/13 - 2.17; 5/14 - 2.17; 5/17 - 2.25; 5/18 - 2.30; 5/19 - 2.36; 5/24 - 2.28; 5/25 - 2.03; 5/26 - 2.32; 5/27 - 2.28; 6/1 - 2.28; 6/2 - 2.25; 6/7 - 2.39; 6/11 - 2.25; 6/16 - 2.34; 6/17 - 2.34; 6/18 - 2.33; 6/21 - 2.39; 6/24 - 2.28; 6/29 - 2.16; and 6/30 - 2,21. During an interview with the staffing coordinator (SC) on 10/16/24 at 5:05 p.m., the SC confirmed the actual DHPPD should not be below 3.5 and the actual CNA DHPPD should not be below 2.4. During an interview with the director of staff development (DSD) on 10/18/24 at 8:53 a.m., the DSD confirmed they had weekend low staffing in April to June 2024. The DSD further stated they were in transition with the staffing coordinator on those months. During an interview with the director of nursing (DON) on 10/18/24 at 9:11 a.m., the DON confirmed they had low staffing especially on weekends in April to June 2024. The DON stated they had some staff who called in sick and were on vacation in April - June 2024. During a review of the All Facilities Letter (AFL) 21-11 dated March 17, 2021, indicated, The 3.5 DHPPD staffing requirement, of which 2.4 hours per patient day must be performed by CNAs, is a minimum requirement for SNFs (Skilled Nursing Facility). SNFs shall employ and schedule additional staff and anticipate individual patient needs for the activities of each shift, to ensure patients receive nursing care based on their needs. The staffing requirement does not ensure that any given patient receives 3.5 or 2.4 DHPPD; it is the total number of actual direct care service hours performed by direct caregivers per patient day divided by the average patient census. During a review of the facility's Certified Nursing Assistant's (CNA) waiver from the California Department of Public Health (CDPH) dated, 7/12/2024, indicated, Your request is approved and valid from July 1, 2024 to June 30, 2025, under the following conditions: .2. The facility shall continue to provide a minimum of 3.5 direct care service hours per patient day .

Based on observation, interviews, and record reviews the facility failed to ensure the Food and Nutrition Services Department, the kitchen, was free from pest and an effective pest control program maintained. This failure had the potential to contaminate food stored in the kitchen which could lead to widespread foodborne illness. Findings: During the initial kitchen tour on 10/14//24 at 8:26 a.m., an observation and interview was conducted with [NAME] (CK) W. A brown bug resembling a cockroach was observed moving across the floor in front of the tray line food preparation area. CK W tried to stomp the bug with her foot but was unsuccessful. CK W stated, I see one or two of them sometimes. On 10/14/24 at 12:01 p.m. an interview was conducted with the Administrator (ADM) about pest control maintenance. The ADM stated the kitchen was due for a quarterly fogging the end of October or the first of November to kill pests like roaches. During an interview on 10/14/24 at 12:05 p.m. with the Pest Company Technician (PCT), the PCT stated the facility's kitchen received a spray out treatment to remove the roaches a couple of months ago. The PCT further stated he did not do a fumigation treatment. On 10/14/24 at 12:51 p.m. during an concurrent interview with the PCT from the pest control company stated he does a Clean Out quarterly treatment. He stated he might need to do more treatments more often. During an observation and interview on 10/14/24 at 3:30 p.m. in the kitchen with Dietary Director (DD) and Maintenance Director (MD) L, the ice machine was checked for cleanliness. The MD L opened the ice machine air filter screen, and it was covered with black and gray debris. The air filter also had a dead brown bug that resembled a cockroach, on it. The DD and MD L acknowledged the air filter screen had black and gray debris and the dead brown bug carcass resembling a cockroach on it. The DD and MD L both stated the ice machine should not have any pests inside. A review of the outside company pest company invoice records from October 2023 through September 2024 indicated Findings- Insects, rodent droppings and pest activity. The invoices from July 2024 and August 2024 indicated Findings - German roach activity. The invoices indicated the technician made recommendations to Seal cracks, crevices and holes with grout as to mitigate potential harbor spots, empty out the trash at the end of the day or as often as possible, trash is possible source of pest food and to make sure to keep all work areas clean to not attract pest activity or create conducive conditions. According to the Centers for Disease Control and Prevention (CDC), the German cockroach is a known vector for diseases including: Salmonellosis - Salmonella food poisoning causes diarrhea, fever, and abdominal cramps within 12 to 72 hours. Symptoms are generally mild, but can be severe, especially for those with a compromised immune system . https://www.cdc.gov/healthypets/pets/wildlife/rodent-control.html According to the Food and Drug Administration, Insects and rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. The presence of insects and rodents is minimized by protecting outer openings to the food establishment. (FDA 2022 Annex 3 - Public Health Reasons/Administrative Guidelines, 6-202.15 Outer Openings, Protected.) According to the 2022 Federal Food Code, section 6-501.111 .Controlling Pest .The premises shall be maintained free of insects, rodents, and other pests .by .routinely inspecting the premises for evidence of pests . A review of the facility's policy dated May 2008 titled, Pest Control, indicated . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for three of four residents (Resident 83, 91, and 249) when: 1. Registered nurse F (RN F) addressed Resident 83 and 91, mama; and 2. Certified nursing assistant G (CNA G) addressed Resident 249, mama. These failures had the potential to affect the emotional and psychosocial well-being of the residents. Findings: 1. Review of Resident 83's face sheet (summary page of a patient's important information) indicated, Resident 83 was admitted to the facility with diagnoses including dementia (a progressive state of decline in mental abilities) with other behavioral disturbance (a pattern of persistent, inappropriate behaviors or emotions that can cause problems in person's life) and unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality). Review of Resident 83's quarterly minimum data set (MDS , a federally mandated resident assessment tool), dated 8/27/24, indicated Resident 83's brief interview for mental status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 3 (a score of 00 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review of the MDS indicated, Resident 83 had the ability to understand others. During an observation inside Resident 250's room on 10/14/24 at 8:48 a.m., Resident 83 was observed trying to enter Resident 250's room. RN F was overheard talking to Resident 83 to stop her from going inside Resident 250's room. RN F stated, Mama, that's not your room. RN F continued to convinced Resident 83 that Resident 250's room was not her room and addressed Resident 83, mama two more times at the facility hallway. Review of Resident 91's face sheet indicated, Resident 91 was admitted to the facility with diagnoses including low back pain, and malignant neoplasm (a cancerous tumor, or abnormal growth of tissue that can spread to other parts of the body) of unspecified part of left bronchus (a large airway that leads from the trachea [windpipe] to a lung) or lung. Review of Resident 91's admission MDS dated [DATE], indicated Resident 91's BIMS score was 8. Further review of the MDS indicated, Resident 91 had the ability to understand others. During an observation inside Resident 91's room on 10/14/24 at 9:14 a.m., RN F was heard speaking to Resident 91. RN F addressed Resident 91, mama three times during her conversation with Resident 91. During an interview with RN F on 10/14/24 at 9:14 a.m., RN F confirmed she addressed both Resident 83, mama at the hallway and Resident 91 inside the room. RN F stated, she got used in calling the residents mama. RN F further stated, staff should address residents with their first names or with use of mister or miss, to provide some dignity. 2. Review of Resident 249's face sheet indicated, Resident 249 was admitted to the facility with diagnoses including Parkinson's disease (a neurologic disease that significantly affects mobility) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (mood swings that range from the lows of depression to elevated periods of emotional highs). Review of Resident 249's admission MDS dated [DATE], indicated Resident 249's BIMS score was 11. Further review of the MDS indicated, Resident 249 had the ability to understand others. During an observation inside Resident 249's room on 10/14/24 at 9:22 a.m., CNA G was heard talking to Resident 249 and addressed Resident 249 mama two times. During an interview with CNA G on 10/14/24 at 9:30 a.m., CNA B confirmed she called Resident 249, mama. CNA G stated she should have addressed Resident 249 with her name. During an interview with the director of nursing (DON) on 10/17/24 at 9:52 a.m., the DON confirmed staff should not label or addressed residents with the use of mama, honey or [NAME]. The DON stated staff should address their residents with their first names or they should use Mister or Miss. Review of the facility's undated policy and procedure titled, Dignity, 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 .Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. A dietary staff member did not demonstrate the correct technique for testing the sanitation level on the dish machine or maintaining the correct wash temperature. 2. Two Dietary Aides did not know how to properly test the sanitizer in the red bucket. These failures in staff competency had the potential to result in improperly sanitized resident dishes and food contact surfaces that could expose residents to food-borne illness in a highly susceptible population of 97 residents. Findings: 1. On 10/14/24 at 8:22 a.m., an observation and interview were conducted with the Dietary Director (DD), and Dietary Aides (DA S and DA Z) about dish washing procedures. DA S stated the dish machine was a low-temp dish machine. DA S was asked to describe how he checked whether the dishwasher was working properly. DA S stated he runs the wash cycle 4-5 times every morning to get the dishwasher hot. Then he writes the temperature on the dish machine log sheet. DA S ran one wash cycle and verified the dish machine thermometer gauge reading with the surveyors. The temperature reading ranged from 110 degrees Fahrenheit ( F, unit of measurement for temperature)-115 F. DA S stated the wash cycle temperature should be 120 F but it had only reached 115 F for the last two months. DA S stated it was reported to the dietary manager. DA S then used a test strip to check the dish machine sanitizer solution in the dish machine. DA S stated the test strip was dark purple and equal to 100-200 on the test strip container. DA S stated the sanitizer should be 100-200. A review of the Dietary Department's document dated October 2024 titled Dish Machine Temperature Log, indicated wash temperatures recorded by DA S from October 1-14, 2024, was 120 F. DA S verified his initials were next to the wash temperatures on the log sheet. During an interview on 10/14/24 at 11:06 a.m., with the DD, the DD stated she was aware the dish machine wash temperature was not reaching 120 F, and they were waiting for a water heater booster that would raise the dishwasher temperature. The DD verified the dishwasher temperature reached 110 F at time of interview and acknowledged the wash temperature needed to be between 120-150 F and the chlorine sanitizer should have been 50 ppm. On 10/14/24 at 11:22 a.m., an interview was conducted with the Maintenance Director (MD) L. The MD L stated the dishwasher had not been working correctly for six weeks and he called the manufacturer for a heat booster but had not received it. On 10/14/24 at 11:26 a.m. an observation and interview were conducted in the kitchen with the administrator (ADM). The ADM acknowledged the dish machine wash temperature was 110 F. The ADM stated, A representative from the dish machine company is coming to install a part to make it hotter. During an interview with the RD U on 10/16/24 at 4:12 p.m., the RD U stated she expected the kitchen staff to operate the dish machine correctly. The RD U further stated she expected the kitchen staff to perform their job functions and duties accurately. A review of the facility's document dated February 2024 titled Job Description: Dietary Aide indicated the Dietary Aides essential duties are to Observe the water temperatures of dishwasher during dishwashing cycles . A review of the manufacturer's operating requirements on the dishwasher indicated Water Temp. 120 F Minimum . A review of the dishwasher's label titled Sanitizer Check Procedures indicated .compare strip with chart on vial. Minimum 50-100 ppm . Review of the facility's policy dated November 2022 titled Sanitization indicated Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: .b. Low-Temperature Dishwasher (Chemical Sanitization): (1) Wash temperature (120 F); 2) Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse; and the chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines . 2. During an interview on 10/15/24 at 11:58 a.m., with DA Z in the kitchen, DA Z stated he did not know how to test sanitizer in red bucket. During an interview on 10/15/24 at 12 p.m., with the DD, the DD stated she trained the kitchen staff on how to test the sanitizer in the red buckets. The DD stated DA Z may have missed the in-service for testing the sanitizer solution because he works part-time. On 10/16/24 at 9:37 a.m., an observation and interview were conducted with DA S. DA S used a yellow cloth from the red sanitizer bucket containing sanitizer solution to wipe down the meal trays and food preparation counter next to the three-compartment sink. DA S stated he checks the red bucket sanitizer strength every morning. DA S tested the sanitizer in the red bucket with a test strip and the reading was 300-400 ppm, a dark teal green color. DA S stated, It kind of looks like 200 ppm on the test strip container. The DD and RD U acknowledged the DA S did not know how to correctly test the sanitizer solution. The DD stated the sanitizer strength should be 200 ppm but was a lighter teal green color on the strip container. During an interview on 10/16/24 at 4:12 p.m. with RD U, RD U stated she expected kitchen staff to perform their job functions and duties correctly. Review of the facility's document dated February 2024 titled Job Description: Dietary Aide indicated Essential Duties- To leave the kitchen in a clean and sanitary manner and . Clean work surfaces and . Review of the manufacturer's label on the sanitizer bottle for the sanitizer used in the red buckets, the effective concentration to sanitize should be at 150-400 PPM. According to section 4-701.10, titled Food-Contact Surfaces and Utensils, Effective sanitization procedures destroy organisms of public health importance that may be present on wiping cloths, food equipment, or utensils after cleaning .It is important that surfaces be clean before being sanitized to allow the sanitizer to achieve its maximum benefit. Review of the facility's policy dated November 2022 titled Sanitization indicated .9. Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration .

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. Multiple expired medications were stored in medication refrigerators (REF) 2 and 1; 2. Two insulin (injectable medication to lower blood sugar) pens identified in REF1 were not labeled with resident-specific information; 3. An oral inhaler was expired and identified in the active stock in the medication room (MR) 2; 4. Discontinued and expired and controlled medication in Medication carts 1 and 2; and 5. Licensed nurses left the medication on the medication cart unattended and the medication cart key on the top of the medication cart unattended. These deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, medication errors due to medications not being labeled, which could lead to unsafe and ineffective medications for the residents. Findings: 1. During a visit to Med room [ROOM NUMBER] with the Nurse Supervisor (NS) on 10/14/24 at 9:10 a.m., an inspection of a MRF 2 identified: a. Two small bottles of latanoprost eye solution (a prescription medication to treat glaucoma) labeled expiration date of 8/9/24 and 6/8/24 prospectively. b. A bottle of Augmentin (a medication used to treat many types of bacterial infections) labeled to be used before 7/9/24. c. A bottle of vancomycin (medications used to treat and prevent various bacterial infections caused by gram-positive bacteria) labeled expiration date 8/6/24. d. A Pneumovax 23 (Pneumococcal polysaccharide vaccine can prevent pneumococcal disease) intramuscularly one time only for immunization labeled expiration date 6/8/24. During a visit to Med room [ROOM NUMBER] with the Nurse Supervisor (NS) on 10/14/24 at 10:24 a.m., an inspection of a medication refrigerator (MRF 1) identified: b. A bottle of Lorazepam (medication used to treat anxiety) oral concentrate 2 mg/ml expired on 10/6/24, c. A bottle of Lorazepam 2 mg/ml oral concentrate expired on 7/29/24, d. A bottle of Lorazepam oral concentrate 2 mg/ml expired on 10/6/24, e. A bottles of Amoxicillin and Clavulanate potassium (used to treat bacterial infection) for oral suspension 250 mg/62.5mg expired on 1/28/24, f. A bottle of Acidophilus probiotic dietary supplement 100 capsules open date 1/22/23 and expired in 8/24, g. A bottle of [NAME] Fluconazole (an antifungal) 40 mg/ml labeled discard date 8/11/24. The NS confirmed the above observation and stated that expired items should not be in MRF 1 but placed in the discard box to prevent medical errors. 2. During the same inspection of MRF 1 with the NS, two insulin pens without labels containing resident-specific identification information were identified. The NS confirmed the above observation and stated that they should be labeled with the resident's name and room number. 3. During a visit to Med room [ROOM NUMBER] with the Nurse Supervisor (NS) on 10/14/24 at 9:48 a.m., one bottle of inhalation (powder) with an expiration date of 2/13/24 During an interview with the NS on 10/14/24 at 09:51 a.m., the NS confirmed the above observation and stated the expired inhaler should be discarded. 4. During a medication cart inspection with Registered Nurse (RN) EE on 10/14/24 at 10:47 a.m., the following items were identified in MC 1: a. A bottle of morphine (controlled pain medication) inside a box labeled expiration date was 7/29/24. b. Three discontinued controlled medications locked in the narcotic box in MC 1. b 1). Hydro/ Apap 10-325mg 55 tablets left in the bottle and the last administeration date was 9/23/24. b 2). Morphine 20mg/ml 29.75 ml left in the bottle and the last administeration date was 9/23/24. b 3). Oxycodone tab 5mg 9 tabs left in the bottle and the last administeration date was 10/6/24. RN EE confirmed the above obervation and stated that residents with the above medications had already been discharged , and she should give the above-controlled medications to the DON immediately after the patient's discharge. 5. During an observation and concurrent interview on 10/16/24 at 10 a.m., in the hallway, seven medication pills in three medication cups and two inhalation medications were left unattended on the top of the medication cart. RN D came out from Resident's 60's room, confirmed the above observation, and stated she should have locked all the medication in the medication cart when she was not there. During an observation on 10/16/24 at 1:58 p.m., in the hallway, a box of Morphine oral solution and the medication cart key were on top of a medication cart, unattended, while four residents were near the cart. LVN J came out from Resident 36's room after administering medication, confirmed the above observation and stated that she should not have left the key and medication on the medication cart while four patients were nearby the cart. A review of the facility's policies and procedures (P&P) titled Administering Medications, dated 2001, indicated that Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse verifies that the correct pen is used for that patient. A review of the facility's P&P titled Medication labeling and, dated 2001, indicated in part, Discontinued, outdated, or deteriorated drugs and biologicals are . destroyed. A review of the facility's P&P titled Medication labeling and, dated 2001, indicated in part, compartments( including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to provide an orderly, comfortable, and homelike environment for one of five sampled residents (Resident 69) when Resident 69's closet door did not latch to remain close. This failure had the potential to result for Resident 69's decreased sense of well-being and an uncomfortable environment. Findings: During an observation and interview on 10/14/24 at 11:18 a.m., inside Resident 69's room, Resident 69 was observed walking inside the room and was about to change clothing. Resident 69 complained about her closet door, located behind the bedroom door. Resident 69 stated her closet door was broken and did not remain close. Resident 69 further stated she complained about it to the facility's housekeeper but instead of fixing or having someone to fix it, the housekeeper placed a surgical tape at the edge of the closet door to temporarily closed it. Resident 69's closet door was observed to have a surgical paper tape to leave the door closed. Resident 69 stated the closet door was broken for a while. During a review of Resident 69's quarterly minimum data set (MDS, a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 69's brief interview for mental status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 14 ( a score of 0 to 7 indicates severe cognition impairment; 8 to 12 moderate impairment; 13 to 15 patient is cognitively intact). During a concurrent observation, and interview with maintenance director L (MD L) on 10/15/24 at 09:34 a.m., inside Resident 69's room, MD L confirmed Resident 69's door did not latch to keep it closed. MD L confirmed nobody reported Resident 69's closet door was broken. During an interview with licensed vocational nurse J (LVN J) on 10/16/24 at 9:21 a.m., LVN J was assigned to Resident 69. LVN J stated she was not aware about Resident 69's broken closet door. LVN J further stated, if something was broken inside resident's room, they would call maintenance right away. LVN J stated housekeeper M (HK M) was available in the evening shift to also help in fixing anything. During an interview with certified nursing assistant K (CNA K) on 10/16/24 at 9:34 a.m., CNA K confirmed she was assigned to Resident 69 and she was not aware about the broken closet door. CNA K stated she would call maintenance if something was broken inside resident's room. During a concurrent interview with MD L and document review on 10/16/24 at 9:46 a.m., MD L reviewed the maintenance log. MD L confirmed Resident 69's broken closet door was not written in the maintenance log. MD L stated staff should write anything that needed to be fixed in the maintenance log binder. MD L confirmed he always checked the maintenance log in the morning and fixed what needed to be fixed right away. MD L stated, staff are lazy, to write down what needed to be fixed in the maintenance log. MD L further stated staff would call him if something was broken. During an interview with the director of nursing (DON) on 10/17/24 at 10:10 a.m., the DON stated nurses and housekeepers should have called maintenance when resident's if there was something wrong with residents' equipments or when something was broken inside residents' rooms. During a review of the facility's undated policy and procedure titled, Maintaining Residents Room, indicated, The Maintenance Department is responsible for maintaining the buildings, always including residents' rooms and equipment in a safe and operable manner .Residents' rooms should be in good repair and free from hazards.

Based on observation, interview, and record review, the facility failed to ensure needs were accommodated for five of 20 sampled residents (Residents 250, 249, 39, 25 and 48) when call light devices were not within reach of the residents. This failure had the potential for a delayed response and not meeting the resident's needs. Findings: 1. Review of Resident 250's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 250 was admitted at the facility with diagnoses including sepsis (a life-threatening blood infection), pneumonia (an infection/inflammation in the lungs), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a concurrent observation and interview with Resident 250 on 10/14/24 at 8:48 a.m., inside Resident 250's room, Resident 250 was lying in bed and his call button (also called call light, a red or white button used to request assistance) was hanging at the head of bed, in between the mattress and the bed's headboard. Resident 250 tried to reach for the call button and stated, I can't. Resident 250 was unable to reach for his call button. 2. Review of Resident 249's face sheet indicated, Resident 249 was admitted to the facility with diagnoses including Parkinson's disease (a neurologic disease that significantly affects mobility) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (mood swings that range from the lows of depression to elevated periods of emotional highs). Review of Resident 249's admission minimum data set (MDS, a federally mandated resident assessment tool) dated 9/30/24, indicated Resident 249's brief interview for mental status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 11 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review of the MDS indicated, Resident 249 had the ability to understand others. During an observation inside Resident 249's room on 10/14/2024 at 9:22 a.m., Resident 249 was seated at the right edge of bed and her call button was hanging at the lowered left bed rail. During a concurrent observation and interview with certified nursing assistant G (CNA G) on 10/14/24 at 9:30 a.m., inside Resident 249's room, CNA G confirmed the location of Resident 249's call button was not within Resident 249's reach for use. CNA G stated call lights or call buttons should always be placed within residents' reach for use. 3. Review of Resident 39's face sheet indicated Resident 39 was admitted to the facility with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition that causes partial paralysis or weakness on one side of the body) following cerebral infarction (also called stroke) affecting right dominant side, aphasia (a disorder that makes it difficult to speak), and vascular dementia (a condition that occurs when blood vessels in the brain are affected, resulting in changes to memory, thinking, and behavior). Review of Resident 39's admission MDS dated [DATE], indicated Resident 39 had memory problem with short term and long-term memory. During an observation on 10/14/24 at 9:49 a.m., inside Resident 39's room, Resident 39 as lying in bed, and her call button was attached to the handle of the bedside drawer. During a concurrent observation and interview with certified nursing assistant I (CNA I) on 10/14/24 at 10 a.m., inside Resident 39's room, CNA I confirmed Resident 39's call button was not within Resident 39's reach for use. CNA I stated the call button should not be placed at the handle of the bedside drawer. 4. Review of Resident 25's face sheet indicated Resident 25 was admitted to the facility with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, psychotic disorder with delusions (having false or unrealistic beliefs) and post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). Review of Resident 25's admission MDS dated [DATE] indicated Resident 25's BIMS score was 15. During an observation on 10/14/24 at 9:58 a.m., inside Resident 25's room, Resident 25 was lying in bed and her call button was located on the floor. Resident 25 tried to look for her call button and was not able to locate it. During a concurrent observation and interview with CNA I on 10/14/24 at 10:02 a.m., inside Resident 25's room, CNA I confirmed Resident 25's call button was on the floor. CNA I stated Resident 25's call button should be placed within Resident 25's reach for use. During an interview with the director of nursing (DON) on 10/17/24 at 10:10 a.m., the DON stated residents' call lights or call buttons should always be placed within resident's reach for use. 46001 5. A review of Resident 48's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including spinal stenosis (the narrowing of one or more spaces within your spinal canal). During an observation in Resident 48's room on 10/14/24 at 3:50 p.m., she was in bed, and her call light was on the oxygen concentrator. Resident 48 was moving her hand but was not able to reach the call light, and stated she wanted to drink water. During a concurrent observation and interview with CNA A on 10/14/24 at 3:55 p.m., he confirmed the above observation and stated that Resident 48 could not reach the call light on the oxygen concentrator and the call light should be placed within her reach all the time. A review of the facility's undated policy and procedure (P&P) titled, Answering the call light indicated, .when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident .

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment and care screening tool) assessment was coded accurately for weight gain for one of 10 sampled residents (Resident 78). This failure compromised the facility's ability to develop and implement a resident-centered care plan and interventions for the resident's severe unplanned weight gain. Findings: Review of Resident 78's face sheet dated 10/15/24 indicated the resident was admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including atrial fibrillation (an irregular heart rhythm which can lead to blood clots and stroke), Type 2 diabetes (elevated blood sugar), duodenal ulcer (a sore in the lining of part of the digestive tract), chronic venous hypertension with ulcer of bilateral lower extremities (end parts of the body- legs), and morbid obesity (having too much body fat). Review of Resident 78's three-month (August, September, and October 2024) Weight Summary indicated on 8/13/24, Resident 78's weight was 276 lbs. (lbs, symbol for pound), and on 10/13/24 his weight was 303 lbs. This was a severe weight gain of 9.78 % in three months. Review of Resident 78's quarterly MDS, section K0300, dated 9/12/24, indicated the question, Has the resident had weight loss of 5% or more in the last month or 10% or more in last 6 months? The answer to this question was coded 2. Yes to indicate that Resident 78 did have a weight loss of 5% or more in the last month or 10% or more in last 6 months. Section K0310 asked the question, Has the resident had weight gain of 5% or more in the last month or gain of 10% or more in last 6 months? The answer to this question was coded 0. No to indicate that resident did not have a weight gain of 5% or more in the last month or gain of 10% or more in last 6 months. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 10/16/24 at 1:30 p.m., the MDSC reviewed Resident 78's monthly weight summary and sections K0300 and K0310. The MDSC confirmed the above weight gain occurred within the last three months and stated Resident 78's MDS sections for weight gain were not coded accurately on the MDS dated [DATE]. She stated the MDS K0310 should have been coded 2. Yes and section K0300 should have been coded 0. No. The MDSC further explained the MDS section K dated 9/12/24 was completed by the Registered Dietitian. During an interview with the Registered Dietitian (RD) U on 10/16/24 at 2:02 p.m., RD U acknowledged Resident 78's weight gain was not coded accurately. The RD U stated the MDS assessment dated [DATE] section K0300 should have been coded as 0. No, and section K0310 should have been coded as 2. Yes. The RD U further stated it was important to have a correct MDS to accurately develop a nutrition plan for the resident. Review of the facility's policy dated November 2019, titled Certifying Accuracy of the Resident Assessment, indicated Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment .

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney that authorizes another person to act on behalf of the resident) and completion of the Physician Order for Life-Sustaining Treatment (POLST, a document that specifies the medical treatments the residents wants to receive during serious illness) form for three out of five sampled residents (Residents 42, 16 and 26). These failures had the potential to lead to the delivery of unnecessary or inappropriate medical services against residents' goals and wishes. Findings: Review of Resident 42's admission record indicated Resident 42 was admitted to the facility on [DATE]. Review of Resident 42's POLST form dated 7/24/24 indicated section D for AD was not completed. Further review of Resident 42's clinical record indicated there was no documented copy of an AD signed by the resident or responsible party, or evidence that the facility offered assistance in establishing an AD prior to the survey period. Review of Resident 16's admission record indicated Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's POLST form dated 8/29/24 indicated section D for AD was not completed. Further review of Resident 16's clinical record indicated there was no documented copy of an AD signed by the resident or responsible party, or evidence that the facility offered assistance in establishing an AD prior to the survey period. Review of Resident 26's admission record indicated Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's POLST form dated 9/20/24 indicated section D for Ad was not completed. Further review of Resident 26's clinical record indicated there was no documented copy of an AD signed by the resident or responsible party, or evidence that the facility offered assistance in establishing an AD prior to the survey period. During a concurrent interview and record review with the facility's Social Services Director (SSD) on 10/17/24 at 8:50 AM, the SSD confirmed section D was not filled out for Residents 42, 16 and 26. The SSD stated the role of social services was to ensure the POLST form was filled out completely and to verify if there was an existing AD for the resident. The SSD stated social services also offer help in completing an advanced directive if the resident or responsible party needs help. Review of facility's undated policy and procedure (P&P) titled Advance Directives indicated If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives and If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.

Based on observation, interview, and record review, the facility failed to ensure the results of the most recent survey of the facility (the survey results in a binder) was readily accessible to residents, and family members and legal representatives of residents when one of 20 sampled residents (6) and six non-sampled residents (20, 21, 27, 34, 43 and 68) stated they could not access the facility's most recent survey results. This failure potentially limited resident's rights to examine and receive the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. Findings: During a group interview on 10/15/24, at 11:30 a.m., with one of 20 sampled residents (6) and six non-sampled residents (20, 21, 27, 34, 43 and 68), Residents (6, 20, 21, 27, 34, 43 and 68) all stated, they did not know where to find the survey binder of the facility's survey results for them to review it. During an observation on 10/15/24, at 12:53 p.m., in the facility's lobby area, the facility survey binder was nowhere to find. During a follow-up interview, on 10/15/24, at 12:55 p.m., with the front desk receptionist (FDR) at the front desk, the FDR stated the survey binder was stored inside the drawer cabinet. During an interview on 10/15/24, at 1:09 p.m., with the director of nursing (DON), the DON confirmed the above findings and stated, the survey results binder should be placed on the table readily for residents or family members' to review. During a review of the facility's undated policy and procedure (P&P) titled, Resident Rights, the P&P indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to examine survey results.

Based on observation, interview, and record review, the facility failed to provide the Ombudsman's (a government employee who investigates, reports on, and helps settle complaints) contact information to all residents when the State Long-Term Care Ombudsman's contact information was not available in the resident's care and activity areas. This failure limited resident's rights to have a confidential avenue to talk about a concern and resolved issues at the lowest possible level. Findings: During a group interview on 10/15/24, at 11:30 a.m., with one of 20 sampled residents (6) and six non-sampled residents (20, 21, 27, 34, 43 and 68), Residents (6, 20, 21, 27, 34, 43 and 68) all stated, they did not have the Ombudsman's contact information in the facility. During a concurrent tour of the facility and an interview with the director of nursing (DON) on 10/15/24, at 1 p.m. to 1:09 p.m., the DON confirmed there was no Ombudsman contact information in any part of the facility. The DON stated the facility recently just had new paint put on the walls and that they forgot to place the Ombudsman contact information back on the wall. The DON further stated the facility should have provided the Ombudsman contact information to the residents. During a review of the facility's undated policy and procedure (P&P) titled, Resident Rights, the P&P indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to communicate with outside agencies (e.g. local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection, or advocacy organizations, etc.) regarding any matter.

Based on observation, interview, and record review the facility failed to prevent two of seventeen sampled residents (Residents 7 and 2) from developing pressure ulcers and promote the healing of the pressure ulcers when: 1) For Resident 7, the facility failed to: a. Identify the specific risk factors that contributed to resident 7's change in condition as evidenced by the presence of a Stage 3 pressure ulcer on the left ischium (hip) and the Stage 4 pressure ulcer on the right buttock/coccyx, and failed to revise the care plan to reflect the risk factors identified; b. Implement care plan interventions such as repositioning, providing support device, and application of a protective barrier to protect the resident's skin; c. Review and revise the care plan to include interventions that facilitate wound healing; and d. Provide wound care treatment for [REDACTED]. plan. The deficient practice resulted in Resident 7 developing four pressure ulcers on four areas of his body from 5/19/15 to 9/11/15, with the largest pressure ulcer measuring 8 x 8 x 5. 2.) For Resident 2, the facility failed to do timely comprehensive skin assessments, and reevaluate the resident's response to the preventive efforts and treatment interventions according to the Care Plan. Resident 2 was admitted on [DATE] without a pressure ulcer, and developed several pressure ulcers (left buttock, left coccyx, and a deep tissue injury (DTI) pressure in the left heel). The facility failed to show evidence that Resident 2 was consistently turned every two hours from 3/10/15 - 7/02/15. The deficient practice resulted to the development of stage IV pressure ulcer in the left buttock, stage III pressure ulcer in the coccyx, and a DTI (Deep Tissue Injury) pressure on the left heel of Resident 2. Definitions: Deep Tissue Injury (DTI) - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. The Braden Scale is a tool predicting Pressure Sore Risk developed to foster early identification of patients at risk for forming pressure sores. Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure resulting in damage to the underlying tissue(s). Although friction & shear are not primary causes of pressure ulcers, friction & shear are important contributing factors to the development of pressure ulcers. The definitions for the stages of pressure ulcers identified below are from the Long-Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0. o Stage I - An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: - Skin temperature (warmth or coolness); - Tissue consistency (firm or boggy); - Sensation (pain, itching); and/or - A defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. o Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister. o Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. o Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Findings: 1) During observation on 9/2/15 at 9:50 a.m., Resident 7 was in bed awake, lying on his right side without pillow support to his back. The head of his bed was raised approximately 45 degrees, and his knees were rubbing against each other. Review of the facility's undated Prevention of Pressure Ulcers Level II policy and procedure indicated, Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity. During interview on 9/2/15 at 9:55 a.m., when asked about Resident 7's positioning, Certified Nursing Assistant (CNA) 1 stated, He keeps turning. He was sitting earlier but because of his legs he keeps sliding. He also has pain on his legs so he ends up leaning. Ideally he should be repositioned every 2 hours, but I don't work on this station. They just put me here today. During observation on 9/2/15 at 10:15 a.m., Resident 7 was in bed on his right side without pillow support, and the head of his bed was raised 45 degrees. There was no pillow support under his head, between his knees nor to his back, and the following were observed: (1) blister to the right heel; (2) eschar to the second and third toes of the right foot; (3) blister to the second toe on the left foot; (4) open blister to the left lateral foot below the fifth toe; and (5) two open areas on the left heel. Review of Resident 7's medical record revealed no documentation of these five [MEDICAL CONDITION]. This was confirmed during interview and record review with ADON on 9/4/15 at 3:00 p.m. On 9/3/15 at 9:05 a.m., CNA3 was observed providing incontinence care to Resident 7. The resident's incontinence pad and the dressing to the coccyx pressure ulcer were soaked with urine and the dressing adhered to the incontinence pad as it peeled off the wound. During incontinence care, CNA3 cleaned the surrounding skin but did not apply a protective skin barrier as indicated on the care plan. In addition, the coccyx pressure ulcer was covered with a gauze dressing which did not provide a protective barrier from urine and bowel incontinence. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 7 was always incontinent of urine (H0300) and always incontinent of bowel (H0400). Review of Resident 7's care plan included an approach, Apply protective barrier products after each incontinence. The care plan did not specify the protective barrier to apply to which pressure ulcer. Review of the facility's undated Prevention of Pressure Ulcers Level II policy and procedure indicated, If moisture cannot be controlled use absorbent pads and/or briefs with a quick drying surface and protect skin with a moisture barrier. During preparation for wound care on 9/3/15 at 9:20 a.m., LVN1 was observed placing wound care materials on Resident 7's overbed table without cleaning the table or placing a barrier to prevent contamination of wound care supplies. In addition the supplies prepared were not adequate so in the middle of wound care, LVN1 left the room to get additional (i.e. QTips) supplies from a treatment cart parked outside the resident's door. Review of the Dressings, Dry/Clean policy (June 2005 revision date) indicated: 1) Assemble the equipment and supplies as needed. 2) Clean bedside stand. Establish a clean field. During wound care observation on 9/3/15 at 9:25 a.m., LVN1 cleaned the healthy skin surrounding the wound bed with the same dirty gauze used to clean the contaminated area of the wound. Review of the facility's policy on Dry/Clean Dressings with revision date of June 2005, indicated, If using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area. Review of medical records indicated Resident 7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS-an assessment tool) dated 11/2/14 indicated Resident 7 required extensive assistance with one-person physical assist for bed mobility, transfer, toilet use and personal hygiene (G0110), and was frequently incontinent of urine (H0300). Resident 7 was also determined at risk for developing pressure ulcers (M0150). Review of Resident 7's care plan for pressure ulcer prevention showed it was initiated on 1/7/15, approximately two months after he was determined at risk for pressure ulcer on 11/2/14. Review of Resident 7's care plan for pressure ulcer prevention dated 1/7/15 showed the following interventions: 1) Use pads, pillows or other devices to reduce pressure and assist with positioning as scheduled; areas of redness or excoriation with each position change; 2) Avoid friction and shearing; 3) Check for moisture with each change in position; 4) Provide incontinence care and dry linens; 5) Apply protective barrier products after each incontinence. Resident 7 has a pressure ulcer to his left hip and right buttock/coccyx, but the care plan intervention did not specify the protective barrier to be applied to the specific pressure ulcer. Review of Resident 7's care plan for pressure ulcer prevention dated 1/7/15 included interventions that did not address the problems or risk factors identified. For example: for Nutrition the care plan intervention was do not turn on trochanter or no 90 degree turn to side. Review of the significant change MDS dated [DATE], indicated Resident 7 developed one unstageable pressure ulcer and one Stage 3 pressure ulcer measuring 1.2 cm (centimeter) in length, 3.5 cm wide and 0.2 cm in depth (M0300) with slough (M0700), defined on the MDS as a yellow or white tissue that adheres to the ulcer bed in strings or thick clumps. However, the MDS did not indicate the location of the pressure ulcer. In addition, the care plan was not reviewed and revised to reflect the unstageable pressure ulcer. Review of the Advantage Wound Care documentation dated 5/19/15 showed Resident 7 had three pressure ulcers: (1) one on the left hip measuring 3.5 x 4 x UTD (unable to determine); (2) on the left inner buttock measuring 1.5 x 0.5 x xSF; and (3) one on the coccyx measuring and 0.5 x 0.2 x SF. Review of the Advantage Wound Care documentation dated 6/9/15 showed a pressure ulcer on the left hip measuring 3 x 3.5 x 1.5 and a newly identified pressure ulcer on the right buttock/coccyx measuring 5 x 7 x UTD. The medical record lacked documented evidence that the pressure ulcer on the right buttock/coccyx was identified at onset, and that it was assessed and treated until 6/9/15, when the pressure ulcer measured 5 x 7 x UTD. Review of the wound care documentation dated 7/14/15 indicated the pressure ulcer on the left hip measured 1.2 x 1.5 x 1.5 and the pressure ulcer on the right buttock measured 8 x 8 x 5, which showed the newly identified pressure worsened. Resident 7 had a care plan dated 1/7/(no year indicated) to turn and reposition resident every two hours. Review of the Reposition/Turning Schedule indicated Resident 7 was not repositioned every two hours for: 1. 33 times from 3/8/15 - 3/21/15; 2. 36 times from 3/22/15 - 4/4/15; 3. 103 times from 5/10/15 - 5/23/15; 4. 72 times from 5/24/15 - 6/6/15; 5. 75 times from 6/7/15 - 6/20/15. The lack of repositioning every two hours as indicated on the care plan was confirmed during interview with ADON on 9/9/15 at 3:35 p.m. Review of the care plan interventions did not reflect the risk factors that contributed to the development of new pressure sores, and the care plan interventions were not reviewed or revised to reflect necessary interventions needed to treat the new pressure sores or to prevent new pressure sores from developing. Review of the care plan interventions for risk of pressure ulcer dated 1/7 (year not indicated), was to, apply protective barrier products after each incontinence. However, it did not specify the barrier and pressure ulcer to apply the barrier on. Further review of the care plan showed the following interventions: (1) Turn and reposition every 2 hours; (2) Use pads, pillows or other devices to reduce pressure and assist with positioning as scheduled; (3)use pressure reducing/relieving products and orthotic per plan or physician's order; (4) inspect skin for areas of redness and excoriation with each position change; (5) Do not turn on trochanter or no full 90 degree turn to side. Review of the significant change MDS dated [DATE] indicated Resident 7 became incontinent and developed a Stage 3 unstageable deep tissue pressure ulcer measuring 1.2 length x 3.5 width x .2 cm in depth. However, the resident's care plan was not reviewed or revised to reflect where this pressure ulcer was located, what caused the pressure ulcer and its planned interventions. Review of the care plan for diabetes, [MEDICAL CONDITION], Renal, Liver, and other health conditions dated 7/13/15 included the following interventions: (1) check for moisture with each change in position; (2) provide incontinent care and dry linens as needed; (3) apply protective barrier products after each incontinence; (4) turning and repositioning every two hours. During interview on 9/4/15 at 3:50 p.m., when notified of the saturated 4x4 gauze dressing covering Resident 7's coccyx pressure ulcer, ADON stated the facility has a lot of occlusive dressing on stock and that the nursing staff had been inserviced on the use of the occlusive dressing. She stated the occlusive dressing should have been used on Resident 7's pressure sore but the staff were not aware the occlusive dressing was available. 2) Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's history and physical exam indicated he was admitted for physical therapy and occupational therapy rehabilitation. During an observation on 9/2/15, at 10:00 AM, with LVN 1 (License Vocational Nurse), Resident 2's left buttock, in the gluteal fold, had what looks like one and half centimeters in diameter wound, with undermining. No exudate, with about 10% granulating tissue in the center, no odor, and periwound-tissue viable. Review of care plan dated 11/01/15, titled Care Plan for Problem, Needs, or Concern: Pressure Ulcer, indicated, Skin will remain intact and clear daily X 30 days. The Braden score was 14 (moderate risk), There was no evidence that it was reviewed after 30 days. The next review date was on 2/09/15. Indicated: Skin will remain intact and clear daily. Review every 3 months. The Braden Scale score was 11 (high risk), meaning, Resident 2 is now on high risk for pressure ulcer. Review of the later care plan dated 4/30/15, titled Care Plan for Problem, Needs, or Concern: Excoriation left buttock, indicated, Skin will remain intact and clear daily x 10 days.There was no evidence that it was reviewed and revised in 10 days. The next review date was 5/10/15. Review of care plan dated 5/10/15, indicated, a stage II Left buttock pressure ulcer- will heal in 14 days.There was no evidence that the resident's response to the preventive efforts and treatment interventions according to the previous care plan was reevaluated. There was no evidence that it was reviewed in 14 days. The next review date was 6/2/15. And by then, the left buttock pressure ulcer was staged, Unstageable. Additional pressure ulcer developed in the coccyx (stage II) and in the left heel (pressure DTI). During interview with Director of Staff Development (DSD), on 9/04/15, at 10:00 AM, she acknowledged that the above care plans were not consistently carried-out, reevaluated, and reviewed as indicated. During an interview with the ADON, on 9/4/15, at 2:00 PM, she acknowledged that there were no record showing that pressure ulcer wounds of Resident 2 was reassessed and reevaluated, accordingly. Review of the Advantage Wound Care record by the Physician 1 dated 5/26/15, indicated, .left heel pressure DTI (DeepTissue Injury, size 0.7 cm in length, and 0.7 cm in width) . During an interview with the DON, on 9/4/15, at 11:30 AM, she acknowledged that the above Physician 1's finding was not care planned, not addressed during the QA (Quality Assurance) meeting of 5/26/15, and no SBAR record was done. During review of the clinical records of Resident 2 indicated there was no Nurses SBAR (Situation Background Assessment Record) for Predicting Pressure Sore Risk notes for Resident 2, when she developed a Stage II pressure ulcer on 5/10/15, in the left buttock and the left heel pressure DTI on 5/26/15 . During an interview with Assistant Director of Nursing (ADON), on 9/8/15, at 2:00 PM, she acknowledged that a filled-in SBAR for the development of Resident 2's left buttock Stage II pressure ulcer and left heel pressure DTI, was not done. Review of the document titled, Repositioning/Turning Schedule, showed no staff initial to indicate that Resident 2 was repositioned on the following dates: 3/10/15 - 3:00 PM to 10:00 PM 312/15 - 7:00 PM to 10:00 PM 3/14/15 - 3:00 PM to 10:00 PM 3/25/15 - 3:00 PM to 10:00 PM 3/27/15 - 7:00 PM to 10:00 PM 6/08/15 - 3:00 PM to 10:00 PM 6/10/16 - 3:00 PM to 10:00 PM 6/11/15 - 02:00 PM to 6:00 AM 7:00 PM to 10:00 PM 6/15/15 - 3:00 PM to 10:00 PM 6/17/15 - 3:00 PM to 10:00 PM 6/21/15 - 11:00 PM to 7:00 AM 6/22/15 - 2:00 PM to 10:00 PM 6/30/15 - 3:00 PM to 10:00 PM 7/02/15 - 3:00 PM to 10:00 PM During interview with DON (Director of Nursing), on 9/4/15, at 11:00 AM, she acknowledged the inconsistency in repositioning Resident 2 according to the above Repositioning/Turning Schedule record. During review of the RD (Registered Dietitian) Nutritional Progress Notes dated 5/27/15, there was no comprehensive nutritional assessment, calculating the estimated nutritional needs for Resident 2's significant change of clinical condition (development of Stage II pressure ulcer in the left buttock on 5/10/15), and there was no nutrition care plan done . Further review of the RD notes showed nutritional assessment dates: 11/12/14, 12/2/14, 12/17/14, 2/10/15, 5/13/15, 5/27/15, 6/8/15, 7/11/15, 8/6/15 During interview with the Dietary Supervisor (DS), on 9/8/15, at 9:00 AM, confirmed that the Registered Dietitian are scheduled to be in the facility two times a week. During interview with the new RD 2 who just started working in the facility for a few days, on 9/8/15, at 10:00 AM, she acknowledged that the previous RD (RD 1) should have done a more comprehensive nutritional assessment, calculating the estimated nutritional needs of Resident 2 at that time, and done a more frequent visits during the significant clinical changes in the Resident 2's condition. Review of the facility policy and procedure titled, Pressure Ulcer Risk Assessment/ Documentation dated 2005, indicated: Assessment: .2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated .3. Monitoring: .c. Nurses will conduct skin assessment at least weekly to identify changes . Review of the facility policy and procedure titled, Care Plan-Comprehensive, indicated .5. Care Plans are revised as changes in the resident's condition dictate . Review of the facility policy and procedure titled, Repositioning, indicated, .Interventions/Care Strategies: 1. Resident who are in bed should be on a every two hour turning program at a minimum. 2. For resident with a Stage I or above pressure ulcer, every two hour turning is inadequate . The facility policy and procedure titled, Acute Condition Changes - Critical Protocol, indicated, .Assessment and Recognition: . 2.the Nurse shall assess and document/report the following baseline information using the SBAR tool .Monitoring and Follow-up: 1. The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly . The facility policy and procedure titled, RD Assessment Guidelines dated 9/3/15, indicated, Objective: To ensure resident's nutritional needs are identified timely and proper interventions are in place to meet their individual nutritional needs. Frequency of visits is agreed upon by the facility .II. Re-assessment weekly: .Significant Change in medical Condition (New Identified Pressure Ulcers) Pressure Ulcers (Stages II, III, IV) .