Every finding on record at The Orchards Post-Acute

Based on interview and record review the facility failed to ensure two of 29 sampled residents (Resident 69 and Resident 5), was able to exercise their rights when: 1. Resident 69 was not provided with a shower when requested. This failure resulted in Resident 69 feeling dirty when going to an appointment. 2. Resident 5 was not provided with a hair cut that he had requested. This resulted in a violation of Resident 5's right to dignified care.Findings: 1. During an interview on 6/15/26 at 10:40 a.m. with Resident 69, Resident 69 stated that when she requests a shower, staff often respond that they are too busy. Resident 69 stated she would like to have showers more frequently than twice a week. Resident 69 stated that she felt unclean when attending physical therapy and believed she should be able to feel clean rather than smell of feces. During an interview on 6/15/26 at 10:55 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated that they maintain a daily shower list for residents, and if a resident requests a shower but is not included on that list, it might not be possible to accommodate them. During a review of Resident 69's Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15, the higher the score the more intact the resident's cognition. A score of 0 – 7 suggests severe cognitive impairment, 8 – 12 suggests moderate cognitive impairment and 13 – 15 suggests the cognition is intact), dated 1/6/26 the BIMS indicated Resident 69's score was 15. During a review of Resident 69's Skin Care Alert (SCA), dated June 2026, the SCA indicated, Resident 69 received a shower on 5/30/26, 6/3/26, 6/6/26, 6/10/26, and 6/13/26. During a review of the facility's P&P titled, Bath, Shower/Tub, dated February 2018, the P&P indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident. 2. During an interview on 6/16/26 at 8:49 a.m. with Resident 5, Resident 5 stated he had asked multiple times for a haircut but had not had one. Resident 5 stated his hair had gotten too long and It bugs the hell out of me. Resident 5 stated he liked to wear his hair short and could not recall the last time he had a hair cut. Resident 5 stated he cannot get out of bed by himself and requires help from staff. During a review of Resident 5's Brief Interview for Mental Status [BIMS - an assessment of cognition (how well a person thinks, remembers, and learns]. A score of 0 – 7 suggests severe cognitive impairment, 8 – 12 suggests moderate cognitive impairment and 13 – 15 suggests cognition is intact], dated 5/26/26, the BIMS indicated Resident 5's BIMS score was 12. During an interview on 6/18/26 at 9:58 a.m. with Activities Aide (AA), AA stated the hair stylist came to the facility every Wednesday or Thursday and Friday. AA stated during one to one (1:1) resident room visits they offer haircuts to the residents. AA stated they do not document when a resident was offered or refused a haircut. During a concurrent interview and record review on 6/18/26 at 10:35 a.m. with Director of Activities (DA), the facility's Beautician Services logs (BS), dated 1/30/26 through 6/18/26 were reviewed. The BS indicated on 1/30/26 Resident 5 received a hair cut. DA stated the last time Resident 5 had a hair cut was on 1/30/26. During an interview on 6/18/26 at 11:01 a.m. with Resident 5, Resident 5 stated he was not offered a haircut on 6/18/26 but would have liked to have one. During a concurrent interview and record review on 6/18/26 at 12:01 p.m. with DA, Resident 5's Activities Progress Notes (APN), dated 2/2/26 through 6/17/26 were reviewed. The APNs did not indicate Resident 5 was offered or refused a haircut. DA stated the activities staff did not document that a haircut was offered or refused by Resident 5. During an interview on 6/18/26 at 12:07 p.m. with Administrator, Administrator stated the facility did not have a policy and procedure (P&P) that addressed who was responsible for overseeing resident hair care services. Administrator stated the activities staff were currently overseeing the hair care services but it was the facility's responsibility to ensure residents are well groomed and feel good about themselves. During a review of the facility's P&P titled, Resident Rights, dated December 2016, the P&P indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . f. communication with and access to people and service, both inside and outside the facility. h. be supported by the facility in exercising his or her rights. During a review of the facility's P&P titled, Quality of Life – Dignity, dated February 2020, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. 3. Some examples of ways in which respect for choices and values are exercised include: a. Personal grooming – residents are groomed as they wish to be groomed.

Based on interview and record review, the facility failed to ensure a discharge notice was sent to the Ombudsman (an advocate for residents of nursing homes, board and care centers and assisted living facilities) for one of one sampled residents (Resident 143). This failure had the potential to result in Resident 143 not having an advocate who could inform them of their admission, transfer, and discharge rights. Findings:During a review of Resident 143's electronic medical record (EMR), Resident 143 was transferred to the hospital for evaluation and treatment on 4/24/26, 5/6/26, and 5/28/26. During a concurrent interview and record review on 6/18/26 at 9:44 a.m. with Social Services (SS), Resident 143's EMR was reviewed. The EMR did not contain a written notice of transfer for Resident 143 for 4/24/26, 5/6/26, and 5/28/26. SS stated the facility did not provide written notification of transfer to hospital, to Resident 143 or to the Ombudsman for Resident 143's 4/24/26, 5/6/26, and 5/28/26 hospitalizations. During an interview on 6/18/26 at 11:35 a.m. with SS, SS stated the facility did not have a policy and procedure for written notice of discharge/transfer.

Based on observation, interview, and record review, the facility failed to ensure two of 71 sampled residents (Resident 137 and Resident 2) IDT (interdisciplinary) comprehensive, nutrition care plan interventions could be effectively monitored and implemented when there was inconsistent and inaccurate meal, meal substitute and snack consumption documentation.This failure had the potential for unrecognized nutrition care needs to not be addressed in a timely manner to prevent a potential outcome such as weight loss or decreased quality of life. Findings:1.During an observation on 6/15/26 at 12:37 p.m. in the dining room, staff were observed checking resident meal tray cards compared to meal trays for accuracy.During a concurrent observation and interview on 6/15/26 at 12:42 p.m. Licensed Vocational Nurse (LVN) 1 in the dining room, approximately four staff stood next to the meal delivery cart, leaving trays undistributed while residents waited at the tables. LVN 1 stated they were waiting another five to 10 minutes for a second cart to arrive before beginning service. LVN 1 stated they usually get the meal trays around 12 p.m.During a concurrent observation and interview on 6/15/26 at 12:43 p.m. with Resident 137 outside the dining room, Resident 137 was rapidly propelling his own wheelchair out of the dining room before his lunch was provided. Resident 137 stated he was upset, very upset.During an observation on 6/15/26 at 1:17 p.m. Resident 137 was in his wheelchair next to his bed in his room using his phone. No lunch meal tray was observed in his room. During an observation on 6/15/26 at 1:50 p.m. in the hallway near Resident 137's room, LVN 1 was checking resident meal trays against their meal tray cards.During an observation and interview on 6/15/26 at 1:59 p.m. with Infection Preventionist (IP) in the hallway near Resident 137's room, IP stated that was the last meal delivery cart for lunch meal service and no residents were waiting on a lunch meal tray.During an observation on 06/15/26 at 2 p.m. Resident 137 was outside on the patio in his wheelchair for a smoke break. Concurrently, there was no meal tray observed in his room.During an observation on 6/15/26 at 2:03 p.m. Resident 137 propelled his wheelchair from the outside patio back into his room.During a concurrent interview and record review on 6/16/26 at 9:17 a.m. with Certified Nursing Assistant (CNA) 4, Resident 137's Electronic Medical Record (EMR) was reviewed. The EMR indicated Scheduled Date: 6/15/26 13:00 [1 p.m.], Effective Date: 6/15/26 10:29 [10:29 a.m.], What percentage of the meal was eaten? 76% [percent] - 100%, Offer Substitute if meal intake is 50% or less: Response Not Required, What percentage of the substitute meal was eaten? - Response Not Required. CNA 4 stated she was assigned to care for Resident 137 during lunch on 6/15/26.CNA 4 stated Resident 137 ate 25% of his lunch while in the dining room as reported to her by CNA 5 who was in the dining room during that time. CNA 4 stated since Resident 137 had eaten 25% of his lunch, she offered him a ham sandwich as a snack. CNA 4 stated Resident 137 ate 75-100% of the ham sandwich. CNA 4 stated that she charted intake of the snack under What percentage of the meal was eaten? in error, as the ham sandwich was not his lunch nor was it a meal substitute, but instead she should have documented the 75-100% intake under snack which normally gets distributed from the kitchen at 2 p.m. During a record review of Resident 137's Documentation Survey Report [DSR], dated 6/16/26 the DSR indicated, 6/15/26, 13:29, 3 [76-100% of meal eaten], [initials of CNA 4].During record review of Resident 137's DSR, dated 6/16/26 the DSR indicated, Snacks, 14:29 [2:29 p.m.], 2 [51-75% consumption of snack], [initials of CNA 4].During a concurrent interview and record review on 6/16/2026 at 9:25 a.m. with CNA 4 the DSR dated 6/16/26 was reviewed. CNA 4 stated she charted 75%-100% due to Resident 137 eating his ham sandwich as a snack after lunch trays were delivered late and he didn't eat in the dining room. CNA 4 stated the percent documented was dependent on what he had in the dining room, resident room, and snack after lunch together. During a concurrent interview and record review on 6/17/26 at 12:22 p.m. with Director of Nursing (DON), Resident 137's Care Plan Report [CP], dated 5/1/24, was reviewed. The CP indicated, [Resident 137] is at risk for altered nutrition/weight loss. The CP indicated, Interventions: Assess [Resident 137] eating patterns at every meal, alert nurse/dietician if resident continues to consume 50% of his meal, Monitor and document fluid intake every shift, Offer substitute if meal intake is 50% or less, Provide & encourage fluids & food intake. DON stated staff did report to her the untimeliness of lunch being served on 6/15/26, the inaccurate and inconsistent documentation of lunch, meal substitute and snack consumption. DON stated the facility would be unable to monitor and implement Resident 137's nutrition IDT (interdisciplinary) care plan when staff were not accurately, and consistently, monitoring and documenting Resident 137's food/fluid intake. 2. During an observation on 6/15/26 at 12:37 p.m. in the dining room, staff were observed checking resident meal tray cards compared to meal trays for accuracy.During a concurrent observation and interview on 6/15/26 at 12:58 p.m. in the dining room, Resident 2 began to propel his wheelchair out of the dining room before his lunch was provided. Resident 2 stated they did this before and he didn't get food. During an observation on 6/15/26 at 1:30 p.m. in central hallway near Resident 2's room, Resident 2 sat in his wheelchair with a large blue bucket on his lap and leaning his face over the bucket.During an observation on 06/15/26 at 1:42 p.m. in central hallway near Resident 2's room, Resident 2 sat in his wheelchair holding a grey bin with 3 cans of unopened Mountain Dew.During a concurrent observation and interview on 06/15/26 at 1:44 p.m. with Resident 2 in the hallway in front of his room, Resident 2 was propelling his wheelchair into his room. Resident 2 stated he was not provided lunch yet. Resident 2 stated he had an appetite and was hungry. During a concurrent observation and interview on 6/15/26 at 1:50 p.m. with Resident 2, all the meal trays that were in the meal delivery cart were distributed to residents based on residents assigned meal tray cards located on the trays. Resident 2 was not provided a lunch tray.During an interview on 6/15/2026 at 3:35 p.m. with Resident 2, Resident 2 stated he did not have lunch. During a concurrent interview and record review on 6/16/26 at 9:53 a.m. with CNA 6 Resident 2's EMR was reviewed. The EMR indicated, Scheduled Date: 6/15/26 11:30 [11:30 a.m.], Effective Date: 6/15/26 11:42 [11:42 a.m.], What percentage of the meal was eaten? Resident Refused, Offer Substitute if meal intake is 50% or less: Yes, What percentage of the substitute meal was eaten? -76-100%. CNA 6 stated he was assigned to care for Resident 2 during lunch on 6/15/26.CNA 6 stated, CNA 6 brought Resident 2's lunch meal tray to Resident 2 in his room. CNA 6 stated Resident 2 refused the food, saying it was cold and he didn't want it. CNA 6 stated he offered a snack when the snack cart came by but resident [Resident 2] got stuff from the vending machine instead. CNA 6 stated he documented that on 6/15/26 Resident 2 consumed a substitute meal with a 76-100% intake at 14:42 [2:42 p.m.] and had a snack with consumption of 76-100% intake at 14:42. CNA 6 stated the documentation was not accurate as Resident 2 did not consume a meal substitute and that he intended to document only a snack consumption of 76% to 100% intake of snacks Resident 2 purchased from a vending machine located inside the facility.During a concurrent interview and record review on 6/17/26 at 12:26 p.m. with DON, Resident 2's CP dated 2/12/26 the CP indicated, [Resident 2] re-admitted at nutritional risk for malnutrition. Goal: Consume at least 76-100% of 3 meals/day, Interventions: Provide, serve diet as ordered. Monitor intake and record q [every] meal. DON stated staff did report to her the untimeliness of lunch being served on 6/15/26, the inaccurate and inconsistent documentation of lunch, meal substitute and snack consumption. DON stated the facility would be unable to monitor and implement Resident 2's nutrition IDT care plan when staff were not accurately, and consistently, monitoring and documenting Resident 2's food/fluid intake. During a review of the facility's policy and procedure (P&P) titled, Documentation Of Food And Fluid Intake, dated 2023, the P&P indicated, Policy: Staff will document the percentage of each meal consumed and fluid intake for each resident on a daily basis. Procedures: 1. Staff will record the percentage of all food and fluid intake in the resident's medical record or electronic format for each meal. The percentage of between meal snacks and milliliters of supplement intake and nourishments will be recorded separately from the meal/fluid intake on the ADL [Activities of Daily Living] sheets or electronic record by the facility designee.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The comprehensive, person-centered plan will: Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Aid in preventing or reducing decline in the resident's functional status and/or functional levels; Reflect currently recognized standards of practice for problem areas and conditions. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on interview, and record review, the facility failed to follow its policy and procedure (P&P), titled Nephrostomy Tube [a thin catheter inserted through your lower back directly into your kidney to drain urine into an external collection bag] Care of, for one of three sampled residents (Resident 11), when Resident 11 had a non-sterile (reduced microbe levels but not completely germ-free) dressing change to her nephrotomy tubes. This failure had the potential for a severe infection in the blood stream with negative outcomes up to and including death.Findings:During a review of Resident 11's Order Summary Report (OSR), dated 5/22/26, the OSR indicated, Cleanse Surgical Site (Nephrostomy Tube) on L [left] posterior flank [back] with iodine & [and] cover with split dressing QD [every day] and prn [as needed]. Monitor and assess during treatments for any worsening, s/sx [signs and symptoms] of infection, or if treatment is ineffective and notify MD.During a concurrent interview and record review on 6/17/26 at 11:22 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 11's Treatment Administration Record (TAR), dated June 2026 was reviewed. The TAR indicated, LVN 1 changed Resident 11's Nephrostomy tube dressing on 6/1/26, 6/2/26, 6/4/26, 6/5/26, 6/8/26, 6/9/26, 6/11/26, 6/12/26, 6/15/26, 6/16/26, and 6/17/26. LVN 1 stated she completed Resident 11's TAR on those days per OSR on the TAR. LVN 1 reviewed the OSR on the TAR and LVN 1 stated the dressing that was changed was a clean dressing, not a sterile dressing. LVN 1 stated she did not use sterile gloves or had a sterile field for the dressing. LVN 1 stated she did not change the dressing per the facilities P&P.During a review of the facility's P&P titled, Nephrostomy Tube Care of, dated October 2010, the P&P indicated, Dressing Change.Put on sterile gloves.Place 1-2 sterile dressings on the nephrostomy tube site.

Based on observation, interview, and record review, the facility failed to ensure oral care was provided for one of three sampled residents (Resident 156). This failure resulted in Resident 156's lips to be dry and cracked.Findings:During a concurrent observation, interview, and record review, on 5/18/26 at 1:38 p.m. in Resident 156 room with Registered Nurse (RN) 1. Resident 156 was sitting up in bed with dry and cracked lips with brown crusty material at the corners of his lips. RN 1 stated Resident 156's lips were dry and chapped; RN1 stated the brown crusty material by the corners of his lips was possibly dry skin. RN 1 stated Resident 156 needed oral care. RN 1 stated residents that are NPO (nothing by mouth) and receiving tube feeding would need oral care and chap stick to keep their lips moist.During a review of Resident 156's Minimum Data Set [MDS - an assessment tool], dated 4/15/26, the MDS indicated, Resident 156's BIMS [Brief Interview for Mental Status - standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember] was not conducted. The MDS indicated, (resident is rarely/never understood). The MDS indicated Resident 156 was dependent [helper does all the effort] for oral hygiene.During an interview on 5/22/26 at 10:05 a.m. with the Director of Staff Development (DSD), DSD stated certified nursing assistant (CNA) should check residents who are NPO and receive tube feeding every two hours while providing care and provided oral care as needed.During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, the P&P indicated, Residents 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. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing dressing, grooming, and oral care). e. Total Dependence- Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice.

Based on observation, interview, and record review, the facility failed to ensure safe administration of enteral feeding [liquid nutrition delivered through a flexible tube directly into the stomach] when two of three sampled residents (Resident 127 and Resident 97) head of bed (HOB was not positioned between 30-45 degree angle during administration of feeding. This failure had the potential to result in Resident 97 and Resident 127 to aspirate [accidental inhalation of liquids or stomach contents into the airway and lungs] and develop an infection. Findings: During an observation on 6/15/26 at 10:09 a.m. in Resident 97's room, Resident 97 was lying in bed with enteral tube feeding running and HOB was slightly elevated. During a concurrent observation and interview on 6/15/26 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 4, in Resident 97's room, Resident 97 was lying in bed with enteral tube feeding running and HOB was slightly elevated. LVN 4 stated while the enteral tube feeding was running Resident 97's head of bed should have been elevated to a 45 degree angle to help prevent aspiration. LVN 4 stated she did not have anything to measure the angle of the bed. During a concurrent observation and interview, on 6/16/26 at 1:38 p.m. with Registered Nurse (RN) 1, in Resident 127's room. Resident 127 was receiving enteral feeding at a rate of 50cc/hour [cubic centimeters per hour - unit of measure]. RN 1 stated Resident 127 was at a 10 to 15 degree angle during enteral feeding administration. RN 1 stated residents who are receiving enteral feeding should be at a 35 to 45 degree angle. During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings – Safety Precautions, revised November 2018, the P&P indicated, To ensure the safe administration of enteral nutrition. Preparation 1. All personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. 2. The facility will remain current in and follow accepted best practices in enteral nutrition. Preventing aspiration 1. Check enteral tube placement prior to feeding or administration of medication. 2. Check gastric residual volume as ordered. 3. Elevate the head of the bed (HOB) at least 30 [degrees] during tube feeding and at least 1 hour after feeding. If elevating the HOB is medically contraindicated, use reverse Trendelenburg position. Monitor the resident for signs and symptoms of respiratory distress during eternal feedings and medication administration. During a review of the facility's P&P titled, Enteral Tube Feeding via Continuous Pump, dated November 2018, the P&P indicated, Steps in the Procedure. 4. Position the head of the bed at 30 degrees – 45 degrees. for feeding.

Based on observation, interview, and record review, the facility failed to ensure prescribed oxygen therapy was administered in accordance with physician orders when:1. Two of two sampled residents (Resident 14 and Resident 78) portable oxygen cylinders were empty. 2. One of two sampled residents (Resident 14) oxygen flow rate did not match physician order. These failures had the potential to result in ineffective respiratory management, respiratory compromise and adverse outcomes.Findings:1. During a concurrent observation and interview on 6/15/26 at 12:42 p.m. with Resident 14 in the dining room, Resident 14 was sitting in a wheelchair that had a portable oxygen cylinder attached. Resident 14 was wearing a nasal cannula (NC, a device with two small prongs that fit into the nostrils and deliver oxygen from the oxygen source) that was attached to the portable oxygen cylinder. The oxygen cylinder pressure gauge needle was in the red zone, which indicated the oxygen cylinder was empty and unavailable to provide oxygen therapy to Resident 14. Resident 14 stated she had told staff in the morning that she did not think the oxygen cylinder attached to her wheelchair was working. During a concurrent observation and interview on 6/15/26 at 12:45 p.m. with Licensed Vocational Nurse (LVN) 1 in the dining room, Resident 14's portable oxygen cylinder had a pressure gauge needle that was in the red zone which indicated the oxygen cylinder was empty. LVN 1 disconnected Resident 14's nasal cannula from the oxygen cylinder and manually assessed for oxygen flow at the outlet. LVN 1 stated no oxygen flow was present and Resident 14's oxygen cylinder was empty. During a review of Resident 14's Order Summary Report (OSR), dated 1/8/25, the OSR indicated, OXYGEN: Administer 02 [oxygen] @ [at] 2 L/min [liters per minute] via NC continuously.During an observation on 6/15/26 at 12:49 p.m. in the dining room, Resident 78 was sitting in a wheelchair that had a portable oxygen cylinder attached. Resident 78 was wearing a NC that was attached to the portable oxygen cylinder. The oxygen cylinder pressure gauge needle was in the red zone, which indicated the oxygen cylinder was empty and unavailable to provide oxygen therapy to Resident 78. During a concurrent observation and interview on 6/15/26 at 12:50 p.m. with LVN 1 in the dining room, Resident 78's portable oxygen cylinder had a pressure gauge needle that was in the red zone which indicated the oxygen cylinder was empty. LVN 1 disconnected Resident 78's nasal cannula from the oxygen cylinder and manually assessed for oxygen flow at the outlet. LVN 1 stated no oxygen flow was present and Resident 78's oxygen cylinder was empty. LVN 1 stated Resident 78's oxygen cylinder should have been changed prior to Resident 78 being brought into the dining room. During a review of Resident 78's OSR, dated 9/11/25, the OSR indicated, OXYGEN: Administer 02 @ 2 L/min via NC continuously.During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration.12. Check the mask, tank.to make sure they are in good working order.13. Observe the resident upon setup and periodically thereafter to ensure oxygen is being tolerated. 2. During an interview on 6/15/26 at 12:42 p.m. with Resident 14, Resident 14 stated she had a physician order to use oxygen at 2 L/min via NC. During a concurrent observation and interview on 6/15/26 at 1 p.m. with LVN 3 in the dining room, Resident 14's portable oxygen cylinder was set to dispense oxygen at 4 L/min. LVN 3 stated Resident 14 was receiving oxygen at 4 L/min. LVN 3 stated she was unsure how much oxygen Resident 14 was ordered to receive. During a concurrent interview and record review on 6/15/26 at 1:08 p.m. with LVN 3, Resident 14's OSR, dated 9/11/25 was reviewed. The OSR indicated, OXYGEN: Administer 02 @ 2 L/min via NC continuously. LVN 3 stated Resident 14 should have been receiving oxygen at 2 L/min. During a review of the facility's P&P titled, Oxygen Administration, dated 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration.Verify there is a physician's order for this procedure. Review the physician's order.Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at a rate of 2 to 3 liters per minute.

Based on observation, interview, and record review, the facility failed to implement infection control standards when:The floor of the over the counter (OTC- medications not requiring a prescription) medication storage room was not cleaned. This failure had the potential to spread infection to residents and staff.The OTC medication storage room's temperature was not monitored or recorded. This failure had the potential to affect the potency of all medications stored in the room. Findings:During a concurrent observation and interview on 6/15/26 at 11:20 a.m. with Registered Nurse (RN) 2, in the OTC storage room, the floor had debris including hair, the top portion of a broken white plastic spoon, and the shell of a flower seed. The tile of the floor was discolored with grime. At the entry, on the floor on left side, there was a black plastic milk crate, placed at an angle, turned upside down, and an air-cooling unit was on top. The milk crate was covered in dust, and the door's threshold (flat, visible piece you step on) was full of dust, and a piece of paper. Behind the milk crate was a white plastic pill bottle, covered in dust. RN 2 stated the OTC storage room is cleaned daily by housekeeping. RN 2 stated the debris on the floor and the pill bottle should not be there.During an interview on 6/15/26 at 11:29 a.m. with Housekeeping/Central Supply Supervisor (HSK/CSS), at the entrance to the OTC storage room, HSK/CSS stated she checked the OTC medication storage room daily but only swept and mopped the room every two to three days.During an interview on 6/16/26 at 8:40 a.m. with Infection Preventionist (IP), IP stated it was her expectation for housekeeping staff to check the OTC storage room, sweep, and mop daily and as needed.During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program dated 12/25, the P&P indicated, An infection prevention and control (IPC) program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 2. During a concurrent observation and interview on 6/15/26 at 1:40 p.m. with RN 1, in the OTC medication storage room, no room temperature log was found. RN 1 stated HSK/CSS is supposed to monitor the temperature in the room.During an interview on 6/15/26 at 1:55 p.m. with HSK/CSS, HSK/CSS stated she checked the temperature of the OTC medication storage room, but she did not enter the temperatures into a log. HSK/CCS stated she did not know the temperature parameters for a room that stores mediation.During an interview on 6/15/26 at 1:56 p.m. with Director of Nursing (DON) and Administrator In-Training (AIT). DON and AIT stated the OTC medication storage room should have a log of the room's temperature. DON stated the task should have been a nursing responsibility.During a review of the facility's P&P titled, Storage of Medication dated 11/20, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 5) was provided with follow up dental care and treatment in a timely manner. This failure resulted in prolonged dental pain for Resident 5 and the potential for Resident 5 developing an infection. Findings:During a concurrent observation and interview on 6/16/26 at 8:40 a.m. with Resident 5, in Resident 5's room, Resident 5 had multiple bottom front teeth that were visible at the gumline. Resident 5 stated his teeth hurt. Resident 5 stated he had been seen by a dentist while at the facility and was supposed to have the teeth removed, but the dentist had not been back. During a review of Resident 5's Brief Interview for Mental Status [BIMS - an assessment of cognition (how well a person thinks, remembers, and learns]. A score of 0 - 7 suggests severe cognitive impairment, 8 - 12 suggests moderate cognitive impairment and 13 - 15 suggests cognition is intact], dated 5/26/26, the BIMS indicated Resident 5's BIMS score was 12.During a concurrent interview and record review on 6/17/26 at 2:34 p.m. with Social Services (SS), Resident 5's electronic medical record (EMR) was reviewed. The EMR indicated Resident 5 was admitted to facility on 8/25/25 and had a dental exam in January 2026. SS stated the exam notes indicated Resident 5 had discomfort, did not want dentures and only wanted extractions. During an interview on 6/17/26 at 2:43 p.m. with SS, SS stated it had been approximately five months since the dental visit in January 2026 and Resident 5 had not received the dental treatment. SS stated the facility does not have a process for ensuring residents receive needed dental treatment. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated December 2016, was reviewed. The P&P indicated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. 6. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services.

Based on interview and record review, the facility failed to ensure the Director of Dietary Services (DDS) met state education qualifications to supervise Food and Nutrition Service (FNS) operations when Title 22 (Section 72035) of the California Code of Regulations and CA Health and Safety Code (HSC) 1265.4(b) Pathway 4 (one of the education-and-experience combination used to qualify for higher-grade certification) was not met as required per the federal regulations. This failure had the potential to adversely affect the foodservice operation related to sanitation, food safety and meeting residents' nutritional needs in accordance with recognized dietary practices.Findings: During an interview on 6/15/26 at 8:31 a.m. with DDS, DDS stated she was full-time and responsible for the day-to-day foodservice operation. During an interview on 06/15/26 at 10:52 a.m. with Registered Dietitian (RD), RD stated she was a consultant RD and worked at the facility 3 to 4 days a week.During a concurrent interview and record review on 6/17/26 at 3:55 p.m. with DDS, and RD, a certificate titled Pathway III(b) Nutrition & Foodservice Professional Training Program, dated 8/14/2024, provided by DDS was reviewed. DDS stated the certificate meant that she had completed the coursework required by ANFP (Association of Nutrition & Foodservice Professionals) to be eligible to sit for the Certified Dietary Manager (CDM) Credentialing Exam. DDS stated she had not taken the CDM credentialing exam and therefore, was not a CDM.During a review of HSC 1265.4 pathway 4 indicated, (4) Is a graduate of a dietetic services program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations [CCR] prior to assuming full-time duties as a dietetic services supervisor at the health facility.During a review of CCR Title 22, 72035. Dietetic Service Supervisor. Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code.During a concurrent interview and record review on 6/17/26 at 4:55 p.m. with the Administrator, a job description (JD) titled Director of Dietary Services, (undated) was reviewed. The JD indicated, Delegation of Authority: As the Director of Dietary Services, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and Responsibilities: Administrative Functions: Assume administrative authority, responsibility, and accountability of supervising the Dietary Department. Education: Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association. Specific Requirements: Must be registered as a Food Service Supervisor in this state. Administrator stated the job description belonged to the DDS. During a review of the facility's contract with the company to provide RD services to the facility (Contract/RD), dated 2/1/2023, the Contract/RD indicated, IV. Responsibilities of the Facility: 1. Provide procedures of communication for the dietitian with Facility's.dietetic services manager. 2. Identify the person designated as the qualified dietetic services manager. Contracted hours for the Facility will be 24-32 hours a week as negotiated with Consultant and Facility's appointed person of contact.

Based on observation, interview, and record review, the facility failed to ensure competency of their dietary aides of what consists of a full liquid diet for one of two sampled residents (Resident 39). This failure had the potential for Resident 39 to not meet his nutritional needs.Findings:During a concurrent observation and interview on 6/16/26 at 12:35 p.m. with Dietary Aide (DA) 1 in the kitchen during lunch trayline, DA 1 removed the pudding from the meal tray and placed apple juice in its place. DA 1 stated she checked the meal tray for accuracy to the meal tray ticket and it is full liquid diet, the meal tray had two bowls of soup and removed the pudding because it was not a liquid.During an interview on 6/16/26 at 12:40 p.m. with Registered Dietitian (RD), RD stated it is okay to place pudding on the tray per the full liquid diet.During a review of Resident 39's admission Record, (AR) dated 6/17/26, the AR indicated, Resident 39 was admitted on [DATE] with a diagnosis of Dysphagia [difficulty swallowing], Weakness, and Hemiplegia [total or partial paralysis of one vertical half of the body] and Hemiparesis [weakness, or partial paralysis on one side of the body] Following Cerebral [relating to the brain] Infarction [death of tissue (necrosis) caused by sudden, severe lack of blood supply and oxygen to affected area] Affecting Right Dominant Side.During a review of Resident 39's Diet Order (DO), dated 6/15/26, the DO indicated, Full Liquid Diet.During a review of Resident 39's Meal Tray Ticket, (MTT) dated 6/16/26, the MTT indicated, Full Liquid for breakfast, lunch and dinner.During a review of the facility's Diet Manual (DM) for the diet titled, Full Liquid Diet, dated 2023, the DM indicated, The full liquid diet consists of foods which are liquid or become liquid at body temperature and are easily digested. Desserts: Custard, plain flavored gelatin, plain ice cream, milk shakes, plain ice, sherbets, hard candy, popsicles, plain yogurt (no seeds or fruit), pudding.During a concurrent interview and record review on 6/6/26 at 12:40 p.m. with RD, a facility provided untitled document, (undated), was reviewed. The document indicated, Full Liquid Diet Menu Options: Pudding: Vanilla or Chocolate. The RD stated the facility used the document as a cheat sheet to help guide dietary aides on what to place on the meal tray and it was posted in the kitchen.During a review of the facility's job description (JD) titled, Job Description: Dietary Aide, (undated), the JD indicated, Dietary Service: Assist in preparing palatable and appetizing meals in accordance with planned menus and temperature requirements on timely basis. Assist in preparing food for therapeutic and texture modified diets in accordance with planned menus with established portion control procedures. Serve supplements, snacks, nourishments and beverages consistent with orders.

Based on observation, interview, and record review, the facility failed to follow the planned menu for regular diet for one of six sampled residents (Resident 121). This failure had the potential to result in serving low-fat milk to residents on a regular diet which posed a risk for decreased milk consumption. During a concurrent observation and interview on 6/16/26 at 12:25 p.m. with Registered Dietitian (RD) in the kitchen during tray line, a dietary aide placed whole milk or 2% milk on regular diet trays. RD stated, it is regular diet, it can be either or, if no preference indicated.During a review of Resident 121's Meal Tray Ticket (MTT), dated 6/16/26, the MTT indicated, Puree Diet: Preferences Milk for breakfast, lunch and dinner.During a review of the facility's dietary menu titled, Winter Menus, (undated), the dietary menu indicated, The regular IDDSI [International Dysphagia Diet Standardization Initiative - a set of testing methods for texture-modified foods and thickened liquids to ensure safe consumption for individuals with swallowing difficulties] menu: 4oz Milk, regular CCHO [Consistent Carbohydrate Diet to manage diabetes] menu: 4oz Milk.During a review of the facility's nutritional breakdown menu titled, Nutritional Breakdown, dated Winter 2024-25, the nutritional breakdown indicated, Regular diet nutritional breakdown based on Whole Milk.During a review of the facility's dietary menu titled, Regular Diet/ IDDSI Level #7, dated 2024, the dietary menu indicated, Description: The regular diet is designed to meet the nutritional needs of residents who do not need dietary modification or restrictions. Individual preferences or intolerances may necessitate the exclusion of certain food items, the diet consists of items served in a variety of unmodified textures and consistencies Nutritional Breakdown: Calories - 2100-2400 .Dairy Group: 16 ounces of milk each day with meals. Whole milk is used in the above nutritional breakdown.During the review of the facility's policy and procedure (P&P) titled, Resident Tray Card, dated 2023, the P&P indicated, 1. A resident tray card should be filled out by the Director of Food and Nutrition Services or designee or electronically produced when the diet order is received. 2. The tray card should include: Resident Name, Diet, Texture Modification, Allergies/Intolerances, Dislikes, Special Requests, Beverages and amount desired for each meal.5. Residents Profile should be updated after receiving diet changes or updates to food preferences. Tray cards will reflect change.

Based on observation, interview, and record review, the facility failed to honor the food preferences for two of 15 sampled residents (Resident 2 and Resident 137) when:1. Resident 2's request for sunny-side up eggs was not honored because the facility stopped purchasing the pasteurized shell eggs required to prepare them safely.2. Resident 137 did not receive margarine on vegetables as indicated on his meal tray card during lunch trayline.These failures had the potential to result in decrease nutritional intake and a decline in the quality of life for Resident 2 and Resident 137.Findings: 1. During an observation on 6/15/26 at 8:40 a.m. in the kitchen, inside the walk-in refrigerator was a box containing an open, unsealed bag of frozen fried eggs with hard egg yolk.During an interview on 06/15/26 at 10:38 a.m. with Director of Dietary Services (DDS), DDS stated they did not have pasteurized shell eggs. DDS stated they also did not have regular (non-pasteurized) shell eggs. DDS stated they purchased pre-cooked fried eggs that they just needed to heat up and/or pre-cooked hard -boiled eggs from their vendor. They also had pasteurized liquid eggs to prepare scrambled eggs. DDS stated if a resident requested a sunny side up (not fully cooked, runny yolk) egg and she did not have pasteurized shell eggs she would not honor the residents request as it would not be safe food preparation. The DDS stated she occasionally purchased pasteurized shell eggs from the local grocery store to prepare sunny side up eggs for residents upon request, but she could not recall when she last did so. DDS was requested to provide receipts for the last time she purchased pasteurized shell eggs from a grocery store for residents.During a concurrent interview and record review on 06/17/26 at 9:58 a.m. with DDS, the facility's food inventory list (undated) was reviewed. DDS stated pasteurized shell eggs were not on the food purchasing inventory list. DDS stated she was unable to provide receipts for pasteurized shell eggs that may have been obtained at a local grocery store.During a concurrent interview and record review on 6/16/26 at 10:00 a.m. with DDS, an invoice from the facility's food vendor, dated 4/11/26, was reviewed. The invoice indicated, Delv. [delivery] Date: 4/11/26, 1 CS [case] pack -1, Size - 15 DZ [dozen], WHLFIMP [Wholesome Farms Imperial] Egg Shell LG [large] Pasteuri [pasteurized]. DDS stated that was the last day the facility received pasteurized shell eggs from their approved vendor.During a concurrent interview and record review on 06/17/2026 at 10:18 a.m. with RD, Resident 2's Nutritional Assessment [NA], dated 2/12/26, was reviewed. The NA indicated, Comments/Food Preferences: Will only [eat] sunny side up eggs, no scrambled or boiled eggs. RD stated she knows they don't have pasteurized shell eggs or regular (non-pasteurized) shell eggs. RD stated it has been at least a month since she last visually saw either regular hard-shell eggs or pasteurized shell eggs in the kitchen. RD stated they should have pasteurized shell eggs readily available at the facility to honor any resident requests for sunny side up eggs. RD stated she should have advised the Administrator the kitchen did not have pasteurized shell eggs. During a review of the facility's policy and procedure (P&P) titled, Resident Food Preferences, dated 2023, the P&P indicated, Procedures: The Director of Food and Nutrition Services or designee should visit residents within 24-48 hours of admission to determine food preferences. Food preferences are recorded in the medical record, profile, and tray card.During a review of Resident 2's tray card, the tray card indicated, Dislikes: corn flakes, no beef or pork, no bread, no chicken, no fish, no scrambled eggs. Preferences: Mashed potatoes with gravy, tomato soup, milk. Sunny side up eggs were not listed as a food preference on Resident 2's tray card for breakfast, lunch or dinner. During a review of the facility's P&P titled, Guidelines For Approved Vendors and Food Purchasing, dated 2023, the P&P indicated, All eggs will be Grade AA, inspected fresh pasteurized or pasteurized frozen.During a review of the Centers for Medicare & Medicaid Services (CMS) Survey and Certification Letter (Ref: S&C: 14-34-NH), dated May 20, 2014, the S&C letter indicated, The use of pasteurized eggs allows for resident preference for soft-cooked, undercooked or sunny-side up eggs while maintaining food safety. Pasteurized shell eggs are commercially available, are clearly labeled and allow the safe consumption of undercooked eggs. Federal regulations expect nursing facilities to make reasonable efforts to respect resident choices and can honor resident choice while maintaining health and safety standards through the use of pasteurized eggs.2. During a concurrent observation and interview on 6/16/26 at 12:19 p.m. with Dietary Aide (DA) 1 and RD in the kitchen during lunch trayline, DA 1 placed Resident 137's lunch meal tray onto the meal delivery cart for distribution to the residents. DA 1 was asked to remove Resident 137's tray and review Resident 137's meal tray card in comparison to what was plated on his lunch plate. DA 1 stated Resident 137's meal tray card indicated, Margarine On Veggies. DA 1 stated Resident 137 was served cooked broccoli without margarine on the broccoli. DA 1 asked the RD if margarine should have been served on Resident 137's broccoli. RD stated either margarine could have been served on top of the cooked broccoli or pats of butter could have been placed on Resident 137's lunch meal tray. DA 1 and RD stated there was neither margarine on the cooked broccoli nor pats of butter on Resident 137's lunch meal tray and should have been.During a review of Resident 137's Care Plan Report [CP], dated 5/01/24, the CP indicated, [Resident 137] is at risk for altered nutrition/weight loss.Goal: Staff will honor food preferences as best as able through next review date.During a review of the facility's P&P titled, Resident Food Preferences, dated 2023, the P&P indicated, Procedures: The Director of Food and Nutrition Services or designee should visit residents within 24-48 hours of admission to determine food preferences. Food preferences are recorded in the medical record, profile, and tray card.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when food items were not covered, were not dated as to when opened, and manufacturer's guidelines were not followed. These failures had the potential to place residents at an increased risk for foodborne illness.Findings:During a concurrent observation and interview on 6/15/26 at 8:31 a.m. with Director of Dietary Services (DDS) in the dry food storage room in the kitchen, there was a large, opened bag of dry pasta without an open date. DDS stated the bag of uncooked pasta should of been labeled with an open date.During a concurrent observation and interview on 6/15/26 at 8:36 a.m. with DDS in the dry food storage room in the kitchen, there was an opened bag of uncooked dry pasta that was not sealed or labeled. DDS stated, the bag of uncooked pasta should have been sealed and labeled with an open date.During a concurrent observation and interview on 6/15/26 at 8:39 a.m. with DDS in the dry food storage room in the kitchen, there was an opened bottle of Kikkoman Teriyaki Marinade and Sauce stored on a wire shelf. DDS stated, it [bottle of Kikkoman Teriyaki Marinade and Sauce] was not used this morning and that location was its [bottle of Kikkoman Teriyaki Marinade and Sauce] permanent place to be stored. DDS read the manufacturer's guidelines on the bottle and DDS stated, Refrigerate after opening. During a concurrent observation and interview with DDS on 6/15/26 at 8:40 a.m. in the kitchen, inside the walk-in refrigerator one box contained an open, unsealed bag of frozen fried eggs. DDS stated the bag of frozen eggs should have been closed.During a concurrent observation and interview on 6/15/26 at 8:42 a.m. with DDS inside the walk-in refrigerator inside the kitchen, there were two unopened cases/boxes of frozen Vital Mighty Shakes without a date indicating when placed in the refrigerator. DDS stated, there was no date to indicate when the box of frozen health shakes were placed in the refrigerator. DDS stated kitchen staff dated the unopened case/box of Vital Mighty Shakes as 06/03/26 and another unopened case/box located in the back of refrigerator as 6/10/26 were dates the facility received the frozen health shakes from the vendor and were placed in the freezer located in the kitchen.During a review of the facility's P&P titled, Food Receiving and Storage of Cold Foods, dated 2023, the P&P indicated, Policy: All the perishable food items purchased by the department of food and dining services will be stored properly. All open food items will have an open date and use-by-date per manufacturer's guidelines . 9. All refrigerated foods will be covered properly . 12. All meat and perishable food, e.g. pudding, milkshakes, juices, etc placed in the refrigerator for thawing must be labeled on pull date and used by date when item was transferred to the refrigerator . 15. Refer to Refrigerated Storage Guidelines for recommended storage time.During a review of the facility's dry goods storage guidelines titled, Dry Goods Storage Guidelines, dated 2023, the dry goods storage guidelines indicated, Pasta and rice mixes: Opened on shelf - 1 year .Sauces - bottled (steak sauce, soy sauce, teriyaki, Worcestershire): Opened on Shelf - refrigerate.During a review of the facility's refrigerated storage guidelines titled, Refrigerated Storage Guide, (undated). the refrigerated storage guide indicated, Supplemental shakes taken from the frozen state and thawed in the refrigerator will be dated as soon as they are placed in the refrigerator. Follow the manufacturer's recommendations (specifications) for shelf life.During review of the manufacturer's guidelines (MGs) listed on each individual sized carton of health shakes, the MGs indicated, Use thawed product within 14 days. Keep refrigerated.During a review of the facility's P&P titled, Canned and Dry Goods Storage, dated 2023, the P&P indicated, 9. Metal, plastic containers (with tight fitting lids and NSF[National Sanitation Foundation] approved), or resealable plastic bags will be used for staples and opened packages of items such as pastas, rice, dry cereals, etc. Food items will be labeled and dated when placed into containers.

Based on observation, interview, and record review, the facility failed to ensure an infection control program was implemented when: 1. Infection surveillance (the systematic, ongoing collection and analysis of data to prevent the spread of healthcare associated infections [HAI]) was not performed. This failure resulted in an increase in urinary tract infections. 2. One of one sampled resident (Resident 101) on Enhanced Barrier Precautions (EBP - gown and gloves are used during care of residents with indwelling medical devices and open wounds, to prevent infection) had foam material wrapped and secured with tape around both upper bed rails. This failure had the potential to result in Resident 101 developing an infection. 3. Two Certified Nurse Assistants (CNA 3 and CNA 4) did not follow EBP for one of one sampled resident (Resident 138) while providing direct care to Resident 138. This failure had the potential to result in Resident 138 developing an infection. Findings: 1. During a review of the facility's Monthly Infection Surveillance [observation, monitoring, or tracking] Report (MISR), dated February 2026, the MISR indicated, there was five HAI for urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of the facility MISR, dated March 2026, the MISR indicated there was ten HAI for UTI. During a review of the facility MISR, dated April 2026, the MISR indicated there was 13 HAI for UTI. During a concurrent interview and record review on 6/17/26 at 9:32 a.m. with Infection Preventionist (IP), the MISR for February, March, and April of 2026 were reviewed. The MISR indicated there were an increase in UTI's. IP stated she did not completing training or surveillance rounds to identify or prevent further infections. During a review of the facility's P&P titled, Infection Prevention and Control Program, undated, the P&P indicated, Surveillance tools are used for recognizing their currents of infection recording their numbers and frequency detecting outbreaks and epidemics monitoring employee infection monitoring adherence to infection prevention and control practices and detecting unusual pathogens [germs] with infection control implication. 2. During an observation on 6/15/26 at 8:44 a.m. in Resident 101's room, Resident 101 was lying in bed with both upper bedrails in the up position. The top of the bedrails were covered by a foam like material that was secured in place with four separate pieces of tape. The tape was pulling away on the left bedrail exposing the adhesive underneath. During a concurrent observation and interview on 6/18/26 at 10:41 a.m. with IP in Resident 101's room, Resident 101's upper bedrails were covered in a foam like material that was secured with tape. IP stated Resident 101 was on EBP for an open wound. IP stated the tape was not changed everyday, and was pulling away from the foam and caused a potential risk for infection for Resident 101. 3. During an observation on 6/15/26 at 9:09 a.m. outside Resident 138's room, an EBP sign was on the wall beside the door and an orange dot was on the nameplate next to Resident 138's name. During an observation on 6/15/26 at 9:12 a.m. in Resident 138's room, CNA 3 was changing Resident 138's bed linens while only wearing gloves. During an observation on 6/15/26 at 9:13 a.m. outside Resident 138's room, CNA 4 entered Resident 138's room, donned gloves and went to Resident 138's bedside to assist CNA 3 with care of Resident 138. During an interview on 6/15/26 at 9:18 a.m. with CNA 4, CNA 4 stated the orange dot on Resident 138's name plate indicated Resident 138 was on EBP and she needed to wear gloves and a gown when providing care to Resident 138. During an interview on 6/18/26 at 10:07 a.m. with IP, IP stated staff are expected to wear a gown and gloves when providing care to residents on EBP. IP stated EBP were used to help prevent the resident from developing an infection. During a concurrent interview and record review on 6/18/26 at 10:14 a.m. with IP, Resident 138's Physician Order (PO), dated 3/10/26 was reviewed. The PO indicated, Enhanced Barrier Precautions during high contact time. IP stated Resident 138 was on EBP for history of Multidrug Resistant Organism (MDRO – bacterial infections that are resistant to antibiotic treatment). During a review of the facility's P&P titled, Enhanced Barrier Precautions, dated December 2024, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multidrug-resistant organisms (MDROs) to residents. 2. Enhanced barrier precautions apply when: a. A resident is infected or colonized with a CDC – targeted MDRO, but does not have a wound or indwelling medical device. 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities. a. Gloves and gown are applied prior to performing high contact resident care activity.

Based on observation, interview, and record review, the facility failed to ensure call lights were in reach of one of 71 sampled residents (Resident 127). This failure had the potential for Resident 127 not to be able to call for needed care and assistance.Findings:During a concurrent observation and interview, on 6/16/26 at 1:38 p.m. in Resident 127's room with Registered Nurse (RN) 1. Resident 127's call light was observed on the floor on the side of Resident 127's bed. RN 1 stated Resident 127 could not reach his call light.During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, revised September 2022, the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) safety when:1. Physician's order (any time the doctor writes or gives verbal instruction for nursing staff to follow) for bilateral landing mats (high-density foam cushions placed beside beds to reduce injury from falls) was not followed for one of three sampled residents (Resident 1).2. Care plan (CP- a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) for bilateral landing mats was not implemented for one of three sampled residents (Resident 1).3. Care plan was not updated and implemented to reflect two-persons assistance during toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) while on a low air loss mattress (LAL- specialized medical surfaces designed to prevent and treat pressure injuries [localized damage to the skin and underlying soft tissue, typically over a bony prominence, caused by prolonged pressure, friction, or shear, frequently affecting immobile individuals] by utilizing a constant flow of air through tiny holes in the mattress cover to manage skin moisture and reduce heat) for one of three sampled resident (Resident 1).These failures resulted in Resident 1 sustaining a fall, suffering a laceration (tear or break in the skin caused by blunt trauma or a sharp object) to the back of his head, which resulted in Resident 1 being sent to the acute hospital where he was admitted for three days and was diagnosed with a subarachnoid hemorrhage (bleeding into the space surrounding the brain, usually caused by head trauma from falls and accidents). Findings:During a review of Resident 1's admission Record, (AR) the AR indicated Resident 1 was admitted on [DATE], with diagnoses including traumatic hemorrhage (condition where bleeding occurs inside the brain or skull due to head trauma, such as falls, accidents, or assaults) of cerebrum (the largest, uppermost part of the brain, responsible for high-level functions like thought, memory, emotion, language, and sensory processing), dementia (brain disorders causing memory loss and behavioral changes that interfere with daily life), bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs and lows), chronic pain (pain that lasts for over three months), contractures (a permanent, often painful stiffening and shortening of muscles, tendons [thick tissue that connect muscle to bone], or skin, causing joint deformity and limited range of motion (ROM- how the body moves), and abnormal posture (a severe, uncontrolled stiffening of the body or positioning of the body such as arched backs, clenched fists, or stretched out and stiff arms and legs).During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 11/24/25, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 99 (score 99 indicates the resident was unable to complete the interview). The MDS indicated Resident 1 had short and long-term memory problems. The MDS indicated Resident 1 had impairments of both lower extremities (hips, knees, ankles, and feet). Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required to complete the activity) for toileting hygiene and with roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed).During a review of Resident 1's SBAR (Situation, Background, Assessment, & Recommendation- communication form used in healthcare) & Initial COC (Change of Condition)/Alert Charting & Skilled Documentation, (SBAR/COC) dated 1/25/26, the SBAR/COC indicated Resident 1 had a witnessed fall with laceration (cut/no measurement noted) to the back of head, on 1/25/26 at approximately 9:50 p.m. The SBAR/COC indicated, Other pertinent data: LAL mattress is present which was fully inflated. No fall matts [sic] present. (Resident 1) was lying on his back next to his bed. Blood was dripping back of his head . CNA (certified nursing assistant 2) was standing to left side of bed, CNA turned the (Resident 1) to his right side. The (Resident 1's) lower extremities shifted toward the edge of the bed to the right side, when CNA was walking to right of bed to put his legs back to bed, meantime he fell from bed.During a review of Resident 1's Physicians Orders, (PO) dated 1/25/26, the PO indicated, May Transfer To Acute Hospital For Further Evaluation And Treatment . for s/p (status post-after) fall with injury .During a review of Resident 1's acute hospital Computerized Tomography (a rapid, non-invasive imaging procedure that combines specialized X-rays with computer software to create detailed, cross-sectional images of body tissues, organs, and bones), (CT) dated 1/25/2026, the CT indicated, Indications: head injury . Findings: . Trace subarachnoid hemorrhage within the sulci (groove) of the right frontal (area of the brain located behind the forehead) and, to a lesser degree, parietal lobes (a major brain area of the brain located behind the frontal lobe)During a review of Resident 1's admission Nursing Assessment, (facility ANA-readmission from the acute hospital) dated 1/29/26, the ANA indicated, Reason for admission: Traumatic subarachnoid hemorrhage . Relevant History/Dx (diagnosis): s/p (status post) fall.1. During a review of Resident 1's Physicians Orders, dated 7/13/2020, the PO indicated, May have Bilateral landing mats to sides of bed. LN (licensed nurse) to check placement Q (every) shift every day and night shift.During an observation on 2/11/26 at 11:17 a.m. in Resident 1's room. Resident 1 was observed lying in a regular bed and no bilateral landing mats were noted at bedside.During a concurrent interview and record review on 2/11/26 at 12:47 p.m. with Director of Nursing (DON), Resident 1's physicians order was reviewed and indicated, May have Bilateral landing mats to sides of bed ordered on 7/13/20. Resident 1's Treatment Administration Record, (TAR) and Medication Administration Record, (MAR) for January 2026 were reviewed. DON stated no documentation LN checked for Resident 1's landing mat placement every shift. DON stated the bilateral landing mats were not in place at the time of Resident 1's fall on 1/25/26 and the PO was not followed.During an interview on 3/11/26 at 10:15 a.m. with CNA 2, CNA 2 stated on 1/25/26 at approximately 9:30 p.m. she was providing toileting care for Resident 1. CNA 2 stated Resident 1 fell out of bed and hit his head. CNA 2 stated there were no bilateral landing mats at bedside when Resident 1 fell (1/25/26) and she does not know if Resident 2 hit his head on the floor or cabinet.On 2/27/26, 3/12/26, 4/9/26, and 4/10/26, requests were sent to the facility for its policy and procedure regarding the implementation of physicians' orders. On 4/10/26 at 12:01 p.m., the DON replied via email, stating that the facility does not maintain a policy or procedure specifically for following physicians' orders.2. During a review of Resident 1's care plan with the focus on (Resident 1) is at risk for Pressure Injury development, The care plan indicated, May have Bilateral landing mats to sides of bed, initiated 07/22/2021.During an observation on 2/11/26 at 11:17 a.m. in Resident 1's room. Resident 1 was observed lying in a regular bed and no bilateral landing mats were noted at bedside.During a concurrent observation and interview on 2/11/26 at 12:23 p.m. with DON in Resident 1's room. DON stated Resident 1 did not have bilateral landing mats at bedside. DON stated Resident 1 did not have bilateral landing mats when he fell (1/25/26) and the CP was not implemented. DON stated she did not know why the bilateral landing mats were indicated under the CP for Pressure Injury Development and not under the Fall CP.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: . (3) which professional services are responsible for each element of care; .3. During a review of Resident 1's care plan with the focus on (Resident 1) is at risk for Pressure Injury development, initiated on 6/14/20. The care plan indicated Apply LAL mattress for wound management/preventive measures. (the CP did not indicate the need for two-persons assistance during ADL [activities of daily living - support provided to individuals struggling with basic, essential self-care tasks required for daily life, such as bathing, dressing, eating, toileting, and transferring] care).During a review of Resident 1's Physicians Orders, dated 3/8/24, the PO indicated, LAL mattress for wound management/preventive measures. Check placement, settings and functionality QS (every shift) every shift.During a review of Resident 1's Medication Administration Record, (MAR) for January 2026, the MAR indicated, LAL mattress for wound management/preventive measures. Check placement, settings and functionality QS (every shift) every shift -Start Date- 03/08/2024 1800 (6 pm). The LAL was documented as in place, functioning, and at the correct setting from January 1, 2026, to January 25, 2026 (date of fall 1/25/26).During a review of Resident 1's care plan with the focus on Presence of contracture on BUEs (bilateral upper extremities- arms and hands) Functional loss in ROM (range of motion- how the body moves) Episodes of striking out others H/o (history of) falls, initiated 9/2/19.During a review of Resident 1's care plan with the focus on (Resident 1) was observed to have Limited functional ROM (range of motion). Related to the following Diagnosis/conditions: Contractures on lower Extremities ., initiated 8/1/23.During an interview on 3/11/26 at 10:15 a.m. with CNA 2, CNA 2 stated when she received report at change of shift, she was told Resident 1 was a one-person assist and easy to manage. CNA 2 stated she had not worked with Resident 1 for some time. CNA 2 stated she worked a double shift on 1/25/26 and at approximately 9:30 p.m. she provided toileting care for Resident 1. CNA 2 stated, When I was rolling (Resident 1) was kind of middle of the bed, cleaning from the side, I was rolling up the dirty chux (absorbent under pad designed to protect bedding, furniture, and car seats from moisture) and placing the new one (chux) under him so when he was on the edge of the bed he began to tense up, his legs went up and he went off (the bed) legs first. CNA 2 stated she tried to get to the other side of the bed to move Resident 1's legs back onto the bed, but Resident 1 fell out of bed and hit his head but does not know if Resident 1 hit his head on the floor or cabinet.During an interview on 3/19/26 at 1:20 p.m. CNA 3 stated Resident 1 was a total dependent on ADL care. CNA 3 stated Resident 1 was always two-persons assistance because Resident 1 could not help with turning on toileting hygiene. CNA 3 stated residents on LAL mattress were always two-persons assistance.During an interview on 3/19/26 at 1:27 p.m. with the Director of Staff Development (DSD), DSD stated she educated the CNAs (no date given) to use two-persons assistance for residents on LAL mattresses, one person on each side of the bed. DSD stated the LAL mattress was too risky because it could move during care. DSD stated the CP should have been updated to indicate two-persons assistance and should have been implemented for Resident 1. DSD stated two-persons assistance for residents on LAL mattress had been the facility's practice before Resident 1 sustained a fall on 1/25/26.On 3/12/26, 4/9/26, and 4/10/26, requests were sent to the facility for its policy and procedure regarding care provided to dependent residents on LAL mattress On 4/10/26 at 12:01 p.m., the DON replied via email, stating that the facility does not maintain a policy or procedure specifically care provided to dependent residents on LAL mattress.During a review of the facility's P&P titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated, Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 2. Safety risk and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. Individualized, Resident-Centered Approach to Safety. 1. Our individualized, resident-centered approach to safety address safety and accidents hazards for individual residents. 3. The care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accidents risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently; . Resident Risk and Environmental Hazards 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in the dedicated policies and procedures. These risk factors and environmental hazards include the following: a. Bed safety; b. Safe lifting and movement of residents; c. Falls .

Based on interview and record review, the facility failed to ensure urine was collected as ordered by the physician after a change of condition for one of four sampled residents (Resident 1) when Resident 1 complained of painful urination. This failure had the potential to result in Resident 1 to receive delay of care.Findings:During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 had a history of Urinary Tract Infection (infection in any part of the urinary system [body system that filters waste from the blood and produces urine]).During a review of Resident 1's Order Summary (OS), the OS indicated, Order Date: 11/05/2025 06:53. Order Summary: UA C&S (Urinalysis with Culture and Sensitivity [urine test to confirm an infection]) one time only for painful urination.During a review of Resident 1's Nurses note (NN), dated 11/7/25, the NN indicated, resident refused to go to dialysis (medical treatment that filters waste and excess fluid from the blood) today related to painful urination, UA (urinalysis [urine test]) collected. Explained risk to the resident. family made aware.During a review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation), dated 11/7/25, the SBAR indicated, resident urine collected this morning related to painful urination, around noon time patient complained of increase in pain upon urinating. Patient refused to wait for UA C&S results, requested to go to the hospital for further evaluation, family and MD (medical doctor) aware.During a review of Resident 1's (Acute hospital) Emergency Department Notes (EDN), dated 11/7/25, the EDN indicated, Discharge Diagnosis: 1. Urinary tract infection.During a concurrent interview and record review on 1/5/26 at 2:47 p.m. with Director of Nursing (DON), Resident 1's SBAR, dated 11/5/25, was reviewed. The SBAR indicated, Resident (1) is having c/o (complained of) pain while urinating. Resident (1) was offered pain medication. Pain medication effective. Vitals are WNL (within normal limits). New orders for UA C&S. DON stated, We want to collect it (urine) as soon as possible. DON was unable to find documentation Resident 1's urine was collected until 11/7/25. DON stated there should have been documentation if the licensed nurses attempted or were unable to collect the urine starting 11/5/25.During an interview on 1/8/25 at 12:13 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse assigned to Resident 1 on 11/5/25 day shift. LVN 1 stated she was unable to recall if she attempted to collect Resident 1's urine during her shift on 11/5/25 when she received the physician's order for UA C&S. LVN 1 stated she was supposed to collect Resident 1's urine so she would know it would be on time and there was no delay of care.During a review of the facility's policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol, dated March 2018, the P&P indicated, Treatment/Management 1. The physician will help identify and authorize appropriate treatments. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly.

Based on observation, interview, and record review, the facility failed to ensure one of five residents' restrooms (room [ROOM NUMBER]) linoleum floor covering was in good repair. This failure had the potential to place residents at risk for accidents and hazards. Findings: During a concurrent observation and interview on 4/29/25 at 1:22 p.m. with the Maintenance Director (MD) in room [ROOM NUMBER]. The restroom linoleum floor covering was torn and lifted causing an uneven surface. MD confirmed the observation and stated the uneven surface was a tripping hazard. During a review of the facility ' s policy and procedure (P&P) titled, Maintenance Service, revised December 2009, the P&P indicated, 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, [sic] but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards.

Based on interview and record review, the facility failed to follow their policy and procedure on Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating to immediately protect all the residents from potential abuse when an alleged (something is claimed or said to be true but hasn't been proven) perpetrator (someone who commits a harmful or illegal act) was allowed to enter the facility after the Administrator was informed of the allegation. This failure had the potential to expose all residents in the facility to harm and spread of infection. Findings: During a review of the California Department of Public Health (CDPH) Intake Form dated 3/20/25, the Intake Form indicated, Caller [complainant] stated a contractor named [Phlebotomist] from [agency which provides diagnostic services] is using needles on residents then cleaning them with alcohol wipes and taking those same needles to other facilities. Caller stated she knows the needles are being used at [another facility] as well as a hospital [Phlebotomist] works at. During an interview on 3/25/25 at 11:57 a.m. with Administrator, Administrator was made aware of the allegation. Administrator stated the responsibility of the facility is to ensure the third-party contracts are good, and the staff is trained to treat the residents appropriately. Administrator stated he is going to initiate an investigation by contacting (agency which provides diagnostic services) and speaking with the consultants as he has never encountered this scenario before. During an interview on 3/27/25 at 1:30 p.m. with General Manager (GM-of the agency which provides diagnostic services), GM stated the Phlebotomist did go to [facility name] yesterday (3/26/25) to complete a blood draw. During an interview on 3/27/25 at 1:35 p.m. with Phlebotomist, Phlebotomist stated she did go to the [facility name] yesterday (3/26/25) to draw labs (laboratory) for one resident. During an interview on 3/28/25 at 1:00 p.m. with Administrator, Administrator stated he was unaware the Phlebotomist entered the facility on 3/26/25 to draw blood. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated April 2021, the P&P indicated, The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on interview and record review, the facility failed follow their policy and procedure (P&P) titled, Enteral Feedings (a method of delivering nutrients and fluids to the body for patients who cannot safely chew or swallow) - Safety Precautions, for one of three sampled residents (Resident 1) who was on gastrostomy tube (G- tube- a tube which delivers liquid, nutrition, and medications through a flexible tube that goes directly into the stomach) feeding when G-tube placement was not checked, gastric residual volume (measures the amount of fluid or contents remaining in the stomach after feeding) was not checked, and signs and symptoms of complications were not reported timely to the physician. These failures resulted in Resident 1 being transferred to the acute hospital and being diagnosed with aspiration pneumonia (a lung infection that occurs when something other than air, like food, liquid, saliva, or vomit, is inhaled into the lungs). Findings: During a review of Resident 1's Admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses including acute (symptoms or signs that begin and worsen quickly) and chronic (continuing or occurring again and again for a long time)respiratory failure (a serious lung condition which makes it difficult to breathe on your own) with hypoxia (a medical condition that occurs when there's not enough oxygen in the body's tissues), paraplegia (paralysis of the legs and lower body, typically caused by spinal cord [part of the body that connects the brain and the body]injury or disease) dysphagia (swallowing problems occurring in the mouth and/or the throat), disorders of diaphragm (diaphragm- is a muscular barrier between the chest and the abdominal cavity; disorders of the diaphragm often interfere with breathing), and gastrostomy status (the presence of a surgical opening into the stomach). During a review of Resident 1's quarterly Minimum Data Set, (MDS- an assessment tool) dated 10/8/24, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- test to evaluate cognitive [how well a person thinks, remembers, and learns] function) score was 12 (a score of 8 to 12 indicates moderately impaired cognition). During a review of Resident 1's Order Summary Report, (OSR- physicians' orders) undated, indicated, continuous feeding via G- tube Glucerna 1.2 (specialized source of nutrition) 90 ml (millimeter- unit of measure) x (times) 20 hours. Enteral Feed (G- tube feeding- delivers liquid nutrition through a flexible tube that goes directly into your stomach) Order every shift Enteral: Assess for any s/sx (signs and symptoms) of aspiration (when food or drink are breathed into the lungs). crackles (abnormal breath sounds that occur when fluid builds up in the airways of the lungs) in lungs, . SOB (shortness of breath) regurgitation (vomiting), drooling (excess saliva flows out of the mouth involuntarily), wheezing (a high-pitched whistling sound that occurs when breathing due to narrowed or obstructed airways, noisy breathing QS (every shift) and notify MD (Medical Doctor)- Start Date- 07/09/2024 0600 (6 a.m.) and Enteral Feed Order every shift Enteral: Assess for formula intolerance QS- NV (nausea [uneasiness in the stomach] and vomiting), . and notify MD if any- Start Date- 07/09/2024 0600 . During a review of Resident 1's SBAR, (situation, background, appearance, and review- a communication form) dated 10/25/24 documented by Licensed Vocational Nurse (LVN) 2, the SBAR indicated, Upon on coming [sic] of my shift (LVN 2 shift started at 6 p.m. on 10/25/24) the (Resident 1) had noted N/V (nausea and vomiting), looked pale and had a noted wheeze (a high-pitched whistling sound that occurs when the airways in the lungs become blocked, making it difficult to breathe) .later (between 7 p.m. and 8 p.m.) due meds (medications) were given (via G-tube) without A/R (adverse result- negative or harmful results). During rounding per shift change (10:30 p.m.) for the CNA'S (certified nursing assistant) the (Resident 1) was found Diaphoretic (excessive sweating due to a secondary condition), labored breathing (increase in effort to breathing) with noted crackles while sitting in high fowlers position (seated upright) and on 2L (liters- unit of measure) O2 (oxygen) via NC (nasal cannula- thin plastic tube placed in nostrils to deliver oxygen). The (Resident 1) looked cyanotic (having a bluish or purplish discoloration of the skin or mucous membranes (moist tissues that line the inside of your mouth and nose) due to low oxygen levels in the blood).Blood sugar was assessed and recorded at 151 mg/dl (milliliter per deciliter- unit of measure [normal blood sugar between 70-100]) O2 sat (saturation-oxygen absorb in blood) @ (at) 88 (percent [unit of measure] a normal oxygen saturation level is between 95 percent and 100 percent). (Resident 1's physician) notified at 10:47 (10:47 p.m.), order given to send out (to the acute hospital). (Ambulance) arrived at 10;58 [sic] (10:58 p.m.). During an interview on 11/24/24 at 1:22 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 10/25/24 (10:30 p.m. to 6 a.m.) she was assigned to Resident 1. CNA 1 stated she checked Resident 1 at approximately 10:30 p.m. CNA 1 touched Resident 1 and noticed he was damp and sweaty. Resident 1 did not verbally respond when she greeted him. CNA 1 stated Resident 1 moaned which was unlike him. CNA 1 stated Licensed Vocational Nurse (LVN) 2 and Registered Nurse (RN) were notified of Resident 1's condition (damp and sweaty) and LVN 2 and RN came into the room with a crash cart (a cart stocked with emergency supplies, used for cardiac [relating to the heart] and respiratory [made up of your lungs, airways, throat, nose, and mouth] emergencies).CNA 1 stated Resident 1 was sent out (acute hospital) via ambulance at approximately 11 p.m. (10/25/24). During an interview on 11/26/24 at 10:03 a.m. with LVN 2, LVN 2 stated on 10/25/24 she came to work at 6 p.m. and noted Resident 1 was vomiting and wheezing. She stated she waited 45 minutes and administered Resident 1's due medications via G- tube at approximately 6:45 p.m. LVN 2 stated Resident 1 had vomited several times from 6 p.m. to 10:30 p.m. and she stopped the G- tube feeding (no time given), Every time I tried to connect (Resident 1) to his feeding tube (Resident 1) would vomit to the point of projectile vomiting (a type of severe vomiting that involves the forceful expulsion of stomach contents). LVN 2 stated, As soon as the CNA would get him cleaned up (Resident 1) would vomit again. LVN 2 stated she did not immediately report Resident 1's vomiting and wheezing to the MD on 10/25/24 at 6 p.m. LVN 2 stated, I felt it was necessary to get (Resident 1) out to the hospital. During a concurrent interview and record review on 12/11/24 at 3:30 p.m. with Director of Nursing (DON), Resident 1's SBAR dated 10/25/24 was reviewed. DON stated LVN 2 noted Resident 1 had vomiting and wheezing episodes at between 6 p.m. and 6:30 p.m. DON confirmed the MD was not notified until 10:47 p.m. (approximately 4 hours and 30 minutes after the first episode of vomiting was noted). Resident 1's medical record was reviewed. DON confirmed no documentation the G- tube placement and/or residuals were checked prior to LVN 2 administration of medication to Resident 1 at 8 p.m. (10/25/24). DON stated the MD should have been notified immediately (after the first episode of vomiting and wheezing were noted between 6:15 p.m. to 6:30 p.m.). During a review of Resident 1's Pre-hospital Care Report, (PCR- paramedic's documentation) dated 10/25/24 the PCR indicated dispatch was notified at 11:01 p.m., the unit arrived at the facility at 11:06 p.m., and arrived at the hospital at 11:25 p.m. The PCR indicated, (Resident 1) is presenting with respiratory distress (difficulty breathing, rapid breathing, and low blood oxygen levels). Staff stated patient had been in the current condition for close to thirty minutes into her shift (6:30 p.m.). Staff stated that the earlier shift had reported (Resident 1) was presenting in the same condition . (Resident 1) has rhonchi (a low-pitched, loud, continuous lung sounds that resemble snoring or gurgling (growling); usually means a blockage or an increased mucus in the airways) on all pulmonary (lungs) fields. (Resident 1) has partial airway obstruction (blockage) due to phlegm (thick mucus produced by the lungs) build up. (Resident 1) has an increased respiratory rate and effort . (Resident 1) has cool, moist, and pale skin signs. During a review of Resident 1's ED (emergency department) Physician Note, (EDPN) dated 10/25/24 at 11:38 p.m. the EDPN indicated, Medical Decision Making . have ordered Rocephin (medications used to treat bacterial infections- no route indicated) and clindamycin (medications used to treat bacterial infections) to cover aspiration pneumonia . (Resident 1) chest x-ray (generate images of tissues and structures inside the body) shows elevation of right hemi (half) diaphragm (is the major muscle of respiration, located below the lungs) is along with what I suspect are infiltrates (a substance that is denser than air and is present in the lung tissue, such as fluid) in the right lung.This chest x-ray was interpreted by myself (ED physician). During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings-Safety Precautions, November 2018, the P&P indicated, To ensure the safe administration of enteral nutrition.Preventing aspiration 1. Check enteral tube placement prior to feeding or administration of medication. 2. Check gastric residual volume as ordered. 4. Monitor the resident for signs and symptoms of respiratory distress during enteral feedings and medication administration. Recognizing and reporting other complications 1. g. Nausea; . i. c. Difficulty breathing. Documentation Document all assessments, findings, and interventions in the medical record. Reporting Report unusual findings and/or signs of complications to the Physician.

Based on interview and record review, the facility failed to ensure: 1. Wound (pressure injury) care was provided and weekly wound assessments were completed for one of 33 sampled residents (Resident 4). This failure resulted in Resident 4's pressure injury/ulcer [a wound caused by pressure] to worsen, develop an infection, and caused an increase in wound pain. 2. Wound (pressure injury) care was provided for 11 of 33 sampled residents (Resident 1, Resident 6, Resident 17, Resident 18, Resident 20, Resident 21, Resident 22, Resident 24, Resident 28, Resident 30 and Resident 31). This failure had the potential for residents' wounds/pressure injury to worsen. Findings: 1. During a review of Resident 4's ADMISSION RECORD (AR), dated 3/31/20, the AR indicated, Resident 4 had diagnosis of respiratory failure, morbid obesity (being 100 pounds or more above ideal body weight), malnutrition (imbalance in a persons intake of nutrients), major depressive disorder, diabetes (group of diseases that result in too much sugar in the blood), gastrostomy status (having a tube inserted into the stomach to provide nutrition). During a review of Resident 4's Minimum Data Set (MDS - an assessment tool), dated 3/11/22, the MDS indicated, Resident 4 was not alert and oriented, and had short/long term memory issues. Resident 4 had unintended weight loss. Resident 4 required total two person/staff assistance with hygiene, bathing, bed mobility, transferring, and dressing. Resident 4 was at risk for pressure injuries but at the time of assessment did not have any pressure injuries. Resident 4 required pressure reducing devices when in a chair and when in bed. Resident 4 required a turning/repositioning program (a program where staff turn residents at minimum every two hours to relieve pressure and prevent wounds). During a review of Resident 4's Braden Scale Record (BSR - predicts pressure ulcer risk), dated 9/28/21, the BSR indicated, Score: 9.Category: Very High Risk. During a review of Resident 4's Situation Background Assessment Request (SBAR-document used to notify physicians of changes), dated 3/16/22, the SBAR indicated, Shearing (pressure and friction injuring the skin at the same time) noted to right elbow. During a review of Resident 4's Weekly Skin Assessment Sheet (WSAS), dated 3/24/22, the WSAS indicated, Stage 2 [an intact blister or shallow open sore] P.U. [pressure ulcer-the sore has broken through the top layer of the skin and part of the layer below] to the right elbow. The shearing was classified as a stage 2 pressure ulcer. During a review of Resident 4's Progress Notes (PN), dated 4/15/22, at 11:38 AM, the PN indicated, Resident is currently receiving treatment to stage 2 pressure injury to right elbow. Upon assessment and re-evaluation of pressure injury slough (dead tissue separation from living tissue) was noted to wound bed. Pressure injury to right elbow has declined and is now a stage 3 (full thickness skin loss involving damage or necrosis [death of cells or tissues through disease or injury] of subcutaneous [under all the layers of skin] tissue that may extend down to, but not through, underlying fascia [tissue that surrounds every part of the body], deep and painful wound.) pressure injury. During a review of Resident 4's Progress Notes (PN), dated 5/1/22, at 4:31 AM, the PN indicated, Resident is showing increases signs of pain through increase frequency of facial grimacing related to wound on right elbow. During a review of Resident 4's Situation Background Assessment Request (SBAR), dated 5/1/22, at 9:40 PM, the SBAR indicated, Resident has a wound on her right elbow that is worsening related to immobilization. The wound is tunneling (penetrates more deeply into tissue) and draining is coming out. M.D. was notified and was started on Doxycycline (antibiotic - medicine that fight infections caused by bacteria [can cause a disease]).Resident shows s/s (signs and symptoms) of pain. The frequency of her scheduled Norco [pain medication] 5-325 mg (milligrams-unit of measure) was increased to q 6 hours. During a review of Resident 4's Progress Notes (PN), dated 6/9/22, at 5:59 PM, the PN indicated, Wound to resident right elbow has increased [NAME] [sic] size and depth. Tendons are visible. Area around the elbow is dark red and warm to touch. Drainage purulent (pus) and odorous. [Physician] notified order received for C&S (culture and sensitivity-identifies bacteria present in the wound) and labs (laboratory). During a review of Resident 4's Minimum Data Set (MDS - an assessment tool), dated 7/13/22, the MDS indicated, Resident 4 was assessed to have a stage 3 pressure injury (location of injury not given). During a concurrent interview and record review, on 6/21/22 at 4:53 PM, with Director of Nursing (DON), Resident 4's Treatment Administration Record (TAR), dated 3/2022, 4/2022, 5/2022, and 6/2022 were reviewed. The TAR's indicated: Mar [March] 2022.Cleanse shearing to right elbow with normal saline, pat dry, apply Medhoney (decreases bacterial growth within the wound), cover with ABD [abdominal pad] dressing QD/PRN [everyday/as needed]. Apr [April] 2022.Cleanse Pressure injury to right elbow stage 2 with NSS [normal saline], pat dry apply med-honey gauze F/B [foam dressing]. Change daily and PRN if soiled or dislodged.Cleanse pressure injury to right elbow stage 3 with NSS, pat dry apply Santyl [ointment that removes dead tissue from wounds] oint. [ointment] calcium alginate [sic] [dressing used on draining wounds] cover with foam dressing. Change daily and PRN if soiled or dislodged. May 2022.Cleanse pressure injury to right elbow stage 3 with NSS, pat dry apply santyl oint. Calcium alginate [sic] cover with foam dressing. Change daily and PRN if soiled or dislodged.Cleanse pressure injury to right elbow stage 3 with NSS, pat dry apply santyl oint. Calcium alginate [sic] AG [silver] cover with foam dressing. Change daily and PRN (as needed) X 7 days (times seven days) if soiled or dislodged.Cleanse pressure injury to right elbow stage 3 with NSS, pat dry pack pressure injury with steril [sic] pack cover with ABD pad and apply transparent dressing, change daily and PRN if soiled or dislodged. Jun [June] 2022.Cleanse Pressure injury to right elbow stage 3 with NSS, pat dry pack pressure injury with steril [sic] pack cover with ABD pad and apply transparent dressing, change daily and PRN if soiled or dislodged. The TAR also indicated, there were no treatments done on 3/18/22, 3/19/22, 3/25/22, and 3/29/22, 4/1/22-4/10/22, 4/14/22, 4/18/22, 4/24/22, 5/2/22, 5/4/22, 5/7/22, 5/14/22, 5/15/22, 5/19/22, 5/30/22, 5/31/22, 6/1/22, 6/2/22, 6/4/22, 6/11/22-6/16/22, and 6/18/22. DON confirmed the findings and stated, the nurses were responsible to do their own treatments when the wound nurse was not available. DON stated, she would expect the wound/pressure injury to decline when treatments were not done. During a concurrent interview and record review on 6/21/22, at 4:53 PM, with DON, Resident 4's Weekly Skin Assessment Sheets (WSAS) were reviewed. There were no weekly assessments/measurements completed for the weeks of 3/27/22, 4/3/22, 4/10/22, 4/24/22, 6/5/22, 6/12, and 6/19/22. DON confirmed the findings and stated, a weekly skin assessment should have been completed by the treatment nurse each week. During a concurrent interview and record review, on 6/29/22 at 4:04 PM with Assistant Director of Nursing (ADON), Resident 4's Physician's Orders (PO), dated 6/1/22 and 6/17/22 were reviewed. The PO indicated, Resident 4 was ordered antibiotics for a wound infection to the right elbow on both dates. ADON confirmed an antibiotic was orderd for a wound infection to the right elbow During a review of the facility's policy and procedure (P&P) titled, Wound Care dated 10/2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.The following information should be recorded in the resident's medical record.The date and time the wound care was given.The name and title of the individual performing the wound care. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries dated 4/20, the P&P indicated, Monitoring.Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. 2a. During an interview on 5/2/22 at 12:48 PM, with Resident 1, Resident 1 stated, he was admitted with a wound vac [device consisting of a dressing which is fitted with a tube and attached to the wound vac providing negative pressure wound therapy. Commonly used with chronic wounds which are not responding to other forms of treatment] and required wound care. Resident 1 stated, when the treatment nurse [nurse assigned to do treatments only] was off, the medication nurses were responsible to do wound care and they did not know how to care for the wound vac or provide the wound care. During a review of Resident 1's Order Summary Report (OSR) dated 3/7/22, the OSR indicated, Wound Vac: Cleanse Stage 4 (a deep wound reaching the muscles, ligaments or bones) pressure injury (wound) to (Right buttock) with NS (Normal Saline), then apply black foam to wound bed and set Wound VAC Therapy at 125 mmgHg (millimeter of mercury-used to measure pressure) (sic) negative pressure on continuous mode. Change VAC dressing q (every) (Tues [Tuesday],Thurs [Thursday], Sat [Saturday]). Assess and evaluate during treatment for progress/worsening/treatment effectiveness and notify MD if treatment is ineffective PRN (as needed). every day shift every Tue, Thu, Sat. start date 1/24/22. During a concurrent interview and record review, on 6/17/22, at 1 PM, with Director of Nursing (DON), Resident 1's Treatment Administration Record (TAR), dated 3/2022 and 4/2022 were reviewed. The TAR's indicated, Wound Vac: Cleanse Stage 4 pressure injury to (Right buttock) with NS, then apply black foam to wound bed and set Wound VAC Therapy at 125mmgHg negative pressure on continuous mode. Change VAC dressing q (Tues,Thurs, Sat). Assess and evaluate during treatment for progress/worsening/treatment effectiveness and notify MD (medical doctor) if treatment is ineffective PRN (as needed),. every day shift every Tue, Thu, Sat. There were missing documentation on 3/17/22, 3/19/22, 4/9/22, 4/14/22, and 4/19/22. DON confirmed the findings and stated, the treatments were either not done or the nurses did not document them when they did them. DON stated, there was no way to know if the treatments were done. 2b. During a concurrent interview and record review, on 7/6/22 at 2:20 PM, with DON, the facility's TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 6: Resident 6 had an order in June 2022 to apply skin prep (medication) to intact blisters on the right elbow daily. DON confirmed Resident 6 ordered treatment was not provided on 6/1/22, 6/2/22, 6/4/22, 6/5/22, 6/11/22, 6/12/22, 6/18/22, and 6/25/22. Resident 6 had an order in June 2022 to clean left antecubital (inner elbow area wound) with normal saline (NS - medicated salt solution), apply xeroform (medicated dressing) and wrap with kerlix (dressing) daily. DON confirmed Resident 6 ordered treatment was not provided on 6/1/22, 6/2/22, 6/4/22, 6/5/22, 6/11/22, 6/12/22, 6/18/22, and 6/25/22. Resident 6 had an order in June 2022 to cleanse open blister on left knee with normal saline, pat dry, apply triple antibiotic ointment (medicated ointment) and cover with dry dressing every day and as needed. DON confirmed Resident 6 ordered treatment was not provided on 6/1/22, 6/2/22, 6/4/22, 6/5/22, 6/11/22, 6/12/22, 6/18/22, and 6/25/22. Resident 6 had an order in July 2022 to cleanse open blister to left knee with normal saline, pat dry, apply triple antibiotic, and cover with dry dressing every day and as needed. DON confirmed Resident 6 ordered treatment was not provided on 7/1/22 and 7/2/22. 2c. During a concurrent interview and record review, on 7/6/22 at 2:20 PM, with the DON, the facility TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 17: Resident 17 had an order in June 2022 to cleanse stage 1 pressure injury (intact skin caused by pressure that results in reddening of the skin that does not lighten when pressed upon over a bony prominence) to right buttocks with normal saline, pat dry, apply zinc oxide ointment (medication) and cover with foam dressing every day. DON confirmed Resident 17's ordered treatment was not provided on 6/24/22, 6/26/22, 6/29/22 and 6/30/22. Resident 17 had an order in July 2022 to cleanse stage 1 pressure injury to right buttocks with normal saline, pat dry, apply zinc oxide ointment and cover with foam dressing every day. DON confirmed Resident 17's ordered treatment was not provided on 7/2/22, 7/3/22, 7/8/22 and 7/10/22. 2d. During a concurrent interview and record review, on 7/6/22 at 2:20 PM, with DON, the facility's TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 18: Resident 18 had an order in June 2022 to cleanse stage 1 pressure injury/ulcer to third right toe with normal saline, pat dry, apply triple ABT ointment, cover with dry dressing every day. DON confirmed the finding and stated, Resident 18's ordered treatment was not provided on 6/4/22, 6/5/22, 6/6/22, 6/11/22, 6/13/22, 6/14/22, 6/15/22, 6/16/22, 6/17/22 and 6/19/22. Resident 18 had an order in June 2022 to apply wound vac to left toe area and change every third day. DON confirmed the finding and stated, Resident 18's ordered treatment was not provided on 6/2/22, 6/5/22 and 6/8/22. Resident 18 had an order in July 2022 to cleanse dorsal (area facing upward while standing) left foot (unidentified pressure injury) with normal saline, apply santyl (medication) to wound and cover with dry dressing every day. DON confirmed the finding and stated, Resident 18's ordered treatment was not provided on 7/14/22. Resident 18 had an order in July 2022 to cleanse left ankle (unidentified pressure injury) with normal saline, apply santyl and cover with clean dressing every day. DON confirmed the finding and stated, Resident 18's ordered treatment was not provided on 7/14/22. 2e. During a concurrent interview and record review, on 7/6/22 at 2:20 PM, with DON, the facility TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 20: Resident 20 had an order in June 2022 to cleanse left ischium (curved bone portion of the pelvis [unidentified pressure injury]) with normal saline, pat dry, apply calcium alginate, and dry dressing daily. DON confirmed the finding and stated, Resident 20's ordered treatment was not provided on 6/26/22 and 6/28/22. Resident 20 had an order in July 2022 to cleanse left ischium (curved bone portion of the pelvis [unidentified pressure injury]) with normal saline, pat dry, apply calcium alginate, and dry dressing daily. DON confirmed the finding and stated Resident 20's ordered treatment was not provided on 7/1/22 and 7/7/22. 2f. During a concurrent interview and record review, on 7/6/22 at 2:20 PM, with the DON, the facility's TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 21: Resident 21 had an order in June 2022 to Cleanse DTPI (deep tissue pressure injury - an injury caused by unrelieved pressure) to left heel with normal saline, pat dry, apply (skin prep or zinc oxide ointment ), cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 6/7/22, 6/11/22, 6/13/22, 6/16/22, 6/17/22, 6/19/22, 6/23/22, 6/25/22 and 6/26/22. Resident 21 had an order in June 2022 to cleanse DTPI to right ankle with normal saline, pat dry, apply (skin prep or zinc oxide ointment), and cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 6/7/22, 6/11/22, 6/13/22, 6/16/22, 6/17/22, 6/19/22, 6/23/22, 6/25/22 and 6/26/22. Resident 21 had an order in June 2022 to cleanse DTPI to right heel with normal saline, pat dry, apply (skin prep or zinc oxide ointment), and cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 6/7/22, 6/11/22, 6/13/22, 6/16/22, 6/17/22, 6/19/22, 6/23/22, 6/25/22 and 6/26/22. Resident 21 had an order in June 2022 to cleanse left buttock stage 2 pressure injury (a wound caused by pressure in which there is an opening in the skin) with normal saline, Pat dry, apply Med-Honey (medication) gauze and Foam dressing every day. DON confirmed Resident 21 did not get his ordered treatment on 6/4/22, 6/5/22, 6/7/22, 6/11/22, 6/13/22, 6/16/22, 6/17/22, 6/18/22, 6/19/22, 6/23/22, 6/25/22 and 6/26/22. Resident 21 had an order in June 2022 to cleanse stage 2 pressure injury to right sacrum (a triangular bone in the lower back) with normal saline, pat dry, apply Medi-honey gel and calcium alginate then cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 6/4/22, 6/5/22, 6/7/22, 6/11/22, 6/13/22, 6/16/22, 6/17/22, 6/18/22, 6/19/22, 6/23/22, 6/25/22 and 6/26/22. Resident 21 had an order in June 2022 to Cleanse stage 4 pressure injury (a wound caused by pressure that has caused extensive tissue damage, tissue death and may involve bone, tendons, and other supporting structures) to sacrum (triangular bone to the lower back) with normal saline, pat dry, apply Hydrogel (medication) or Santyl ointment and calcium alginate, then cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 6/7/22, 6/11/22, 6/13/22, 6/16/22, 6/17/22, 6/18/22, 6/19/22, 6/23/22, 6/25/22 and 6/26/22. Resident 21 had an order in July 2022 to cleanse blanchable (able to go away when press upon) redness to right foot (unidentified pressure injury), apply sure prep (medication) and cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 7/1/22, 7/4/22, 7/5/22, 7/8/22, 7/10/22, 7/11/22, 7/13/22, 7/16/22, 7/17/22, and 7/19/22. Resident 21 had an order in July 2022 to cleanse blanchable redness to left foot (unidentified pressure injury), apply sure prep and cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 7/1/22, 7/4/22, 7/5/22, 7/7/22, 7/8/22, 7/10/22, 7/11/22, 7/13/22, 7/16/22, 7/17/22,7/19/22, 7/23/22, 7/25/22, and 7/26/22. Resident 21 had an order in July 2022 to cleanse closed filled blister on left inner heel (unidentified pressure injury) with normal saline, pat dry, apply Sure prep, and cover with dry dressing every day. DON confirmed the fiding and stated, Resident 21's ordered treatment was not provided on 7/1/22, 7/4/22, 7/5/22, 7/7/22, 7/8/22, 7/10/22, 7/11/22, 7/13/22, 7/16/22, 7/17/22, and 7/19/22. Resident 21 had an order in July 2022 to Cleanse DTPI to left heel with normal saline, pat dry, apply (skin prep or zinc oxide ointment), cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 7/1/22, 7/8/22, and 7/10/22. Resident 21 had an order in July 2022 to cleanse DTPI to right heel with normal saline, pat dry, apply (skin prep or zinc oxide ointment), and cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 7/1/22, 7/8/22 and 7/10/22. Resident 21 had an order in July 2022 to cleanse left buttock stage 2 pressure injury with normal saline, pat dry, apply Med-Honey gauze and Foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 7/1/22, 7/8/22 and 7/10/22. Resident 21 had an order in July 2022 to cleanse stage 4 pressure injury to sacrum with normal saline, pat dry, apply Hydrogel or Santyl ointment and calcium alginate, then cover with foam dressing every day. DON confirmed the finding and stated, Resident 21's ordered treatment was not provided on 7/1/22, 7/8/22 and 7/10/22. 2g. During a concurrent interview and record review, on 7/6/22 at 2;20 PM, with DON, the facility's TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 22: Resident 22 had an order in June 2022 to cleanse stage 2 wound (pressure injury) to upper mid back with normal saline, pat dry, apply med honey, apply calcium alginate and cover foam dressing every day. DON confirmed the finding and stated, Resident 22's ordered treatment was not provided on 6/3/22, 6/4/22, 6/5/22, 6/11/22, 6/13/22, 6/15/22, 6/16/22, 6/17/22, 6/19/22, 6/23/22, 6/24/22, and 6/26/22. 2h. During a concurrent interview and record review on 7/6/22, at 2:20 PM, with DON, the facility's TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 24: Resident 24 had an order in June 2022 to cleanse open area to coccyx (area above buttock [unidentified stage]) with normal saline, pat dry, apply Medi-honey, and cover with foam dressing every day. DON confirmed the finding and stated, Resident 24's ordered treatment was not provided on 6/1/22, 6/2/22, 6/3/22, 6/4/22, 6/5/22, 6/6/22, 6/11/22, 6/14/22, 6/15/22, 6/16/22, 6/17/22, 6/18/22, 6/19/22 and 6/30/22. Resident 24 had an order in June 2022 to cleanse stage 2 pressure injury to right inner ankle with normal saline, pat dry, apply Medi-honey, and then cover with dry dressing every day. DON confirmed the finding and stated, Resident 24's ordered treatment was not provided on 6/1/22, 6/2/22, 6/3/22, 6/4/22, 6/5/22, 6/6/22 and 6/8/22. Resident 24 had an order in June 2022 to cleanse pressure ulcer (unidentified stage of pressure ulcer) to scrotum with normal saline, pat dry, apply med-honey and cover with foam dressing every other day. DON confirmed the finding and stated, Resident 24's ordered treatment was not provided on 6/2/22, 6/4/22, 6/6/22, 6/14/22, 6/16/22, 6/18/22 and 6/30/22. Resident 24 had an order in July 2022 to cleanse open area to coccyx (area above buttock [unidentified stage of pressure injury]) with normal saline, pat dry, apply Medi-honey, and cover with foam dressing every day. DON confirmed the finding and stated, Resident 24's ordered treatment was not provided on 7/3/22 and 7/9/22. 2i. During a concurrent interview and record review, on 7/6/22 at 2:20 PM, with the DON, the facility's TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 28: Resident 28 had an order in July 2022 to cleanse open area to left buttock (unidentified stage of pressure injury) with normal saline, pat dry, apply triple antibiotic ointment, cover with dry dressing until assessed every day. DON confirmed the finding and stated, Resident 28's ordered treatment was not provided on 7/9/22. 2j. During a concurrent interview and record review, on 7/6/22 at 2:20 PM, with DON, the facility's TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 30: Resident 30 had an order in June 2022 to cleanse left buttock wound (unidentified pressure injury) normal saline, pat dry, apply med-honey and cover with a foam dressing every other day. DON confirmed the finding and stated, Resident 30's ordered treatment was not provided on 6/2/22, 6/6/22, 6/12/22, 6/14/22, 6/16/22, 6/18/22, 6/22/22, 6/24/22 and 6/30/22. Resident 30 had an order in June 2022 to cleanse right buttock wound (unidentified pressure injury) with normal saline, pat dry, apply med-honey and cover with foam dressing every other day. DON confirmed the finding and stated, Resident 30's ordered treatment was not provided on 6/2/22, 6/6/22, 6/12/22, 6/14/22, 6/16/22, 6/18/22, 6/22/22, 6/24/22 and 6/30/22. Resident 30 had an order in June 2022 to apply santyl ointment to right buttocks (unidentified pressure injury) topically every day shift for stage 3 pressure injury (wound that has gone through the second layer of the skin into the fat tissue) cleanse with normal saline, pat dry, apply santyl to slough (thin white/yellow layer in a wound) area and Medi-honey gauze to granulated area, then cover entire wound bed with Xeroform dressing, and cover with foam dressing then secure with transparent dressing. Change every day. DON confirmed the finding and stated, Resident 30's ordered treatment was not provided on 6/1/22, 6/2/22, 6/3/22, 6/4/22, 6/5/22, 6/6/22, 6/12/22, 6/14/22, 6/15/22, 6/16/22, 6/22/22, 6/23/22, 6/24/22 and 6/30/22. Resident 30 had an order in July 2022 to cleanse left buttock wound (unidentified pressure injury) normal saline, pat dry, apply med-honey and cover with a foam dressing every other day. DON confirmed the finding and stated, Resident 30's ordered treatment was not provided on 7/6/22. Resident 30 had an order in July 2022 to cleanse right buttock wound (unidentified pressure injury) with normal saline, pat dry, apply med-honey and cover with foam dressing every other day. DON confirmed the finding ans stated, Resident 30's ordered treatment was not provided on 7/6/22. Resident 30 had an order in July 2022 to apply santyl ointment to right buttocks (unidentified pressure injury) topically every day shift for stage 3 pressure injury (wound that has gone through the second layer of the skin into the fat tissue) cleanse with normal saline, pat dry, apply santyl to slough (thin white/yellow layer in a wound) area and Medi-honey gauze to granulated area, then cover entire wound bed with Xeroform dressing, and cover with foam dressing then secure with transparent dressing. Change every day. DON confirmed the finding and stated, Resident 30's ordered treatment was not provided on 7/6/22, 7/7/22 and 7/17/22. 2k. During a concurrent interview and record review, on 7/6/22 at 2:20 PM, with DON, the facility's TAR, dated June 2022 and July 2022 were reviewed. The TAR indicated the following for Resident 31: Resident 31 had an order in June 2022 to cleanse unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic [dead] tissue or by an eschar [dead tissue]) to left lateral (side) ankle with normal saline, pat dry, apply iodine (medication) solution or Santyl ointment and calcium alginate, and cover with dry or foam dressing every day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 6/6/22, 6/11/22, 6/12/22, 6/13/22, 6/14/22, 6/15/22, 6/16/22, 6/17/22, 6/23/22, 6/25/22 and 6/26/22. Resident 31 had an order in June 2022 to cleanse unstageable pressure injury to left posterior (back) heel with normal saline, pat dry, apply iodine solution or Santyl ointment and calcium alginate, and cover with dry or foam dressing every day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 6/6/22, 6/11/22, 6/12/22, 6/13/22, 6/14/22, 6/15/22, 6/16/22, 6/17/22, 6/23/22, 6/25/22 and 6/26/22. Resident 31 had an order in June 2022 to cleanse unstageable pressure injury to top of right foot with normal saline, pat dry, apply iodine solution or Santyl ointment and calcium alginate, and cover with dry or foam dressing every day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 6/6/22, 6/11/22, 6/12/22, 6/13/22, 6/14/22, 6/15/22, 6/16/22, 6/17/22, 6/23/22, 6/25/22 and 6/26/22. Resident 31 had an order in June 2022 to cleanse left dorsal (top of foot) (unidentified pressure injury) with normal saline and pat dry. Apply skin prep and let dry. Apply thin layer of Thera honey (medication) and fill with aquacel (type of dressing with medication) and then cover with Mediplex (type of dressing) every third day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 6/6/22, 6/12/22, 6/15/22, and 6/24/22. Resident 31 had an order in June 2022 to cleanse left lateral foot (unidentified pressure injury) with normal saline and pat dry. Paint (cover) peri-wound (tissue surrounding a wound) with skin prep and allow to dry. Apply Thera honey, cover with small piece of aquacel to fill the wound then cover with Mediplex dressing every third day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 6/6/22, 6/12/22, 6/15/22, and 6/24/22. Resident 31 had an order in June 2022 to cleanse right dorsal foot (unidentified pressure injury) with normal saline and pat dry. Paint with skin prep and let dry. Apply Thera honey, cover with small piece of aquacel to fill the wound then cover with Mediplex dressing every third day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 6/6/22, 6/12/22, 6/15/22, and 6/24/22. Resident 31 had an order in June 2022 to cleanse right first toe (unidentified pressure injury) with normal saline then pat dry. Apply skin prep and let dry. Apply thin layer of Thera honey and aquacel to fill in wound (not identified). Cover with Mediplex dressing every third day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 6/6/22, 6/12/22, 6/15/22, and 6/24/22. Resident 31 had an order in June 2022 to cleanse right lateral foot (unidentified pressure injury) with normal saline and pat dry. Paint with skin prep and let dry. Apply thin layer of Thera honey and cover with small piece of aquacel then cover with Mediplex dressing every third day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 6/6/22, 6/12/22, 6/15/22, and 6/24/22. Resident 31 had an order in June 2022 to cleanse right lateral heel (unidentified pressure injury) with normal saline and pat dry. Paint area with skin prep and allow to dry. Apply thin layer of Thera honey and cover with aquacel. Apply Mediplex dressing every third day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 6/6/22, 6/12/22, 6/15/22, and 6/24/22. Resident 31 had an order in July 2022 to cleanse unstageable to left lateral ankle with normal saline, pat dry, apply iodine solution or Santyl ointment and calcium alginate, and cover with dry or foam dressing every day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 7/2/22 and 7/9/22. Resident 31 had an order in June 2022 to cleanse unstageable pressure injury to left posterior (back) heel with normal saline, pat dry, apply iodine solution or Santyl ointment and calcium alginate, and cover with dry or foam dressing every day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 7/2/22 and 7/9/22. Resident 31 had an order in June 2022 to cleanse unstageable pressure injury to top of right foot with normal saline, pat dry, apply iodine solution or Santyl ointment and calcium alginate, and cover with dry or foam dressing every day. DON confirmed Resident 31 did not get his ordered treatment on 7/2/22 and 7/9/22. Resident 31 had an order in July 2022 to cleanse left dorsal foot (unidentified pressure injury) with normal saline and pat dry. Apply skin prep and let dry. Apply thin layer of Thera honey and fill with aquacel then cover with Mediplex every third day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 7/9/22. Resident 31 had an order in July 2022 to cleanse left lateral foot (unidentified pressure injury) with normal saline and pat dry. Paint peri-wound with skin prep and allow to dry. Apply Thera honey, cover with small piece of aquacel to fill the wound then cover with Mediplex dressing every third day. DON confirmed the finding and stated, Resident 31's ordered treatment was not provided on 7/9/22. Resident 31 had an order in July 2022 to

Based on observation, interview, and record review, the facility failed to maintain a clean, safe, and sanitary kitchen for 126 out of 133 residents' receiving meals when: 1. One of one live cockroaches (roaches - small insects that cause spread of bacterial infection) and two of two of two dead cockroaches were observed in the kitchen during daylight (11:53 AM) and while the kitchen was being operated. 2. A black and green substance approximately 56 and 1/2 X 42 X 11 and 1/4 inches (length by width by height) was observed in one of one produce refrigerators above the food items ready to be served for residents consumption and empty plates ready to be used to serve residents' food. 3. Resident lunch food temperatures were not taken prior to being served for resident consumption. 4. Kitchen was not kept clean and maintained in good repair (tile, food prep station, storage containers, water filters, coffee dispensing area, oven doors, burners, produce refrigerater, dry storage area, freezer, kitchen sink area, knive pep station, kitchen carts). 5. Food preparation for one of one resident sandwiches (non specific resident) in the kitchen was not done in a sanitary manner. 6. Food items (in dry storage, facility freezer, produce refrigerator, and main kitchen area) were not labeled, dated, or thrown out per facility SANITATION AND INFECTION CONTROL, policy and procedure. 7. Infection Control Nurse (ICN) did not make observational rounds of the kitchen environment to ensure sanitation and cleaning processes were being done to prevent the spread of foodborne illness. 8. Facility leadership (Administrator, Certified Dietary Manager [CDM] and Kitchen Supervisor [KS]) did not promptly address the monthly issues/concerns (regarding cleaning and sanitation) in the kitchen reported by the Registered Dietician (RD) from March 2022 to August 2022. These failures had the potential to result in bacterial or physical contamination of residents' food which may lead to food borne illnesses further compromising the medical status of 126 highly susceptible residents' receiving meals in a facility census of 133. According to the FDA (Food and Drug Administration) Food Code 2017, A Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised (immune system's defenses are low, affecting its ability to fight off infections and diseases);.or older adults; and (2) Obtaining food at a facility that provides services such as.health care. On 9/7/22 at 5:19 PM, an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has cause, or it is likely to cause, serious injury, harm, impairment, or death to a resident) under Federal tag 812 was declared with the Administrator, Director of Nursing (DON), Kitchen Supervisor (KS), and Registered Dietician (RD) regarding the following identified concerns: 1. Live and dead cockroaches were observed during food service. 2. A black and green substance identified as mold (a toxic mold that may cause health issues in humans) and mildew (a discoloration caused by fungi) by Maintenance Director (MD) was found in the produce refrigerator above food items ready to be served to the residents. 3. Food temperatures were not taken prior to food service. 4. Kitchen was not kept clean and maintained in good repair . 5. Food preparation was not done in a sanitary manner. 6. Food items were not labeled, dated, or thrown out per policy and procedure. 7. Infection Control Nurse did not make observational rounds of the kitchen environment to ensure sanitation and cleaning processes were being done to prevent the spread of foodborne illness. 8. Facility leadership did not promptly address the monthly issues/concerns in the kitchen reported by the Registered Dietician (RD). On 9/8/22 at 5:09 PM, the California Department of Public Health (CDPH) notified the Administrator, DON, Administrative Consultant 1, Administrative Consultant 2, and Quality Control Nurse, the IJ was abated after verifying and confirming on-site the facility had implemented the acceptable written plan of correction that addressed the following: The pests control company was contacted and scheduled to make a visit on 9/8/22. The black and green substance identified as mold/mildew in the produce refrigerator was removed and cleaned on 9/8/22. Kitchen staff were in-serviced on taking food temperatures prior to food service on 9/7/22. A thorough and deep cleaning of the kitchen was completed on 9/8/22 and cracked tiles were repaired on 9/8/22. Kitchen staff were in-serviced on safe food handling on 9/7/22. Refrigerators and freezers were inspected, and any unlabeled/undated foods items were discarded and replaced on 9/8/22. Infection Control Nurse will conduct routine kitchen observation and Facility leadership will follow-up on the RD's recommendation. Findings: 1. During a concurrent observation and interview on 9/7/22, starting at 11:53 AM, with Dietary Aide (DA) 2, in the kitchen, during lunch food service, there was a live cockroach approximately one inch by one inch (1 X 1 length by width) in size crawling around the coffee dispensing station of the kitchen. DA 2 stated, It's a cockroach and I will notify the management immediately. During a concurrent observation and interview on 9/7/22, at 12:50 PM, with Kitchen Supervisor (KS), a dead 2 X 2 inches cockroach was noted in front of the ice machine, close to the food preparation tables, amongst grime, food remnants and trash on the floor. There was also a dead 2 X 2 inches cockroach under the sink by the food preparation table amongst grime, food remnants, and trash on the floor. KS stated he would have the pest control contacted. During a review of the facility ' s policy and procedure (P&P) titled, PEST CONTROL, dated 4/2008, the P&P indicated, Our facility shall maintain an effective pest control program.Garbage and trash are not permitted to accumulate and are removed from the facility daily. 2. During an observation on 9/7/22, starting at 11:53 AM, in the kitchen, a double wall entry door into the kitchen produce refrigerator was observed with a greenish black substance wet looking type of growth covering an approximately 56 1/2 X 42 X 11 1/4 inches. This growth was noted above empty plates and food prepped and ready to be served to residents. These item were salads, cheeses, condiments, and vegetables that were observed being pulled by kitchen staff and placed onto resident lunch trays. During an interview on 9/7/22, at 12:50 PM, with KS, during lunch service, KS stated he would have produce refrigerator cleaned. During a concurrent observation and interview on 9/7/22, at 2:48 PM, with Maintenance Director (MD), in the kitchen, MD stated the black and green substance growth found in the produce refrigerator were black mold (a toxic mold that may cause health issues in humans) and mildew (a discoloration caused by fungi). MD stated the black mold and mildew can cause illness for people that are exposed to it by breathing it in or if it is on their food. During a concurrent observation and interview on 9/7/22, at 3:38 PM, with Registered Dietician (RD), in the kitchen, RD stated, The black mold found in the produce refrigerator could drop on the plates or containers of food stored for residents' consumption and can potentially cause residents' illness. During a review of the facility ' s policy and procedure (P&P) titled, Refrigerators and Freezers, dated 12/2014, the P&P indicated, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines.Refrigerators and freezers will be kept clean, free of debris. 3. During a concurrent observation and interview on 9/7/22, at 11:45 AM, with DA 1, in the kitchen, DA 1 was observed beginning to serve residents' their lunch meal from the steam tables. On the steam tables were stuffed peppers, carrots, and corn. These food items were prepared in a pureed texture and regular texture. On top of the kitchen stove was appeared to be pizza, a type of brown gravy, chicken patties, and chicken noodle soup. DA 1 stated she did not take the food temperatures yet, but I will take it [food temperatures] immediately. DA 1 reached for a white binder and documented the lunch meal temperatures. The breakfast meal portion for 9/7/22, was observed to be empty when DA 1 was documenting the food temperatures for lunch (9/7/22). During a concurrent interview and record review on 9/7/22, at 4:07 PM, with Kitchen Supervisor (KS), the Facility Food Temperature Logs (FFTL), dated September and August 2022, were reviewed. KS reviewed the FFTL and stated it was confusing to understand the entries since there were no dates indicating when the food temperatures were taken. KS stated there were multiple entries missing for the month of August and September 2022, but could not tell when the exact date was or if the meal documented was what was served. KS stated the food temperatures should be reviewed consistently to ensure it was being done. KS stated he would need to create a simplified FFTL. During a review of the facility policy and procedure (P&P) titled FOOD PREPARATION, dated 2018, the P&P indicated, Employees will prepare food in a clean and safe manner to protect residents/patients and staff from foodborne illness. Employees will prepare foods by methods that conserve nutrients, enhance flavor, and maintain attractive appearance.Prepared food will be stored at proper temperature until serving time.Hot foods at [equal to or greater than] 140 [degrees Fahrenheit].Cold foods at [equal to or less than] 41 [degrees Fahrenheit]. 4A. During an observation on 9/7/22, starting at 11:53 AM, in the kitchen, the following were observed during lunch food service: a. On a food preparation station (approximately four steps from where steam tables containing residents' food for lunch was being served), there were two approximately 4 X 4 inches metal type boxes. One box secured two electrical outlets and the other covered the wires to the outlets. The boxes were covered with thick brown, black, and dark yellow sticky substances with food remnants throughout. To the left side of the boxes was a large AT - Express toaster oven that was covered from top to bottom and inside with dark brown, black, yellow, and white sticky material. b. A plastic 3 drawer storage container covered on the outside with old food remnants was noted on the preparation table next to the ovens. Inside of each drawer were various food scoops (drawer 1 had three scoops, drawer 2 had seven scoops, and drawer 3 had nine scoops) prepped and ready to be used to dispense residents' food. Inside each drawer were scattered remnants of old food and debris. c. Floor of the kitchen most notably by the coffee dispensing area, ice machine, water filters, ovens, steam tables, freezer, refrigerators, kitchen sink, and food preparation areas, were noted with thick amounts of dark brown and black grime (built up dirt), trash and food particle residue. d. Water filters entering into the ice machine were covered in thick dust, debris, and black grime. e. Kitchen cart where the facility staff places clean trays for food to be served was noted with thick amounts of grime and debris. f. Four oven burners were noted with thick build-up amounts of dark black substance, food debris, grease, and soot (residue), approximately half an inch thick. g. Two oven doors below the burners were covered in food debris and grease. The door handles were slippery to touch and extremely sticky. During an interview on 9/7/22, at 12:50 PM, with KS, KS stated he would clean up the food prep station, storage containeres, kitchen floor, water filters, kitchen carts, oven burners and oven doors. During a concurrent observation and interview on 9/7/22, at 3:03 PM, with KS, in the kitchen, the following were observed in the meat/vegetable walk-in freezer. Large amounts of foods were present throughout the floor of the walk-in freezer for an unknown amount of time. There were large amounts of debris and food particles littered around the entirety of the floor (Approximately nine feet in length and 3 feet in width). A frozen dirty glove noted on the floor next to the residents' food containers. KS stated he would have the area cleaned. During a concurrent observation and interview on 9/7/22, at 3:38 PM, with RD, in the kitchen, there were 10 enclosed kitchen carts ready to be used by kitchen staff for sending out food to residents. Seven out of the 10 kitchen carts were noted to have slippery to sticky yellow to light brown residue on the inside walls and floor. Seven out of 10 carts contained old remnants of food debris. RD stated the food carts needed to be wiped down and cleaned better. RD stated if the kitchen carts were not wiped down better, then food-borne illness can occur causing upset stomach or loose bowel movements to the residents. During a concurrent interview and record review on 9/7/22, at 4:07 PM, with KS, the kitchen cleaning log (a log that details assigned cleaning objectives for kitchen staff - sweeping, mopping, sanitizing) for the month of September 2022, was reviewed. KS stated he ensured the kitchen was cleaned by providing in-services to the kitchen staff and making sure the cleaning log is signed off. KS stated there were missing entries throughout the log that indicated the kitchen had not been cleaned per expectation (did not specify what his expectation was). KS stated he could not locate any cleaning log prior to 7/17/22. KS stated the kitchen is not cleaned to his standards. KS stated it is all kitchen staffs' job to ensure the kitchen was cleaned. KS stated he last did observations of the kitchen cleanliness last week. During a concurrent interview and record review on 9/7/22, at 5 PM, with Dietary Aide (DA) 4, the kitchen's cleaning log (a log that details assigned cleaning objectives for kitchen staff - sweeping, mopping, sanitizing) for September 2022, was reviewed. DA 4 stated, I cleaned the walk-in freezer in the dishwashing area on Saturday (9/3/22). DA 4 stated she organized the boxes in the freezer but did not sweep it. DA 4 stated she did not sweep the freezer floor yesterday (9/6/22) or Monday (9/5/22). DA 4 was asked if there had been food debris or dirty gloves on the floor when she cleaned it. DA 4 stated she was not sure. DA 4 stated she had worked in the facility for three months. DA 4 stated no one had ever told her how to clean the walk-in freezer or her specific chores or checked her work. During a concurrent interview and record review on 9/8/22, at 1:30 PM, with KS, facility Kitchen in-services, were reviewed. KS stated he taught an in-service class on 4/11/22, titled, Maintaining a sanitary food storage, cleaning food debris off dry ingredients storage. On 7/22/22, another in-service titled, New Cleaning Schedule, was conducted by KS. KS stated, I did not specify cleaning solution [how to prepare and what type to use] or sanitizer to be used. During a concurrent interview and record review on 9/8/22, at 1:50 PM, with KS, the Kitchen Cleaning Log dated 8/13-20/22, 9/2-3/22, 9/4-10/22 were reviewed. Each log had one calendar week with job title responsible to do specific cleaning of 40 chores. Thirty-six chores were listed to be cleaned daily and four were weekly. Some of the specific chores nighttime sweeping & mopping, [cleaning] walk -in freezer, walk in Fridge (both) Food Carts. KS stated there were entire days of no cleaning documented by kitchen staff during the above dated logs. KS stated there were no days when all 40 chores were documented as done during the above dated logs. KS stated, Sometimes I review the logs, maybe ten percent of the time. During an interview on 9/8/22, at 3:15 PM, with DA 5, DA 5 stated, I have worked here one and a half years. Whoever worked with me taught me how to clean the kitchen carts [did not identify who]. Normally, I just wipe them down after dinner with a rag. If there is a really bad stain, I fill the bucket with water and put in about a half a teaspoon [pause in speaking] a teaspoon [pause in speaking] two tablespoons of bleach. DA 5 was asked specifically how much bleach was added to the bucket of water. DA 5 stated, A teaspoon. No supervisor has ever taught me how to clean. During an interview on 9/8/22, at 3:22 PM, with DA 6, DA 6 stated, To deep clean food carts, use the pressure washer outside in the patio. I ' ve never done that. I routinely clean food carts using a disinfectant spray, Redi San RTU Hard Surface Sanitizer [a type of cleaner], after each meal. I learned how to clean at my previous job, nobody here taught me. During a review of the facility ' s policy and procedure (P&P) titled, Cleaning Schedules, dated 3/2018, the P&P indicated, Employees will initial on the schedule when designated tasks are completed.All staff will be trained to use the cleaning schedules/procedures during orientation and follow up with in-services as needed.Cleaning procedures should specify products to be used.Cleaning solutions must be used in the proper concentration and dilution.The Registered Dietitian will check the cleanliness of the kitchen and dining area.and make recommendations to the facility as needed to maintain a sanitary environment.The Director of Food and Nutrition Services [Kitchen Supervisor] should routinely check cleaning schedules and cleanliness of the kitchen using the Food Service Evaluation Checklist. 4B. During a concurrent observation and interview on 9/7/22, at 2:48 PM, with Maintenance Director (MD), a walk through in the kitchen was conducted and the following findings were verified by MD: a. Floor by the coffee machines had a 48 X 15 inches area of missing/cracked floor tiles. The exposed area had thick brown to black grime with food remnants. b. The middle door entry into the kitchen had a 12 X 3 and 1/2 inches area of missing/cracked floor tiles. The exposed area had thick brown to black grime with food remnants. c. Under the kitchen steamer was a 36 X 24 inches area of missing/cracked floor tiles. The exposed area had thick brown to black grime with food remnants. d. In front of the produce refrigerator was a 24 X 12 inches area of missing/cracked floor tiles. The exposed area had thick brown to black grime with food remnants. e. In the drainage area next to the ice machine was an area covered in moisture and water amongst missing/cracked floor tiles 12 X 12 inches in size. The exposed area had thick brown to black grime with food remnants. f. In the dry food storage were two areas of missing/cracked floor tile. One measuring 12 X 12 inches and the other was a 24 X 6 inches. The exposed area had a thick brown to black grime with food remnants. g. The baseboard covering the dairy walk-in refrigerator measuring 47 inches long was noted to be brittle, extremely cracked and contained (inside the areas it was exposed) black/brown thick amounts of sticky grime. Remnants of food particles and trash were noted inside the open baseboard. h. The kitchen handwashing station had a piece of broken wall located where the soap dispenser was and below the sink. i. The area of the kitchen where clean knives for preparing food were stored on the wall by a metal magnetic strip, was a 2 X 2 inches hole in the wall. In the hole was built up grime, dirt, and possible food remnants (could not be identified by dietary staff what it was). The Maintenance Director (MD) stated the observations made identified areas in need of repair in the kitchen and he would work on them. During a review of the facility ' s policy and procedure (P&P) titled, Sanitization, dated 10/2008, the P&P indicated, The food service area shall be maintained in a clean and sanitary manner.All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. 5. During a concurrent observation and interview on 9/7/22, at 3:20 PM, with Dietary Aide (DA) 7, in the kitchen, DA 7 was observed preparing sandwiches with deli meat wearing gloves. DA 7 left the preparation area (wearing the gloves used to prepare the sandwiches), returned a few minutes later pushing a cart and resumed making sandwiches with the same gloves on. DA 7 did not change his gloves or wash his hands prior to making sandwiches again. DA 7 stated there were no classes provided at this facility regarding washing his hands and changing gloves (he had worked at the facility for three months). DA 7 stated he had fast food experience prior to working here and felt comfortable with his knowledge of hand hygiene. During a review of the facility policy and procedure titled, FOOD PREPARATION, undated, the P&P indicated, Employees will prepare food in a clean and safe manner to protect residents/patients and staff from foodborne illness.Hands should be properly washed prior to food preparation.Plastic gloves should be worn to avoid direct contact with food, i.e., handling ground beef, mixing salads, ready-to-eat foods, etc. Hands must be washed prior to putting on gloves and any glove changes. 6. During a concurrent observation and interview on 9/7/22, starting at 11:53 AM, with KS, in the kitchen, the following were observed during lunch food service: a. A large clear bag with an assortment of nuts and dried fruits was noted close to a food preparation table. The bag did not have a label, a date, or time indicating how long it had been there. KS stated the bag of nuts and dried fruits probably belonged to staff. b. One gallon of Canola Oil was noted placed to the side of the oven ranges. The Canola Oil was half full but did not have an open date marked. c. There was a 22-quart (a unit of measurement) container of brown rice that was less than half full. The container had no date listed when the brown rice was placed into the container. KS verified the findings and stated he would remove the unlabeled and undated food items. During a concurrent observation and interview on 9/7/22, at 2:35 PM, with the Registered Dietician (RD), in the kitchen ' s walk-in produce refrigerator. There were eight peeled, hard-boiled eggs in a clear bag. RD stated there was no date on the bag when the eggs became hard boiled or put into the refrigerator. There was a plastic bin containing sandwiches already made, estimated as, 20 sandwiches by RD. RD stated, They are not individually dated, but they are all in a dated container. It could be confusing regarding date made if the sandwich is removed from the container. During a concurrent observation and interview on 9/7/22, at 3:03 PM, with KS, in the kitchen, the following items were noted in the meat/vegetable walk-in freezer in open clear plastic bags with no identifying label or date: a. 10-ounce (a unit of measurement) packet of fish fillets. b. 5 beyond breakfast sausages. c. 3 chicken patties in a plastic bag. d. Chicken breast strips 22-ounce package. e. 2 more chicken patties in a plastic bag. f. Bag of 16 hashbrowns. KS verified the findings and stated the food items should have been labeled and dated. During a concurrent observation and interview on 9/8/22, at 1:15 PM, in the dry storage area, with the Administrator Consultant (AC) 1, two Glucerna (liquid protein nutrition) containers (eight ounces) were noted to be outdated as of April 2022. AC 1 confirmed the findings. During a review of the facility ' s policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, undated, the P&P indicated, All the perishable food items purchased by the department of food and dining services will be stored properly.All Open food Items will have an open date and use-by-date per manufacturer's guidelines. Leftover food or unused portions of packaged foods should be covered, labeled and dated to assure they will be used first. 7. During an interview on 9/8/22, at 1:26 PM, with Infection Control Nurse (ICN - a nurse designated in the facility to help prevent infection), ICN stated the largest area in the facility for potential of widespread infection is the kitchen. ICN stated when she goes into the kitchen [randomly and with no routine] she just, pops her head in and does not really look at things. ICN stated, I don ' t go searching for stuff when I ' m in there (kitchen). ICN stated she thought the kitchen supervisor and staff were attending to the kitchen ' s sanitation and cleaning needs therefore she did not have to look at it. ICN stated in consideration of what was found she had concerns with the kitchen from an infection control standpoint. ICN stated some of her concerns included pests/bugs laying eggs in resident food, mold falling on resident food, and these issues causing residents to have nausea, vomiting and loose bowel movement. During a review of the facility's Job Description titled, Job Description: Infection Control Coordinator Department: Nursing, undated, the Job Description indicated, The primary purpose of your job is to plan, organize, develop, coordinate, and direct our infection control program and its activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such programs.Develop and maintain a good working rapport with all department directors and personnel to ensure that infection control services and activities can be properly maintained to meet the needs of the residents. 8. During an interview on 9/7/22, at 2:35 PM, with the RD, RD stated, I work 24 hours a week. I have not done any formal In-service classes in the eight months I ' ve worked here. I do a monthly report regarding issues I have found or noticed. I send these reports to the Administrator and the Kitchen Supervisor [KS]. During a review of the facility ' s Quality Assessment for Performance Improvement [RD reports], the following was noted as reported by the RD: a. Quality Assessment for Performance Improvement dated 3/15/22 indicated - Problem General cleaning issues (microwave, toaster, coffee maker outside, fan to outside window, range vents dirty, plate warmer outside dirty, outside of dish machine). Action Steps Brought to the attention of the staff and Dietary manager. Manager to conduct Inservice. Date To Be Done By Next Review Problem Cooling logs steps could not be explained without assistance Action Steps Educated steps on the spot and will conduct Inservice [in-service] on cooling log before the end of the month. Date to be Done By Before Next Review Garbage disposal under produce sink is leaking Maintenance has been made aware. Date To Be Done By next week. Problem 2 Compartment sink washing method, staff uncertain of facility policy Action Steps Dietary management made aware and Inservice will be completed before the end of the month. Date To Be Done By Before Next Review.Sanitation Problem 1. All food is dated and labeled with received, open and use by dates. Not met. Kitchen Area 1. Work areas are clean and organized? Not Met General cleaning needed 6. Shelves, floors, walls and ceilings are clean? Not Met Walls, & upright surfaces were dirty . Dish machine area clean and organized: Not Met Wet area, machine outside in need of cleaning. 5. 3-compartment sink used properly/2- Compartment Sink used properly Not Met Kitchen in need of firm policy on 2 sink method so staff can adequately explain. During a review of the facility ' s Quality Assessment for Performance Improvement [RD reports], the following was noted as reported by the RD: a. Quality Assessment for Performance Improvement dated 3/15/22 indicated - Problem General cleaning issues (microwave, toaster, coffee maker outside, fan to outside window, range vents dirty, plate warmer outside dirty, outside of dish machine). Action Steps Brought to the attention of the staff and Dietary manager. Manager to conduct Inservice. Date To Be Done By Next Review Problem Cooling logs steps could not be explained without assistance Action Steps Educated steps on the spot and will conduct Inservice on cooling log before the end of the month. Date to be Done By Before Next Review Garbage disposal under produce sink is leaking Maintenance has been made aware. Date To Be Done By next week. Problem 2 Compartment sink washing method, staff uncertain of facility policy Action Steps Dietary management made aware and Inservice will be completed before the end of the month. Date To Be Done By Before Next Review.Sanitation Problem 1. All food is dated and labeled with received, open and use by dates. Not met. Kitchen Area 1. Work areas are clean and organized? Not Met General cleaning needed 6. Shelves, floors, walls and ceilings are clean? Not Met Walls, & upright surfaces were dirty.Dish machine area clean and organized: Not Met Wet area, machine outside in need of cleaning. 5. 3-compartment sink used properly/2- Compartment Sink used properly Not Met Kitchen in need of firm policy on 2 sink method so staff can adequately explain. b. Quality Assessment for Performance Improvement dated 5/9/22 indicated - Summary and Recommendations:.General cleaning of appliances still a need, & [refrigerated food] items still in need of dates, labels, & receive by dates. Action Steps Brought to the attention of the staff and Dietary manager. Manager to conduct Inservice. Will update cleaning schedule sheet.Cold temperatures not taken before start of tray line Action steps Dietary manager made aware. Will reeducate staff. Problem Steam table 1 segment not working Sanitation 1. All food is dated and labeled with received, open and use by dates. Not Met 3. Thermometers are present. Monitored and recorded properly Not Met Comment Incomplete log 6. Raw meat is stored properly in the refrigerator: Not Met Bacon on top of milk cartons Kitchen Area 1. Work areas are clean and organized: Not Met Comments General cleaning needed, Drain blockage disabling garbage disposal & dish machine. 6. Shelves, floors, walls and ceilings are clean? Not Met Comments walls, ceiling, & upright surfaces 26. Range/Grill Not Med Comments Outside in need of cleaning c. Quality Assessment for Performance Improvement dated 6/14/22 indicated- Summary and Recommendations: Left oven is unable to be used, General cleaning of appliances still a need, & [refrigerated food] items still in need of dates, labels & receive by dates. Cold milk temperatures not taken before start of tray line. [Food] temperatures not documented before tray line started. Raw ground meat placed on top of bacon. General cleaning logs positions most missing June documentation. Toaster may need to be replaced d/t [due to] flaking external material, Food processor makes loud noises-needs maintenance attention. Problem Ice Machine past cleaning date & need of cleaning [due 5/11/22] Meal Production 12. Are the food thermometers calibrated often and documented: Not Met Comments Incomplete log with gaps. Sanitation 1. All food is dated and labeled with received, open and use by dates. Not Met Comments No dates on salad, cut strawberries, bread 1/out current review by date 2. Refrigerators and freezers are clean inside and outside Not Met Comments Walk in mild refrigerator needs cleaning 10. All food that is not from its original container are put away properly. Well labeled, dated and covered with use by date? Not Met Comments Refrigerator: boiled eggs without open date, breads 2/out review by date. Storage Rooms 6. Food bins clean, labeled, and scoops kept outside container: Not Met Comments Rice in container without any dates. Kitchen Area 1. Work areas are clean and organized: Not Met Comments General cleaning [NAME][TRUNCATED]

Based on observation, interview, and record review, the facility failed to re-assess one of four sampled residents' ability to smoke independently (1) which resulted in Resident 1 catching on fire while smoking and then being transferred to a hospital for severe burns. Findings: The clinical record for Resident 1 was reviewed on 1/10/17. The admission record for Resident 1, dated 3/6/14, indicated she was a [AGE] year-old female, with [DIAGNOSES REDACTED]. It frequently affects the feet and hands causing weakness loss of sensation pins-and-needle sensations or burning pain), and nicotine dependence (an addiction to tobacco products). The History and Physical for Resident 1, dated 3/8/14, indicated Resident 1 had paralysis to her left arm and left leg. The Minimum Data Set (MDS- a comprehensive assessment tool), dated 12/5/16, indicated Resident 1's cognition was moderately impaired (a decline with mental processes of perception, memory, judgment, and reasoning). The care plans for Resident 1 was reviewed. The care plan titled SMOKING CARE PLAN, initiated on 9/30/16 and revised on 12/6/16, indicated Resident 1 IS ABLE to smoke independently. One of the interventions listed was to Assess resident for ability to smoke independently per facility policy. The Change of Condition for Resident 1 dated 1/8/17, at 10:14 AM, indicated: Resident was outside smoking when CNA (Certified Nursing Assistant 1) heard resident yell for help, (CNA 1) was in another patients room and saw resident catch (sic) fire thru patio door, (CNA 1) ran thru the patio door immediately to help resident while yelling for help. Licensed Nurse (LN 1) responded to (CNA 1) yells and helped put fire out while (CNA 2) also helped remove patients burnt clothing, when questioned patient stated sparks from her cigarette were blown by wind onto her sweater causing the fire. 911 was called, Fire Department and ambulance responded and took patient to a local acute hospital Burn unit. During an interview with CNA 2, on 1/10/17, at 9:47 AM, she stated, on Sunday (1/8/17), at approximately 10 AM, she was in the hallway when she heard a loud voice yelling for help. CNA 2 responded and went to the outside smoking patio and saw the fire on Resident 1's jacket. CNA 2 stated It's so bad; it's like what you see in the movie. CNA 2 stated she saw CNA 1 taking Resident 1's jacket off the resident's right arm, but the fire moved to the left arm. While another Licensed Nurse (LN 1) was reaching over from the resident's back and was also helping in removing Resident 1's jacket. But LN 1 realized the fire was so bad, and so LN 1 took the water hose and put the fire out. CNA 2 stated Resident 1 [MEDICAL CONDITION] the right face, right arm, right breast, and right side of the body. CNA 2 stated Resident 1 was smoking independently but she always felt Resident 1 needed supervision in smoking, because Resident 1 was paralyzed to the left side of her body. CNA 2 stated Resident 1 smoked in the smoking patio all day long (everyday) and was keeping her own cigarettes and lighters. During a concurrent observation and interview with Resident 2, on 1/10/17, at 10:58 AM, in the smoking area, Resident 2 stated Resident 1 needed a smoking apron and supervision while smoking because Resident 1 was not paying attention to what she was doing. Resident 2 stated, Sometimes (Resident 1) falls asleep while she was smoking. Resident 2 stated he had informed the staff Resident 1 needed supervision while smoking over a month ago. Resident 2 stated in one incident, Resident 1 was smoking with her cigarette in her right hand and suddenly placed her right hand on top of her left chest and burned her clothes and created holes. Resident 2 stated when that happened; it was good thing he was there to put out the fire. Resident 2 stated he told a CNA about the incident, and the CNA told him Resident 1 should pay attention to what she was doing, and that he (Resident 2) was there to supervise Resident 1. Resident 2 could not recall the name of the CNA he talked to. Resident 2 stated he also informed the Activity Director (AD) about the same incident. Resident 2 stated he had informed the facility staff on several occasions that Resident 1 needed supervision while smoking but they (facility staff) did not listen. Resident 2 stated they (facility staff) expected him (Resident 2) to supervise Resident 1. The clinical record for Resident 2 was reviewed. The Minimum Data Set for Resident 2, dated 11/28/16, indicated Resident 2 was cognitively intact (normal mental processes). During an interview with the AD, on 1/10/17, at 11:20 AM, the AD stated he noticed Resident 1 had declined and could not properly hold her cigarettes anymore; the resident was having a problem with her balance while sitting in her wheelchair, and was usually leaning on her left side. The AD stated Resident 1 had burned her clothes on multiple occasions but Resident 1 did not like to wear a smoking apron. The AD stated he thought Resident 1 needed supervision while smoking. The AD stated he informed the Previous Director of Nursing (PDON) regarding Resident 1 burning her clothes and she could not smoke independently anymore. The AD could not provide further information if the facility staff had reassessed Resident 1's ability to smoke independently after his conversation with the PDON. The PDON's last day with the facility was 12/19/16. During a concurrent observation in Resident 1's room and interview with CNA 3, on 1/10/17, at 2:50 PM, CNA 3 stated Resident 1 usually used a purple blanket to cover her lap when smoking outside. The purple blanket was on top of the bed and was noted with approximately 14 holes (each hole was measuring approximately 0.5 centimeters in diameter). CNA 3 stated Resident 1 would also place a square pillow on her left side to improve her positioning while sitting in the wheelchair. CNA 3 stated Here's the pillow. The square pillow was noted with two holes. CNA 3 stated the holes were from cigarette ashes that were dropping off onto Resident 1's blanket and pillow while she was smoking. CNA 3 stated she noticed, in the past weeks, Resident 1 was sleeping more in her wheelchair and stated Resident 1 needed supervision in smoking. CNA 3 stated she did not notify the licensed nurse the resident was sleeping more in her wheelchair because she (CNA 3) thought it was Due to her meds (medications). During a further review of Resident 1's SAFE SMOKING EVALUATION, dated 10/22/16, the summary of the evaluation deemed Resident 1may smoke independently. On this form, under OBSERVATIONS, it indicated Resident 1 was able to smoke safely by demonstrating Does not allow ashes or lit material to fall while smiling, inhaling or holding smoking items. Remains alert and aware while smoking. Does not forget he/she is smoking or falls asleep holding them. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self or others. Turns oxygen off prior to lighting cigarettes. Smokes only in designated area. The facility SAFE SMOKING EVALUATION document indicated under Directions: For a resident who wishes to smoke (e.g., cigarettes, cigars, pipe) perform evaluation on admission, quarterly, annually, at a significant change, or if there has been an incident of unsafe smoking observed or reported (or per facility policy). Evaluate Resident Status and Potential Risk Factors and check YES or NO under the appropriate evaluation date . During a concurrent interview with the AD, and review of Resident 1's SAFE SMOKING EVALUATION, on 2/9/17, at 2:33 PM, the AD reviewed the document and stated Yeah. The AD stated the PDON was aware of Resident 1's unsafe smoking behavior and stated I'm just waiting for her (PDON) to act. The AD stated the PDON told him she (PDON) was the Leader of the team and he could not perform the reassessment by himself. During a concurrent interview with the Director of Nursing (DON), and review of the clinical record for Resident 1, on 2/9/17, at 3:05 PM, she stated she was the one who performed the SAFE SMOKING EVALUATION on 10/22/16, and Resident 1 was Fine. The DON stated she was not aware of Resident 1's unsafe smoking behavior in the past few weeks. The DON stated, on 12/29/16, she was included in the CARE PLAN CONFERENCE for Resident 1. The DON was asked if the IDT (Interdisciplinary Team- a group of people organized to do a task together) had discussed in the CARE PLAN CONFERENCE about Resident 1's smoking ability to smoke independently, with supervision, or discussion about smoking reassessment for Resident 1. The DON stated she could not recall if they (the interdisciplinary team) discussed the unsafe smoking behavior. The DON stated she could not say Yes or No, because it was not documented. During a review of Resident 1's emergency room record, dated 1/8/17, the emergency room report indicated: She (Resident 1) apparently ignited herself and several team members had to put fire out essentially with her hands and with other implements. The patient now is screaming in pain. She [MEDICAL CONDITION] over the face, neck, right breast and right hand. There is also mild left [MEDICAL CONDITION] well .predominantly 3rd [MEDICAL CONDITION](third [MEDICAL CONDITION] a full thickness burn. This type of burn destroys the outer layer of skin and the entire layer beneath) are present. The patient does have areas of second-[MEDICAL CONDITION](a second-degree burn affects the outer layer of skin and part of the inner layer of skin) over the trunk and over the right arm. The hand itself is 3rd, has 3rd [MEDICAL CONDITION] (a condition of shortening or hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints) present on the right. Indicated under Impression: Multiple second-degree and third-[MEDICAL CONDITION]. The patient will require .endotracheal intubation (the placement of a flexible plastic tube into the windpipe to maintain an open airway and usually requiring ventilation of the lungs by a machine), central line placement (tubing inserted for continuous access to a chest vein for administering fluids and medicines) and admission to Burn ICU (ICU-intensive care unit). The facility policy and procedures titled Smoking, dated 10/2012, indicated, under Action Steps, In accordance with the state fire safety codes, the Executive Director/designee implements methods for the storage of smoking materials. The Interdisciplinary Team ensures an assessment is completed by the Licensed Nurse/designees at the time of admission, quarterly, annually and upon significant change. The community staff will make reasonable accommodations to assist residents identified through the Safe Smoking Evaluation as unsafe to smoke with supervision. The Interdisciplinary team/designee will document interventions related to safe smoking on the resident's individualized plan of care. Violations of the smoking rules will be addressed by the Executive Director/designee. Several facility staff was aware of Resident 1's unsafe smoking behavior but failed to conduct a reassessment as required managing her increasing risk of injuring herself due to a change of mental alertness.

Based on observation, interview, and record review, the facility failed to protect the dignity of one sampled resident (1) and six random residents (25, 37, 39, 43, 44, and 45) when: 1. Resident 25's lower body was exposed for 45 minutes which resulted in humiliation and anguish. 2. Call lights were not answered in a timely manner which resulted in one random resident (25) left to sit in her urine or feces for long periods of time. 3. Call lights were not answered in a timely manner which resulted in one random resident (44) left to sit in their urine or feces for periods of time. 4. Resident 45 was called by a racial name which resulted in emotional anguish. 5. Staff were overheard being verbally derogatory to other residents (43, 1, 37, and 39) which resulted in an undignified environment and negatively impacting the psychosocial well being of the residents. Findings: 1. During an interview with Resident 25 on 3/26/15, at 11 AM, she stated she did not want Certified Nursing Assistant (CNA) 4 to care for her anymore. Resident 25 stated on one occasion "...CNA 4 started to change me (soiled adult brief). She had me naked, then she left the room. I was exposed. It was humiliating and I was cold. She left me like that for 45 minutes. I was so ashamed. I told the Director of Staff Development (DSD) I didn't want CNA 4 to care for me anymore..." Resident 25 stated CNA 4 was moved to a different section. Resident 25 stated she was able to time how long she was left exposed because there was a clock mounted to the wall across from her bed. During a review of the clinical record for Resident 25, the current "History and Physical" indicated Resident 25 is alert and oriented, and has the capacity to make her own medical decisions. During a review of the facility "Grievance Log," dated between 2/2015 and 3/2015, there was no documentation of Resident 25's complaints regarding the care provided by certified nursing assistants. 2. During an interview with Resident 25 on 3/26/15, at 11 AM, Resident 25 stated she frequently had to wait at least 30 minutes to an hour for her call light to be answered. The afternoon and the night shift were the worst, but it was also a problem on day shift. Resident 25 stated, "If the CNA didn't like you or your roommate, the CNA would turn the call light off without asking what you needed and leave the room. Sometimes they won't answer it (call light) at all." Resident 25 stated she was able to time how long it took for the CNAs to answer the call light because there was a clock mounted to the wall across from her bed. Resident 25 stated there were two CNAs, (one she was not sure of the name since the CNA did not wear a name badge, and the other was CNA 6) who would answer her call light but refuse to clean her; "I'll tell them I'm dirty and they say 'Oh well' or 'You were just cleaned, so you can't need to be cleaned up again'. I don't like feeling dirty...it's embarrassing." Resident 25 stated she had to find another CNA to clean her up. 3. During a concurrent observation and interview on 3/27/15, at 9:32 AM with Resident 44, she stated her call light had not been answered promptly. She was asked how long, on average, she had to wait for her call light to be answered, she stated, "How long? It could take half an hour to two hours." She said about one and half or two weeks ago, she was soiled in bed and needed a nurse to clean her up. She waited from 4 PM to 6:30 PM. She stated her male CNA would come in, turn off her call light, and told her he would be back. Resident 44 stated after two and half hours, she was not going to wait any longer and lit up a cigarette. Soon after that, she said, several nurses ran into her room. She stated, "I got changed then." During an interview with the Executive Director on 3/27/15, at 11:40 AM, he recalled the incident with Resident 44 occurred as stated above but could not confirm the date. 4. During an interview with Resident 45 on 3/26/15, at 11:22 AM, she stated a CNA called her "...the N word...they are verbally abusive... it hurts, I feel sad..." Resident 45 stated she did not know the name of the CNA who called her the "N word". During a review of the clinical record for Resident 45, the current "History and Physical" indicated Resident 45 is alert and oriented, and has the capacity to make her own medical decisions. 5. During an interview with Resident 43, on 3/25/15, at 11:36 AM, she stated, "They should speak nicely to all residents even if they are aggravated". She added she heard staff talking in the hallway, referring to her roommate as the "Fat" lady. Resident 43 stated, "If they would speak to me like that I will feel bad". Resident 43 stated she has overheard staff being mean to residents who can't speak for themselves, telling them "You're fat", "You're old", and "You're ugly". During the Group Interview on 3/25/15, at 2:06 PM, Residents 1, 37, and 39 stated when they are in the smoking area (shared by both residents and staff), staff can be overheard talking about other residents. Resident 39 stated staff have made faces at her in the past. The facility policy and procedure titled "Abuse and Neglect Prevention Standard", dated 2013, indicated in part, "The resident has the right to be free from verbal... and mental abuse... verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents... or within their hearing distance... examples include name calling..."

Based on observation, interview, and record review, the facility failed to implement their care plan for one (12) of 24 sampled resident to promote healing of the wound. 1. A pressure reducing mattress was not provided to the resident as per resident's care plan. 2. Resident 12 was not kept clean, dry at all times after episodes of incontinence as per resident's care plan. 3. The pressure ulcer was not appropriately identified to the right buttock. These resulted in progression of Resident 12's wound to his right buttock. Findings: During an observation on 3/23/15, at 10:20 AM, Resident 12 was in bed lying on his right side on a concave mattress (mattress with curve sides for safety). During a concurrent observation and interview with Certified Nursing Assistant (CNA) 7, on 3/24/15, at 9:25 AM, Resident 12 was up in a gerichair (recliner chair with a high back and wheels) by the hallway in front of his room. Resident 12 was screaming. CNA 7 stated, "He has a big sore on his bottom where he is hurting". During a concurrent observation with Resident 12 and interview with the CNA 7, on 3/24/15, at 9:32 AM, CNA 7 stated "He has been screaming and hollering when we turned and touched him." Resident 12 was asked by CNA 7 if he wanted to go back to bed and Resident 12 stated "Yes". Resident 12 was put back to bed lying on his right side on a concave mattress. CNA 7 stated, "He prefers to stay on his right side. He would scream if he's being turned to his left side". During a subsequent interview with CNA 7, on 3/24/15, at 1:15 PM, she stated Resident 12 did not have a pressure reducing mattress. CNA 7 stated Resident 12 had a sore on his right buttock for awhile and it was not getting any better. During a concurrent observation and interview with CNA 7, on 3/24/15, at 1:20 PM, Resident 12 was repositioned by CNA 7 to his left side. Resident 12 was screaming when he was being repositioned. Resident 12 was noted with an open wound to his right buttock with yellow slough (yellow tissue or accumulation of necrotic tissue/dead tissue) in the center of the wound bed. During an interview with Licensed Nurse (LN) 8, on 3/25/15, at 10:20 AM, he stated Resident 12's open wound on the right buttock started as a scratch. It had a yellow slough now. During a subsequent interview with LN 8, on 3/25/15, at 2 PM, he stated, "I just placed the roho cushion (pressure reducing mattress) yesterday (3/24/15) when the staff told me he didn't have a pressure reducing mattress. He added Resident 12 was scratching his right buttock when he got wet". During an interview with CNA 7, on 3/27/15, 10:40 AM, she was asked about Resident 12 being left wet and he was not changed promptly. CNA 7 stated, "I believe it's from the night shift. When I came in the morning the diaper was dry but the bed was wet". During a review of the clinical record for Resident 12, the document "Weekly Wound Condition Record" dated 2/23/15 indicated "...Site Location: Right Buttock... Condition:... Scratch....", measuring 3 cm (centimeters) in length, 1 cm in width, 0.1 cm in depth... Characteristics..."Partial Thickness", Wound Bed..."Dark pink/red tissue...". On 3/16/15 on the same site and location to the right buttock measuring 2.5 cm in length, 0.8 cm in width, and 0.1 cm in depth, "Partial Thickness", Wound Bed..."Pink, Pale tissue 100%"... On 3/23/15, on the same site and location to the right buttock indicated "MD was notified that wound deteriorated and now has 80 % granulation tissue and 20 % Slough..." measuring 3.5 cm in length, 1 cm in width and 0.2 cm in depth. During a review of the clinical record for Resident 12, the resident's plan of care was reviewed. The "Pressure Ulcer/Skin Breakdown" dated 8/16/14 indicated in part "Provide pressure reducing mattress... Keep resident clean, dry at all times after episodes of incontinence..."

Based on observation, interview, and record review, the facility failed to provide adequate assistance for one of one sampled resident (1) while using a Mechanical Lift (used for transfer of residents). This failure resulted in Resident 1 having a fall which resulted in multiple fractures; femur (thigh bone), humerus (long bone of the arm), and iliac crest (top of the hip bone) that required surgery. Findings: During a concurrent observation and interview with the Administrator on, 11/12/14, at 2:45 PM, he stated Resident 1 was still in the hospital. He called to medical records for the clinical record. The Administrator stated, "Resident 1 has her own sling for the lift." The sling was a blue full body mesh with all straps intact. The Administrator stated, "During our investigation we found there was nothing wrong with the lift...it was operator error. Talking to Certified Nurse Aide (CNA) 1 she knows that she messed up" During a review of the clinical record for Resident 1, a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 1 is alert, makes her own decisions, and needs extensive assistance with her activities of daily living (ADL). The Fall Risk Evaluation, dated 7/15/14, indicated a score of 18. The form indicated "A resident who scores a 10 or higher is at risk, interventions should promptly be put in place." The resident care plan "Fall/Injury" dated 7/14/14, indicated risk factors: impaired balance and unsteady gait, poor muscle coordination, weakness, underlying health problems..., and Interventions: assist resident in ADL's, Anticipate needs..." During an interview with Licensed Vocational Nurse (LVN) 1, on 11/12/14, at 3:15 PM, she said she entered the room to assist Resident 1's roommate. LVN 1 stated "I saw CNA 1 with Resident 1, and she (Resident 1) was laying down in a shower chair. All of a sudden I hear a loud noise and Resident 1 screamed. I looked and she was on the floor." LVN 1 was asked if CNA 1 requested her help with the lift. LVN 1 stated "She didn't ask for my help with the lift." During an interview with Registered Nurse (RN) 1, on 11/12/14, at 3:30 PM, she stated on the day of the fall she heard the call and went into Resident 1's room. RN 1 said "Resident 1 was lying on her left side yelling for a pillow and pain shot." RN 1 stated "She (CNA 1) had training on the lifts." During a concurrent interview with RN 1 and review of the facility training log sign in sheet for: Accident/Safety Measure on 9/8/14 and Transfers via Hoyer Lift (2) persons on 10/14/14, CNA 1 did not attend. RN 1 stated "CNA 1 was on-call, and didn't attend training. She has her Restorative Nurse Aide (RNA), so she got training then." Review of CNA 1's Restorative Training certificate dated 11/22/11 indicated it was an 8 hour classroom/field work course. During a review of the clinical record for Resident 1, the Nurses Notes dated 11/7/14, at 10:20 AM indicated "Resident encountered fall from lift. Resident heard to be yelling "my leg" and found to be leaning towards left side of body on floor... c/o (complains of) pain 10/10 to left leg, left hip, left arm, and left shoulder. Resident transferred to hospital and left facility at approx (approximately) 1040." During an interview with CNA 1, on 12/2/14, at 4:25 PM, she stated "The resident told me to put the sling on backwards... I did what she asked." CNA 1 said when she was picking up Resident 1 with the lift when she slid from the sling and fell to her left side. CNA 1 said she had used a lift before. CNA 1 was asked if she is supposed to follow the residents' instructions instead of how she was trained, and stated "No." CNA 1 stated "I'm aware that I didn't use it properly, but she was alert and that's how she wanted it." CNA 1 was asked if the lift requires two people and she stated "Yes." During an interview with the Assistant Director of Nurses (ADON), on 12/3/14, at 3:30 PM, she was asked the amount of staff when using the Mechanical lift. The ADON stated "It should always be two people." During a review of the clinical record for Resident 1, the hospital "Operative Report" dated 11/12/14 indicated the following operations were performed: 1. Open Reduction Internal fixation (method of surgically repairing a fractured bone with the use of plates and screws), left femur. 2. [DEVICE] (screws and pins that are inserted into the bone through the skin) of the left elbow, stabilizing the fracture and dislocation of the elbow. During an observation and interview with Resident 1, on 12/3/14, at 4:30 PM, she was lying in bed with an [DEVICE] to the left elbow. Resident 1 was asked what happened the day of her fall. Resident 1 stated "The CNA put me on the shower bed. She used the sling... it was only her using the sling." Resident 1 was asked if she instructed the CNA how to use the sling. Resident 1 stated "No, I didn't tell her what to do. I don't think she put it on correct in the back. It was like once she did the back...I fell ." Resident 1 was asked how she felt, and stated "I wake up crying at night... I think that I'm falling." During an interview with CNA 2, on 12/3/14, at 5 PM, she was asked how to use the Mechanical lift. CNA 2 stated "You have to use two people to use the lift. I never use it by myself... not suppose to." During an interview with CNA 3, on 12/3/14, at 5:10 PM, she was asked how to use the Mechanical lift, and she stated "You always use two people when you use the lift." The facility policy and procedure titled "Mechanical Lift Usage" undated, indicated "Assess physical characteristics of the resident...determine if assistance is needed from another caregiver." The education module titled "Mechanical Lifts", approved curriculum-Unit 13 undated, indicated "Enough assistance to assure safe transfer." Medline Owner's Manual with revised date 4/5/2007 indicated "Always fit the sling according to the instructions provided."

Based on interview and record review, the facility failed to answer one Confidential Resident's call light in a timely manner. This resulted in the resident remaining soiled for an extended period of time in an undignified manner. Findings: During a confidential group interview on 5/3/11 which started at 10:15 AM, Confidential Resident (CR) indicated it took one hour and 40 minutes to answer the call light. The CR, stated when she placed the call light on for assistance a staff member would come and turn the call light off and then tell the resident, "I'll go get your CNA (certified nursing assistant)." During a subsequent interview with CR, she indicated many times someone would come and answer the call light, but then you were told the nurse was busy passing medications and then "you don't talk to them (referring to the nurse)." CR stated on one occasion, she called because her [MEDICAL CONDITION] (a surgical procedure that brings one end of the large intestine out through the abdominal wall) bag "exploded". The feces from the [MEDICAL CONDITION] bag spread from her legs, one side of the stomach to the other and up to the chest area. It took "them four to five hours to change the [MEDICAL CONDITION] bag" and clean all the feces off. Throughout the course of the interview the resident was teary eyed and indicated, "I have never been treated so bad." The clinical record for CR, was reviewed on 5/4/11 at 11:15 AM. The admitting [DIAGNOSES REDACTED]. The resident required extensive assistance from staff with toileting, which included managing her [MEDICAL CONDITION] and extensive assistance with bathing whether a shower or a sponge bath. During an interview with MDS Coordinator, on 5/5/11 at 10:25 AM, she was informed of the CR's issue.