Every finding on record at The Villas at Poway

Based on interview and record review, the facility failed to obtain residents' weight upon admission for seven of 18 sampled residents (36, 280, 282, 430, 19, 9, 3). In addition, the facility did not ensure input and outputs (I & Os) were documented accurately for one sampled resident (Resident 73) on intravenous (IV - giving medications, fluids, or nutrients directly into the bloodstream through a needle or tube inserted into a vein) medications. These failures had the potential to delay identification of risk factors related to nutrition and hydration for Resident 2, 36, 280, 282, 430, 19, 9, 3, and 73. Findings: 1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), per the facility's Patient Information. 2. Resident 280 was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), per the facility's Patient Information. 3. Resident 282 was admitted to the facility on [DATE] with diagnoses which included hypertension, per the facility's Patient Information. 4. Resident 430 was admitted to the facility on [DATE] with diagnoses which included pneumonia (an infection/inflammation in the lungs), per the facility's Patient Information. On 5/21/25 at 9:41 A.M., a joint review of Resident 36, Resident 280, and Resident 282's clinical record and an interview was conducted with Licensed Nurse (LN) 11. Clinical record review as follows: - Resident 36 was admitted on [DATE]. Resident 36's weight was taken/ documented on 5/11/25. - Resident 280 was admitted on [DATE]. Resident 280's weight was taken/ documented on 5/18/25. - Resident 282 was admitted on [DATE]. Resident 282's weight was taken/ documented on 5/11/25. LN 11 stated residents' weights should have been taken upon admission for a baseline to ensure the residents were not losing weight or developing edema (swelling). On 5/21/25 at 10:19 A.M., an interview was conducted with Restorative Nursing Assistant (RNA) 11. RNA 11 stated the RNAs were responsible for weighing the residents on Saturdays and Sundays. RNA 11 stated when residents were admitted to the facility on weekdays, the Certified Nursing Assistants (CNAs) were responsible to weigh the residents upon admission. RNA 11 stated when the staff were not able to obtain the residents weights on the day of admission, the staff were supposed to weigh the residents the following day within a 24-hour period. On 5/21/25 at 3:58 P.M., a joint review of Resident 36, Resident 280, Resident 282 and Resident 430's clinical record and an interview was conducted with the Unit Manager (UM) 11. Clinical record review as follows: - Resident 36 was admitted on [DATE]. Resident 36's weight was taken/ documented on 5/11/25. - Resident 280 was admitted on [DATE]. Resident 280's weight was taken/ documented on 5/18/25. - Resident 282 was admitted on [DATE]. Resident 282's weight was taken/ documented on 5/11/25. - Resident 430 was admitted on [DATE]. Resident 430's weight was taken/ documented on 5/7/25. UM 11 stated residents' weights should have been taken upon admission and readmission unless contraindicated like orthopedic procedures. UM 11 stated the residents' weights as zero indicated, Someone was trying to bypass the assessment. UM 11 stated the resident's weight should have been accurate. UM 11 stated the residents should have been weighed within 24 hours upon admission for baseline to check if a resident was gaining or losing weight. UM 11 stated per the regulation the residents should be weighed upon admission or within 24 hours. On 5/22/25 at 11:07 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the facility's policy was to weigh the residents within 72 hours on admission. The DON stated, Even so with our policy, we are not abiding with our policy. A review of the facility's policy titled, Weighing Residents, revised 8/29/23, indicated, Residents are weighed to determine nutritional status and evaluation of overall health . A review of the facility's policy titled, Documentation Schedule, revised 9/20/19, indicated, .To provide guidelines for documentation which will provide a pertinent and timely clinical or behavioral picture of the patient .C. admission documentation is completed within 24 hours of the admission . 5. Resident 19 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney failure), per the facility's, Patient Information. On 5/22/25 at 10:19 A.M., a joint record review and an interview were conducted with LN 23. LN 23 described the facility's process on weighing residents. LN 23 stated the residents would be weigh upon admission, then every week for 4 weeks and then every month or if there was an order that weighing was contraindicated. Resident 19's Weight Detail Report indicated Resident 19 admission weight was taken on 3/14/24. LN 23 stated that Resident 19 should have been weighed on 3/4/24 and not 10 days later. 6. Resident 9 was re- admitted to the facility on [DATE], with diagnoses which included pyelonephritis (kidney infection), per the facility's, Patient Information. On 5/22/25 at 10:20 A.M., a joint record review and an interview were conducted with LN 23. A review of Resident 9's Weights Detailed Entry Report indicated Resident 9's admission weight was taken on 1/5/25. LN 23 stated Resident 9 should have been weighed on 12/24/25 upon admission and should not have waited 12 days later. 7. Resident 3 was admitted to the facility on [DATE], with diagnoses which included Liver abscess (pus filled pocket caused by infection), per the facility's, Patient Information. On 5/22/25 at 10:22 A.M., a joint record review and an interview were conducted with LN 23. A review of Resident 3's Weights Detailed Entry Report indicated Resident 3's admission weight was taken on 1/28/24. LN 23 stated Resident 3 should have been weighed on 1/11/24 upon admission and should not have waited 17 days later. On 5/22/25 at 11:37 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff should have followed the policy and procedure for weighing residents. The DON stated she expected staff to weigh residents on admission. A review of the facility's policy titled, Weighing Residents, revised 8/29/23, indicated, Residents are weighed to determine nutritional status and evaluation of overall health . A review of the facility's policy titled, Documentation Schedule, revised 9/20/19, indicated, .To provide guidelines for documentation which will provide a pertinent and timely clinical or behavioral picture of the patient .C. admission documentation is completed within 24 hours of the admission . 8. According to the facility's Patient Information record, Resident 73 was admitted on [DATE] with diagnoses that included congestive heart failure (CHF - condition when the heart isn't pumping blood as efficiently as it should, leading to fluid buildup in the body, especially the lungs). A record review of Resident 73's physician's orders indicated on 5/7/25, Resident 73 was started on Zosyn (antibiotic) 3.375 grams IV every 6 hours x 10 days for pneumonia (PNA - lung infection). A record review of Resident 73's I&Os for the month of May 2025 indicated that recorded input did not include the IV fluid amount Resident 73 received from the IV antibiotics. On 5/20/25, at 3:30 P.M., an interview was conducted with the licensed nurse (LN 1). LN 1 stated IV fluids and IV medication amounts are not recorded or documented. LN 1 stated they stopped recording IV intake amounts when the electronic medical records (EMR) system was changed. On 5/21/25, at 3:00 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that all fluids, including IV medications, need to be recorded in the residents' I&Os. A review of the facility policy titled Procedure: Intake and Output, dated 1/31/04, indicated .3. Licensed nurse records fluids administered by intravenous lines as intake .

Based on observations, interview, and record review the facility failed to ensure infection control procedures were followed when: A. Resident 36 and Resident 282 were not identified and placed on enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]), and licensed staff did not wear a gown when providing care to Resident 36 and Resident 282. B. Licensed Nurses (LN) did not perform hand hygiene (a process of washing hands or using a hand sanitizer) while dispensing medications, when changing gloves in a contact precaution room, and did not sanitize stethoscope and pulse oximeter after resident use. C. A bottle of body spray was found in the drawer of respiratory cart. These failures had the potential for cross contamination and spread of infection between residents, visitors and staff. Findings: A 1.Resident 36's Information Record indicated Resident 36 was admitted to the facility on [DATE], with diagnoses which included Methicillin Resistant Staphylococcus Aureus (MRSA - a type of organism that was resistant to several antibiotics [anti-infective] medications) and had a peripherally inserted central catheter (PICC, is a medical device with a tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) for antibiotics. On 5/19/25 at 9:02 A.M., an observation and an interview of Resident 36 was conducted in her room. Resident 36 laid in bed, with PICC line on her right upper arm. Resident 36 stated she was receiving antibiotics through the PICC line due to an infection to her knee. Resident 36 stated she had the PICC line inserted prior to facility admission. There was no EBP sign noted prior to coming to Resident 36's room. On 5/20/25 at 3:37 P.M., a follow up observation and an interview of Resident 36 was conducted in her room. Resident 36 laid in bed, with PICC line on her right upper arm. There was no EBP sign noted prior to coming to Resident 36's room. On 5/20/25 at 3:52 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 12. CNA 12 stated Resident 36 was incontinent on her bowel and bladder and needed assistance. CNA 12 stated Resident 36 was not on isolation and no reported isolation precautions for the resident. CNA 12 stated the CNAs did not have to wear a gown when providing care to Resident 36 since she was not on isolation. On 5/21/25 at 8:29 A.M., an interview was conducted with CNA 14. CNA 14 stated Resident 36 was not on isolation and PPE were not needed when providing care to the resident. On 5/21/25 at 11:40 A.M., an observation and an interview was conducted with CNA 14. CNA 14 changed Resident 36's incontinence brief. CNA 14 was not wearing a gown while providing care to Resident 36. CNA 14 stated Resident 36 was not on isolation and no gown was required when changing her incontinence brief. On 5/21/25 at 11:50 A.M., an interview was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 36 was not on isolation precautions and did not require PPE when providing care to Resident 36. LN 11 stated there was no sign which indicated the staff had to wear PPE when providing care to Resident 36. On 5/21/25 at 3:23 P.M., a joint review of Resident 36's clinical record and an interview was conducted with Infection Preventionist (IP). The IP stated Resident 36 had history of MRSA and had a PICC line. The IP stated residents with history of MRSA and with medical devices, the expectation was for the staff to wear PPE which consisted of mask, gown and gloves when providing care to residents with medical devices. The IP stated it was important for the staff to wear PPE when they were in contact with the residents like providing care, accessing the resident's medical device, and transferring the resident when they had long contact time with the resident. The IP further stated this was to prevent increase of acquiring organisms and infection and transmitting them to other residents. On 5/22/25 at 11:07 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to follow EBP protocol. The DON stated it was important since the residents were vulnerable and were high risk of developing an infection. A review of the facility's policy titled, Enhanced Barrier Precautions, revised 11/20/24, indicated, In conjunction with other infection control measures, Enhanced barrier precautions (EBP) will be used to maintain a safe, sanitary and comfortable environment. The targeted use of proper personal protective equipment (PPE) along with the use of standard precautions during high-contact resident care activities will help prevent the transmission of communicable diseases and infections . A2. Resident 282's Information Record indicated Resident 282 was admitted to the facility on [DATE], with diagnoses which included bacteremia (presence of bacteria in the blood stream), had a peripherally inserted central catheter (PICC, is a medical device with a tube that's inserted through a vein in your arm and passed through to the larger veins near the heart) for antibiotics and a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings and medications to be administered directly to the stomach). On 5/19/25 at 9:23 A.M., an observation and an interview were conducted with Resident 282 in her room. Resident 282 had a right upper arm PICC line, and a g-tube. Resident 282 laid in bed and stated she received antibiotics in her PICC line and received nutrition via her g-tube. There was no EBP sign noted prior to coming to Resident 282's room. On 5/20/25 at 4:03 P.M., an interview was conducted with CNA 12. CNA 12 stated Resident 282 had a g-tube and was not on isolation. CNA 12 stated the staff only have to wear PPE when providing care to resident with a sign that indicated the resident was on isolation. CNA 12 stated she did not have to wear a gown when providing care to Resident 282. On 5/21/25 at 8:35 A.M., an interview was conducted with CNA 15. CNA 15 stated Resident 282 had a g-tube. CNA 15 stated since Resident 282 was not on isolation, staff were not to wear a gown. On 5/21/25 at 11:50 A.M., an interview was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 282 was not on isolation precautions and did not require PPE when providing care to Resident 282. LN 11 stated there was no sign which indicated the staff had to wear PPE when providing care to Resident 282. On 5/21/25 at 3:23 P.M., a joint review of Resident 282's clinical record and an interview was conducted with Infection Preventionist (IP). The IP stated Resident 282 had bacteremia, a g-tube and a PICC line. The IP stated residents with medical devices, the expectation was for the staff to wear PPE which consisted of mask, gown and gloves when providing care to residents with medical devices. The IP stated it was important for the staff to wear PPE when they were in contact with the residents like providing care, accessing the resident's medical device, and transferring the resident when they had long contact time with the resident. The IP further stated this was to prevent increase of acquiring organisms and infection and transmitting them to other residents. On 5/22/25 at 11:07 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to follow EBP protocol. The DON stated it was important since the residents were vulnerable and were high risk of developing an infection. A review of the facility's policy titled, Enhanced Barrier Precautions, revised 11/20/24, indicated, In conjunction with other infection control measures, Enhanced barrier precautions (EBP) will be used to maintain a safe, sanitary and comfortable environment. The targeted use of proper personal protective equipment (PPE) along with the use of standard precautions during high-contact resident care activities will help prevent the transmission of communicable diseases and infections . B. On 5/21/25 at 8:49 A.M., an observation and interview was conducted with LN 1 during Resident 15's medication administration. LN 1 had administered medications via feeding tube (a tube inserted into the stomach to give nutrition) to Resident 15. Resident 15 was in a contact precaution room (a room with a resident who has an infectious disease). LN 1 took off used gloves and applied a new pair of gloves without performing hand hygiene. LN 1 used a stethoscope (a medical device used to listen to the heart and lungs) and pulse oximeter (a medical device used to monitor heart rate and oxygen levels) on Resident 15. LN 1 then put the pulse oximeter into her pocket and placed the stethoscope around her neck without disinfecting them. LN 1 stated she removed her gloves in Resident 15's room and did not perform hand hygiene and she should have done so in a contact precaution room. LN 1 stated she also had not disinfected the stethoscope and pulse oximeter before exiting Resident 15's room and she should have. On 5/21/25 at 9:36 A.M., an observation and interview was conducted with LN 4 during Resident 20's medication administration. Resident 20 was on enhanced barrier precautions (use of PPE to prevent spreading infection to vulnerable residents during care). LN 4 was observed touching his face mask several times. LN 4 was observed dispensing medications and did not perform hand hygiene. LN 4 then applied a pair of gloves, carried Resident 20's medication tray, and set it down on a cabinet. LN 4 applied a PPE gown and then doubled gloved (applying another pair of gloves over the first pair of gloves). LN 4 entered Resident 20's room. LN 4 gave Resident 20 his oral medications and then removed the outer pair of gloves. LN 4 administered eye drops to Resident 20. LN 4 stated he did not perform hand hygiene after touching his mask and prior to dispensing Resident 20's medications. LN 4 stated he should not have been wearing double gloves during medication administration. C. On 5/21/25 at 11:14 A.M., an observation and interview was conducted with Respiratory Therapist (RT) 1. A bottle of (brand name) body spray gingham love was found in the right upper drawer of a respiratory medication cart. RT 1 stated he was not sure who it belonged to and it May be a co-worker's. RT 1 stated the body spray should not have been stored in the respiratory medication cart. On 5/21/25 at 3:38 P.M., an interview was conducted with Infection Preventionist (IP). The IP stated hand hygiene was to be performed before changing gloves. The IP stated staff should have disinfected the stethoscope and pulse oximeter prior to exiting a contact precaution room to decrease the spread of infections. The IP also stated alcohol-based rub or handwashing should have been performed before dispensing or administering medications to residents. The IP further stated body spray should not have been in a respiratory medication cart, and it was an infection control risk. On 5/22/25 at 2:05 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated staff would need to change gloves and perform hand hygiene within a patient room when changing care tasks, or if soiled. The DON further stated items like a stethoscope and pulse oximeter should not leave a contact precaution room without being disinfected. The DON stated LNs should perform hand hygiene prior to dispensing and administering medications and LNs should not be double gloving. The DON stated, Perfume should be not allowed in any medication cart. The DON further stated this was a potential for contamination and an infection control issue and Residents could be put at risk. A review of the facility's policy titled Procedure: Standard Precautions revised 11/01/2024, indicated, .3. Hand Hygiene .c. If hands are not visibly soiled, use alcohol gel routinely for decontaminating hands: .ii. before donning sterile gloves .vii. after removing gloves .d. Remove gloves promptly after use and immediately perform hand hygiene 7. Cleaning and Disinfecting Patient Care Equipment a. Shared equipment must be cleaned and disinfected before use on another patient by the immediate user . A review of the facility's policy titled Procedure: Cleaning and Disinfection of Equipment revised 06/10/2024, indicated, .10. Cleaning and disinfection of movable medical equipment will be done regularly and after equipment is taken into an isolation room .

Based on observation, interview, and record review, the facility failed to treat one of seven residents reviewed for resident rights, in a dignified manner when one resident (Resident 47) waited for 30 minutes to be served her meal while the other residents ate their meals. This deficient practice had the potential for Resident 47's self-esteem and self-worth to be devalued. Findings: According to the facility's Patient Information, Resident 47 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure). On 5/19/25, at 11:30 A.M., an observation was conducted of dining room lunch service. On 5/19/25. at 12:03 P.M., lunch meal trays were passed out to the seven residents in the dining room. On 5/19/25, at 12:07 P.M., all but one meal tray were served. Resident 47's tray was not served. On 5/19/25, at 12:30 P.M., an interview was conducted with Resident 47. Resident 47 stated she does not know why it is taking so long for her lunch tray. She stated it made her feel frustrated that everyone was already eating and that she's waited almost 30 minutes for her tray and now, almost everyone was finished eating their lunch. On 5/19/25, at 12:37 P.M., Resident 47's meal tray was served by the Restorative Nursing Assistant (RNA 11). On 5/19/25, at 12:40 P.M., an interview was conducted with RNA 11. RNA 11 stated after the RN checked the tray for Resident 47, she delivered the tray to the wrong resident. She stated that she should have doubled checked the meal ticket and stated that it is important for residents to receive the correct meal tray for dignity and safety. On 5/22/25, at 2:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that all residents should be served in a timely manner. A review of the facility policy titled Procedure: Villa Meal Service- Meal Tray Delivery and Pick-Up, dated 2/5/24, indicated .4. Trays are delivered within the scheduled meal times for each unit .

Based on interview and record review the facility failed to ensure Advance Directive information was provided to a resident (Resident 10). This failure had the result for Resident 10 to not have the opportunity to express wishes for care if capacity for decision making was lost. Findings: On 5/19/25 Resident 10's clinical record was reviewed. Resident 10 was re-admitted to the facility on [DATE] per the facility's Patient Information. A document titled Advance Directive Acknowledgment dated 2/19/19, 4/19/19, and 2/13/24 indicated, I do not have an Advance Directive, however, I am interested in receiving an Advance Directive Brochure . which was initialed by Resident 10 and Resident 10's family member. There was no notation on either of the forms of whether the brochure was given to the resident or family member. On 05/21/25 at 08:29 A.M., a joint review of Resident 10's record was conducted with the Patient Financial Advocate (PFA). The PFA stated there was no documentation of whether Resident 10 received the Advance Directive brochure. The PFA stated Business Office staff should have documented on the Advance Directive Acknowledgment form if the brochure was provided. On 05/21/25 at 10:28 A.M., Resident 10 was interviewed in her room. Resident 10 stated she had been at facility for six years. Resident 10 stated she did not know what an Advance Directive was and did not receive a brochure or information from the facility about it. On 05/21/25 at 02:21 P.M., a joint review of Resident 10's chart was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 10 did not have an Advance Directive on the chart. LN 23 stated if there was an Advance Directive it should have been on the physical paper chart. On 05/21/25 at 2:32 P.M., a joint review of Resident 10's record was conducted with the Administrator (ADM). The ADM stated if there was an Advance Directive, it should have been on the physical paper chart. On 05/22/25 at 08:48 A.M., a joint review of Resident 10's record was conducted with the Health Information Services Coordinator (HISC). The HISC stated if a resident had an Advance Directive, the HISC scanned it into the electronic record, and then placed the hard copy on the physical paper chart. The HISC verified there was not an Advanced Directive on the chart for Resident 10. On 05/22/25 at 09:05 A.M., the ADM was interviewed. The ADM stated it was a duplicative process to have the Advance Directives Acknowledgment form handled by the Business Office in addition to the Social Services Evaluation Form. The ADM stated there was no Advanced Directive available for Resident 10. Per facility procedure Advance Directives, revised 5/13/24, .Inquiry and documentation regarding advance directive should occur as soon as reasonably possible during the admission process on all patients. At the time of admission, the patient .should be asked about and provided with, if requested, written information about the advance health care directive .the patient .who does not have an advance directive should be offered Your Right to Make Decisions about Medical Care .should make every effort to obtain the patient's Advance Directive .a copy should be placed in the patient's medical record .

Based on observation, interview, and record review, the facility failed to protect confidential information for one unsampled resident (Resident 15). This failure had the potential for Resident 15's confidential health information to be accessed by unauthorized individuals. Findings: On 5/19/25 Resident 15's clinical record was reviewed. Resident 15 was admitted to the facility on [DATE] per the facility's Patient Information with a diagnosis of Respiratory Failure (when the lungs cant properly exchange oxygen). On 5/21/25 at 8:37 A.M., an observation and interview was conducted with LN 1 during preparation for medication administration for Resident 15. LN 1 was observed putting the packaging for Prosource no carb 102 (a supplement used to increase protein intake) into the medication cart trash. The identification label attached to the Prosource packaging had Resident 15's first and last name on it. LN 1 stated she should have put Resident 15's identification label into the confidential bin. On 5/21/25 at 3:38 P.M., an interview was conducted with Unit Manager (UM) 11. UM 11 stated labels with a resident name on it should have been put in the confidential bin and not into the trash. On 5/22/25 at 2:05 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated any resident identification label would need to go in the confidential shred machine and should not be present on packaging placed in the trash can. A review of the facility's policy titled Procedure: Privacy- Confidentiality and Access to Patient Information revised 12/31/2021, indicated .1. Protected Health Information or PHI is any individually identifiable health information .Individually identifiable means that the health or medical information includes or contains any element of personal identifying information sufficient to allow identification of the individual such as a patient's name .10. All hospital personnel are responsible for controlling and enforcing the principle of confidentiality, .Each department is responsible for providing a secure location for patient identifiable information, and will take reasonable measures to ensure the security of the information against unauthorized access

Based on observation, interview, and record review, the facility failed to ensure dialysis (the process of cleaning the blood through a machine) access site was properly cared for one of one resident reviewed for dialysis (Resident 19). This deficient practice had the potential for Resident 19's dialysis access to clot. Findings: Resident 19 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney failure), per the facility's Patient Information. On 5/19/25 at 11:03 A.M., an interview was conducted with Resident 19 in her room. Resident 19 stated she was a dialysis resident and scheduled for dialysis on Tuesday, Thursday, and Saturday. Resident 19 showed her right arm dialysis access site. On 5/20/25 at 4 P.M., an observation and an interview were conducted with Resident 19 in her room. Resident 19 was up in her wheelchair. Resident 19 stated she came back from her dialysis at 1 P.M. and showed a dressing on her right upper arm dialysis access site. Resident 19 stated the facility nurse will remove the dressing after 24 hours. On 5/21/25 at 8:07 A.M., an observation and an interview were conducted with Resident 19 in her room. Resident 19 was seated in bed for breakfast. Dressing noted in her right arm dialysis access site. On 5/21/25 at 8:25 A.M., an interview was conducted with Licensed Nurse (LN) 21. LN 21 stated, Resident 19 went to dialysis yesterday and came back with a dressing on her dialysis access site. LN 21 stated she did not know when to remove the dressing in Resident 19 dialysis access site. On 5/21/25 at 11:30 A.M., a concurrent record review and an interview were conducted with LN 23. Resident 19 dialysis communication record was reviewed. There was no documentation indicated when to remove the dressing. LN 23 stated dressing on Resident 19's access site would be removed 24 hours after dialysis. On 5/21/25 at 4:20 P.M., an interview and an observation were conducted with Resident 19 in her room. Resident 19 was seated in her wheelchair and noted that there was no dressing on her right upper arm. Resident 19 stated the dressing was removed by the staff around 12 noon. On 5/22/25 at 4:32 P.M., an interview was conducted with LN 22. LN 22 stated Resident 19 access site dressing should be removed 24 hours after dialysis. On 5/22/25 at 8:06 A.M., a phone interview was conducted with the Hemo Dialysis Nurse (HDN). The HDN stated she was one of Resident 19's dialysis nurses and very familiar with her care. The HDN stated Resident 19 went to dialysis on Tuesday, Thursday, and Saturday. The HDN stated dressing on Resident 19's access site should be removed at the end of the day or between 4 - 6 hours after dialysis. The HDN stated the dressing should not be left on for 24 hours due to increased risk of clotting. On 5/22/25 at 8:42 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the dressing for the dialysis access site should be removed 24 hours after the dialysis. The facility did not have a Dialysis Care policy and procedure upon request. -

Based on observation, interview, and record review, the facility failed to ensure four of four license nurses were knowledgeable in assessing the thrill and bruit (thrills are palpable, vibratory sensations felt on the skin, while bruits are abnormal, audible sounds heard through a stethoscope) related to dialysis (the process of cleaning the blood through a machine) access. This failure had the potential for dialysis access to develop complications that may not be identified timely and addressed. Findings: Resident 19 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney failure), per the facility's, Patient Information. On 5/19/25 at 11:03 A.M., an interview was conducted with Resident 19 in her room. Resident 19 stated she was a dialysis resident and scheduled for dialysis on Tuesday, Thursday, and Saturday. Resident 19 showed her right arm dialysis access site. On 5/20/25 at 4 P.M., an observation and an interview were conducted with Resident 19 in her room. Resident 19 was up in her wheelchair. Resident 19 stated she came back from her dialysis at 1 P.M. and showed the dressing on her right upper arm dialysis access site. Resident 19 stated the facility nurse will remove the dressing after 24 hours. On 5/21/25 at 4:32 P.M., an interview was conducted with LN 22. LN 22 was unable to described how to check Resident 19's dialysis access site's bruit and thrill. On 5/22/25 at 7:25 A.M., an interview was conducted with Resident 19 in her room. Resident 19 was seated in her wheelchair. She stated that she was waiting for her transportation for dialysis. Resident 19 stated staff checked her dialysis access site every shift. Resident 19 described how the LNs checked if her dialysis access was working. Resident 19 stated the LNs placed their hands on the dialysis access and felt it. Resident 19 stated the LNs did not use a stethoscope in checking her dialysis access. On 5/22/25 at 7:36 A.M., an interview was conducted with LN 25. LN 25 stated she checked Resident 19's bruits and thrills by placing her hand over the dialysis access. LN 25 stated she did not receive training on how to take care of dialysis residents. On 5/22/25 at 9:32 A.M., an interview was conducted with LN 23. LN 23 stated she placed her hand over Resident 19's dialysis access to check the bruit and thrill. On 5/22/25 at 2:07 P.M., an interview was conducted with LN 11. LN 11 described how she checked the bruit and thrill of the dialysis access. She stated she placed her hand over the dialysis access and felt it. On 5/22/25 at 2:12 P.M., an interview was conducted with Unit Manager (UM) 11. UM 11 stated she did not receive educational training on how to take care of dialysis residents. On 5/22/25 at 2:29 P.M., an interview was conducted with LN 27. LN 27 stated she did not receive educational training on how to take care of dialysis residents. On 5/22/25 at 1:41 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she was not able to find evidence of training provided to staff related to dialysis care. On 5/22/25 at 1:50 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated she expected her staff to know how to properly check the bruit and thrill for a dialysis resident by using their stethoscope in listening to the bruit and palpating to feel the thrill. The DON further stated that she was not able to find evidence that staff were provided training on how to take care of dialysis residents. A review of the facility's Policy and Procedure(P&P) titled, Competency Evaluation, revision date 7/30/21, indicated .to identify the processes by which individual competence is evaluated and documented initially and on an ongoing basis to ensure employees at [name of the organization] can provide safe and effective quality care, treatment, and services .III .2. Competency evaluation focuses on key safety content such as specific processes and procedures related to the provision of care; conditions or diseases treated; services provided; the environment of care; infection control and equipment .

Based on interview and record review the facility failed to ensure the Medical Director (MD) participated in the development and implementation of written policies and procedures, related to the care of residents receiving dialysis services. This had the potential to affect the effectiveness and quality of care delivered to residents on dialysis. (Cross reference to F698 and F726) Findings: On 5/22/25 at 4:15 P.M., a telephone interview was conducted with the MD. The MD stated part of his role was to participate and attend the QAPI (Quality Assessment and Improvement Plan) meeting. Participate in the development and implementation of written policies governing the medical, nursing and related health care services provided in the facility, and oversight with the physician provider. The MD stated he was not aware there was no written policy and procedure for nursing care of dialysis residents and no inservice training provided to the licensed nurses (LN) in assessing dialysis access. The MD stated that there should have been a policy and procedure for nursing to follow standard care practice for dialysis residents. The MD stated LNs should have been educated and trained on how to take care of dialysis residents including the assessment of bruit and thrill (thrills are palpable, vibratory sensations felt on the skin, while bruits are abnormal, audible sounds heard through a stethoscope). On 5/22/25 at 4:40 P.M., an interview was conducted with the Administrator (ADM) and the Director of Nursing (DON). The ADM and the DON stated that in coordination with the MD, the facility would develop and implement policy and procedures for resident receiving dialysis services. A review of the facility's assessment, dated 9/18/17, indicated the facility provided dialysis services to residents. A review of a procedure for the Medical Director dated 2/16/11, indicated, .the standard of practice performed by the Medical Director included .plays a pivotal role in provision of clinical leadership regarding application of current standards of practice for resident care, new or proposed treatments, practices and resident outcomes. Knowledgeable regarding regulatory issues and the manner in which they may affect care practices. Provides input and approval for resident care policies and practices .

Based on interview and record review the facility failed to ensure accurate documentation related to: 1. Advance Directives for two residents (10, 131). 2. A documentation for a resident's capacity to understand and make decisions was missing for one resident (40) 3. Resident's consent for treatment was incomplete (40). This failure resulted in conflicting records regarding the presence of Advance Directives (10, 31) and did not provide an accurate representation of the care provided and had the potential to cause confusion amongst care providers (40). Findings: 1a. On 5/19/25 Resident 10's clinical record was reviewed. Resident 10 was admitted to the facility on [DATE] per the facility's Patient Information. A document titled Advance Directive Acknowledgment dated 2/19/19, 4/19/19, and 2/13/24 indicated, I do not have an Advance Directive, however, I am interested in receiving an Advance Directive Brochure . and was initialed by Resident 10 and Resident 10's family member. On 05/21/25 at 10:57 A.M., a joint review of Resident 10's record was conducted with Social Services (SS). The SS stated when residents were admitted Social Services assessed and documented the status of Advance Directives. Resident 10's Social Services Evaluation dated 11/20/19 indicated, Advance Directive: Yes/copy obtained and on chart. The SS stated the Advance Directive should have been on the chart. On 05/21/25 at 02:21 P.M., a joint review of Resident 10's chart was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 10 did not have an Advance Directive the on chart. LN 23 stated if there was an Advance Directive it should have been on the physical paper chart. On 05/21/25 at 2:32 P.M., a joint review of Resident 10's record was conducted with the Administrator (ADM). The ADM stated if there was an Advanced Directive, it should have been on the physical paper chart. The ADM acknowledged the documentation discrepancy regarding the presence of an Advanced Directive. On 05/22/25 at 08:48 A.M., a joint review of Resident 10's record was conducted with the Health Information Services Coordinator (HISC). The HISC stated if a resident had an Advanced Directive, HISC scanned it into the electronic record, and then placed the hard copy on the physical paper chart. The HISC verified there was not an Advanced Directive on the chart for Resident 10. On 05/22/25 at 09:05 A.M., the Administrator (ADM) was interviewed. The ADM stated it was a duplicative process to have the Advance Directives Acknowledgment form handled by the Business Office in addition to the Social Services Evaluation Form. The ADM stated the documentation had a discrepancy regarding if Resident 10 had an Advanced Directive. The ADM stated there was no Advanced Directive available for Resident 10. Per facility procedure Advance Directives, revised 5/13/24, .should make every effort to obtain the patient's Advance Directive .a copy should be placed in the patient's medical record . 1b. On 5/19/25 Resident 131's clinical record was reviewed. Resident 131 was admitted to the facility on [DATE] per the facility's Resident Information. A document titled Advance Directive Acknowledgment dated 5/3/25 indicated; I do not have an Advanced Directive, however, I am interested in receiving an Advanced Directive Brochure. was initialed by Resident 131. On 05/21/25 at 10:59 A.M., a joint review of Resident 131's clinical record was conducted with Social Services (SS). The SS stated upon admission Social Services did an assessment which included Advanced Directive status. Resident 131's assessment indicated, Reg Adv Dir Info: Yes/copy requested. The SS stated the Advance Directive should have been on the chart. On 05/21/25 at 02:21 P.M., a joint review of Resident 131's chart was conducted with Licensed Nurse (LN) 23. LN 23 stated Resident 131 did not have an Advance Directive the on chart. LN 23 stated if there was an Advance Directive it should have been on the physical paper chart. On 05/22/25 at 08:48 A.M., a joint review of Resident 131's record was conducted with the Health Information Services Coordinator (HISC). The HISC stated if a resident had an Advance Directive, HISC scanned it into the electronic record, and then placed the hard copy on the physical paper chart. The HISC verified there was not an Advanced Directive on the chart for Resident 131. On 05/22/25 at 09:05 A.M., the Administrator (ADM) was interviewed. The ADM stated it was a duplicative process to have the Advance Directives Acknowledgment form handled by the Business Office in addition to the Social Services Evaluation Form. The ADM stated the documentation had a discrepancy regarding if Resident 131 had an Advance Directive. The ADM stated there was no Advanced Directive available for Resident 131. Per facility procedure Advance Directives, revised 5/13/24, .should make every effort to obtain the patient's Advance Directive .a copy should be placed in the patient's medical record . 2. Resident 40 was re-admitted to the facility on [DATE] at 1:41 P.M. according to the facility's Patient Information. A review of Resident 40's physician progress notes dated 11/7/24 at 1:27 P.M., indicated diagnoses which included cognitive developmental delay with left cerebral hydrocephalus (fluid buildup causing increase pressure in the brain) and dependence on a ventilator (a medical device that helps a patient breathe by delivering oxygen). On 5/22/25 at 8:35 A.M., an interview and record review were conducted with licensed nurse (LN) 41. LN 41 stated residents' capacity to understand and make decisions were documented in the physician orders during each admission and re-admission. LN 41 stated re-admission on [DATE] documentation indicated Resident 40 did not have capacity to understand and make decisions. LN 41 stated Resident 40 was re-admitted to the facility on [DATE] but Resident 40's capacity to understand and make decision was not documented. On 5/22/2025 at 9:37 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the physician determined resident's capacity to understand and make decisions and should have been documented in the history and physical examination (H&P). The DSD stated a physician determination of resident's capacity to understand and make decision should have been completed upon admission and on readmission. On 5/22/2025 at 10:22 A.M., an interview and record review were conducted with the Director of Nursing (DON). The DON stated physician the H&P did not mention Resident 40's capacity. The DON stated the physician determines a resident's capacity to understand and make decisions. The DON stated during readmission, LNs would ask the physician to resume a physician order including a resident's capacity to understand and make decisions. The DON stated physician should resume all orders including the resident's capacity to understand and make decisions. According to the facility policy entitled Policy: Capacity to Make Health Care Decisions, revised date 1/8/2025, indicated .III .B. Determination of Capacity .1. The primary physician is responsible for determining the patient's capacity to make health care decisions. 2. If there are indications that the patient lacks the capacity to make health care decisions, the primary physician should evaluate the patient .C. Documentation and Communication .1. The determination that a patient lacks or has a recovered capacity should promptly recorded in the patient's medical record . According to the facility policy entitled Procedure: Documentation Schedule, revised date 9/20/2019, indicated .IV. STEPS OF PROCEDURE: C. admission documentation is completed within 24 hours of the admission . 3. A review of Resident 40's facility [name of facility] Consent to Treatment did not indicate two witnesses for Resident 40's responsible party's (RP) verbal consent on 11/7/24 and was incomplete. On 5/22/25 at 9:03 A.M., an interview and record review were conducted with LN 41. LN 41 stated two licensed nurses should witness a verbal or telephone consent. LN 41 stated Resident 40's Consent to Treatment did not indicate two witnesses and was incomplete. On 5/22/25 at 10:40 A.M., an interview was conducted with the DON. The DON stated two licensed nurses should have witnessed verbal consent. On 5/22/25 at 10:56 A.M., an interview and record review were conducted with the administrator (ADM) and the DON. The DON stated the facility should complete Resident 40's Consent to Treatment because the facility was not authorized to do anything for her. The ADM stated the licensed nurses should complete the Consent to Treatment. The ADM stated two witnesses were required to verify verbal consent. According to the facility policy entitled Procedure: Documentation Schedule, revised date 9/20/2019, indicated .IV. STEPS OF PROCEDURE: C. admission documentation is completed within 24 hours of the admission . According to the facility policy entitled Policy: Conditions of Admission, revised date 2/14/25, indicated .5. If the patient or legal representative verbally consents to the CoA, two hospital employees should witness the verbal consent .

Based on interview and record review, the facility failed to ensure the controlled drug record (CDR- an accounting of controlled medications, drugs with a high abuse potential) reconciled with the medication administration record (MAR- documentation that a resident received a medication) for one of three residents (Resident 3 ). As a result, this failure had the potential for the facility to be unable to readily identify drug diversion (illegal distribution or abuse of prescription drugs) of controlled medications. Findings: Resident 3 was admitted to the facility on [DATE] per the facility's Patient Information sheet. A record review of Resident 3's physician's order, CDR, and MAR was performed. Resident 3's physician's order dated 3/19/24, indicated the Resident was to receive oxycodone 5 milligrams (medication used to relieve pain) one tab every six hours as needed for moderate to severe pain. A review of Resident 3's CDR indicated 3 doses of the resident's oxycodone 5 milligrams was removed from the locked supply on 3/10/2025, 3/12/25, and 3/18/25. Resident 3's MAR for oxycodone 5 milligrams had blank entries on 3/10/2025, 3/12/25, and 3/18/25 and it could not be determined if the medication had been given to the resident. During an interview on 5/22/25 at 10:53 A.M., Unit Manager (UM)11 stated the Licensed Nurse (LN) had to sign controlled medications out on the CDR and document on the MAR when the medication was given to the resident. UM 11 stated that it was important to keep track of controlled medications so that other LNs knew when the medication was given. During a concurrent interview and record review on 5/22/25 at 11:07 A.M., the Director of Staff Development (DSD) reviewed the resident's CDR and MAR. The DSD stated Resident 3's oxycodone 5 milligrams tablet was removed and was not documented as administered on Resident 3's MAR on 3/10/25, 3/12/25, and 3/18/25. The DSD stated her expectation was for the LN to sign the CDR when controlled medications were removed from the locked drawer and then for the LN to document on the resident's MAR once the medication was given to the resident. During an interview on 5/22/25 at 2:15 P.M., the Director of Nursing (DON) stated Resident 3's oxycodone 5 milligram tablet was removed on 3/10/25, 3/12/25 and 3/18/25 but was not documented as given to the resident on the MAR. The DON stated there was currently no audit of controlled medications being done. The DON stated that the significance of doing an audit was to make sure there was no diversion. A review of the facility's policy and procedure titled Procedure: Controlled Drugs revised 9/12/2019, did not provide guidance related to reconciling and accounting for controlled medications.

Based on observation, interview, and record review, the facility failed to ensure medications in carts were properly stored and labeled when the following was found in two of twenty medication carts: 1. An expired insulin pen. 2. A use by sticker on a medication bottle was illegible. 3. There was a white pill in an unlabeled medication cup. As a result, medications had the potential to be improperly administered. Findings: On [DATE] at 3:39 P.M., an observation and interview was conducted with Licensed Nurse (LN) 2 during a review of a medication cart. Lantus 100 units/mL (milliliter) pen (a medication given to lower blood sugar), was found in the top drawer of the medication cart labeled with an orange sticker: do not use after [DATE]. LN 2 stated when insulin was opened the nurse put an orange sticker with the use by date on the insulin pen. LN 2 stated insulin once opened was good for 28 days. LN 2 stated nurses were supposed to check the date and double check the time to discard since the insulin is not potent after expiration. In the bottom drawer of the medication cart, a bottle of Constulose 10 g/15 mL (a medication to treat constipation) had an illegible date written on the use by sticker. LN 2 stated labeling should be legible to make sure it was not expired. On [DATE] at 11:36 A.M., an observation and interview was conducted with LN 3. One white pill in an unlabeled medication cup was found in the top drawer of a medication cart. LN 3 stated it should have had the resident's name and name of medication written on the cup. On [DATE] at 3:38 P.M., an interview was conducted with the Unit Manager (UM) 1. UM 1 stated open insulin should have been discarded within 28 days per their pharmacy's guidance. UM 1 stated use by labels on medications should be legible. On [DATE] at 2:05 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the orange use by label lets the facility know when the medication would expire. The DON stated open Lantus with a use by date of [DATE] should not have been stored and ready for use in the medication cart. The DON stated labeling on medications should be legible. DON stated all medications needed to be dated and labeled with the resident name. A review of the facility's policy titled Medications and Medication Labels dated 5/16, indicated, .1. Each prescription medication will be labeled to include: .f. Date medication is dispensed .h. Expiration or end-of-use date, if not dispensed in original manufacturer packaging .End-of-use dating, which only includes the month and year (01/2017), falls to the last day of that month (expires [DATE]) 8. Medication containers having soiled, damaged, incomplete, illegible or makeshift labels are returned to pharmacy for re-labeling or destroyed in accordance with the medication destruction policy A review of the facility's undated document provided by their pharmacy titled Abridged List of Medications with Shortened Expiration Dates indicated, .Insulins .Long Acting . Brand name Lantus . Beyond Use Date (BUD) Notes After Accessing Insulin for First Use .pen - 28 days .

Based on observation, interview, and record review, the facility failed to ensure Resident 7 was not abused. As a result, Resident 7 experienced abuse from two staff members. In addition, other residents who were cognitively impaired (problem with the ability to think, learn, remember, use judgement, and make decisions) had the potential to suffer abuse from the two staff members. Findings: On 9/4/24 at 9:50 A.M., an unannounced visit was made to the facility in response to a reported abuse incident. An observation was conducted on 9/4/24 at 12:49 P.M. Resident 7 was sitting in a wheelchair in the hallway with other residents. Resident 7 had a frown on her face and was hugging a doll. A review of Resident 7 ' s record was conducted. Per the facility ' s face sheet, Resident 7 was admitted to the facility on [DATE]. The Physician Progress Note, dated 8/8/24 indicated Resident 7 ' s diagnoses including senile dementia (a progressive decline leading to loss of memory, language, problem solving, other thinking abilities and loss of independence in daily activities). Resident 7 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/31/24, section C0700 through section C1000 indicated Resident 7 had short and long-term memory problem, memory/recall problem and had severely impaired daily decision making. On 9/4/24 at 12:07 P.M., an interview was conducted with the Director of Nursing (DON), with the Administrator present in the facility ' s conference room. The DON stated that on 1/26/24, she and the administrator received a video call from an attorney who represented Resident 7 ' s family. The DON stated that the attorney informed the DON and the Administrator that Resident 7 ' s family placed a hidden camera in Resident 7 ' s room from 11/29/23 through 1/26/24, which showed assaultive behavior by staff, evidence of shoving and hitting Resident 7, and lack of compassion by staff. The DON stated that she ended the call and directed the issue to the facility ' s risk management (department; the facility ' s process of identifying and controlling threats to an organization). The DON stated that on 8/22/24, she was notified by the [health care system ' s] Chief Nursing Officer (CNO) of videos that involved Resident 7. The DON stated she first viewed the video footage on 8/22/24. The DON stated that she and the Administrator identified two CNAs (CNA 1 and CNA 2) in the video footage. The DON stated that in one video, a third staff member was observing (the abusive behavior toward Resident 7) in the room. The DON stated she was able to identify the third staff member as LN 3 and confirmed all three staff members were employed by the facility in November 2023. A review of the videos from Resident 7 ' s room was conducted on 9/25/24 at 8:56 a.m. in the facility ' s conference room with the Administrator. The Administrator provided a laptop computer to view the eleven recorded videos. All eleven video footages were not identified with a date and/or time that indicated when the videos of the abuse incidents were taken/recorded. The Administrator identified CNA 1, CNA 2, and LN 3 on the videos. The undated video number one showed Resident 7 lying in bed wearing only a bra. Resident 7 was speaking in Spanish (unable to understand what the resident was saying in the video), and CNA 1 placed her right hand over Resident 7 ' s mouth and told Resident 7, Shh. CNA 1 then turned/positioned Resident 7 on the right side in a rough manner, pulled out Resident 7 ' s brief from underneath Resident 7, wiped Resident 7 ' s perineum (peri; area of skin between the anus and genitals; private area between the thighs), then turned Resident 7 in a rough manner on to the left side after putting a new brief on Resident 7. Resident 7 was frowning and was communicating to CNA 1 in Spanish (unable to determine what the resident was saying), but CNA 1 was not responding. Video number one lasted one minute. The undated video number two showed Resident 7 lying in bed. CNA 1 was standing near Resident 7 ' s left side with a vital sign machine (machine that takes temperature, heart rate, blood pressure and oxygen saturation [(oxygen level]). The blood pressure cuff was fastened on Resident 7 ' s left upper arm. CNA 1 placed a thermometer under Resident 7 ' s left underarm and the pulse oximeter (device to take oxygen level) on Resident 7 ' s left finger. Resident 7 moved her left arm and CNA 1 held Resident 7 ' s left arm down and tapped (to strike lightly, usually repeatedly) Resident 7 ' s right side of face with CNA 1 ' s right hand. CNA 1 told Resident 7, Calmate [calm down], do not move, while holding the resident ' s left arm down, Calmate, I told you. Video number two lasted two minutes and 47 seconds. The undated video number three showed Resident 7 lying in bed and CNA 1 was putting a shirt on Resident 7. CNA 1 put Resident 7 ' s left arm through the sleeve, then resident ' s head. While Resident 7 ' s head was up, CNA 1 hit Resident 7 with an open hand at the back of Resident 7 ' s head. Video number three lasted 22 seconds. The undated video number four showed Resident 7 lying in bed. CNA 1 was standing near Resident 7 ' s left side. CNA 1 took a pillow and a doll from Resident 7 ' s right side and threw the pillow and doll on to the overbed table next to the right side of the bed. CNA 1 pulled down the white top sheet, exposed Resident 7 ' s legs, took the pillow from Resident 7 ' s right side, and hit resident on the face with the pillow. CNA 1 then threw the pillow at the foot of the bed. Resident 7 spoke to CNA 1 in Spanish (unable to determine what the resident was saying) and pulled the bottom of her hospital gown and covered her face. CNA 1 took the pillow from under Resident 7 ' s head and threw it at the foot of the bed. Video number four lasted 41 seconds. The undated video number five showed Resident 7 sitting in a wheelchair positioned at the left side of the bed, facing the head of the bed. CNA 1 stood in front of Resident 7 and lifted Resident 7 to a standing position by holding on to Resident 7 ' s left arm. Resident 7 wore a long sleeve shirt and a brief. As CNA 1 lifted Resident 7 off from the wheelchair and almost to a sitting position on the bed, CNA 1 unfastened the tape on the left side of Resident 7 ' s brief. CNA 1 sat resident on the bed, then hit Resident 7 with an open hand on the back of the head with her right hand and placed both hands on Resident 7 ' s head while CNA 1 forcefully pushed Resident 7 ' s head down to lay on Resident 7 ' s left side in bed. Resident 7 was frowning and speaking (unable to determine what the resident was saying) in Spanish. Video number five lasted 26 seconds. The undated video number six showed Resident 7 lying in bed exposed, wearing a long sleeve shirt and brief. CNA 1 was standing at the left side of the bed. CNA 1 pulled off Resident 7 ' s blanket and the pillow from Resident 7 ' s right side and threw the pillow toward the foot of the bed. Resident 7 grabbed a hospital gown, which was on the right side of bed, and CNA 1 grabbed it from Resident 7 and threw it on the floor. CNA 1 raised the height of the bed, pulled the pillow from Resident 7 ' s left side, and threw it on the overbed table on the right side of bed. CNA 1 unfastened Resident 7 ' s brief and stated to resident, Open your legs. Resident 7 was saying something in Spanish (unable to determine what the resident was saying) and tried to hold on to her brief with her right hand. CNA 1 slapped (contact with an open hand) Resident 7 ' s right hand that was holding on to the brief. Resident 7 was speaking in Spanish (unable to determine what the resident was saying), frowning, and crying. Video number six lasted 40 seconds. The undated video number seven showed Resident 7 lying in bed wearing only a brief. CNA 1 was changing Resident 7 ' s brief and was positioned standing at the left side of the bed. CNA 1 walked to the right side of the bed and pushed Resident 7 on the hip to turn the resident on to the left side. Resident 7 held on to the left bedrail and CNA 1 pushed Resident 7 ' s legs, which caused Resident 7 to sit up halfway, at the edge of the bed. CNA 1 pushed on resident ' s right shoulder as she pulled off a gray gown, then a blue gown from under Resident 7. CNA 1 grabbed Resident 7 ' s right arm and pushed Resident 7 to lay back down in bed and pulled Resident 7 ' s legs from a dangling position back to the center of the bed. CNA 1 threw the gowns on the floor and turned Resident 7 ' s body on to the left side. CNA 1 wiped Resident 7 ' s back and buttocks and removed the pad from under Resident 7 while pushing Resident 7 ' s right leg. CNA 1 then pushed Resident 7 ' s right leg again with CNA 1 ' s right hand while CNA 1 ' s left hand held on to Resident 7 ' s right arm. CNA 1 slapped Resident 7 ' s right upper thigh with her right hand. Video number seven lasted one minute. The undated video number eight showed Resident 7 lying in bed wearing a long sleeve shirt and purple pants that were pulled up to Resident 7 ' s thigh. CNA 1 put pants on Resident 7, turned Resident 7 towards her, then grabbed and pulled Resident 7 ' s long hair up to elevate Resident 7 ' s head, and pulled Resident 7 ' s hair and head towards her (CNA 1). LN 3 entered Resident 7 ' s room and was talking (unable to determine what LN 3 was saying) to CNA 1. LN 3 was facing CNA 1 and Resident 7. The video showed LN 3 ' s back and part of the left side of LN 3 ' s face. As LN 3 was speaking with CNA 1 (unable to determine what LN 3 was saying), Resident 7 ' s head was still being pulled with resident ' s head raised up to CNA 1 ' s upper body. CNA 1 quickly lowered Resident 7 ' s head and fixed (straightened/smoothed over) Resident 7 ' s clothing. Resident 7 was frowning and speaking in Spanish during this video footage (unable to determine what the resident was saying). Video number eight lasted one minute. The undated video number nine showed Resident 7 lying in bed. CNA 1 walked to Resident 7 ' s right side of the bed and pulled the pad under Resident 7 towards her. CNA 1 took a brief from the foot of the bed and walked to Resident 7 ' s right side of the bed. Resident 7 sat up at the side of the bed and CNA 1 pushed Resident 7 ' s head back down in bed, in a rough manner with CNA 1 ' s left hand, then lifted Resident 7 ' s legs from dangling at the edge of the bed and placed them in bed. Video number nine lasted one minute. The undated video number 10 included a title which indicated Shaving cream was applied to Resident 7. Video number ten showed Resident 7 lying on her right side in bed without clothes or a brief. CNA 1 wiped Resident 7 ' s back, back of thighs, and buttock with a white cream. CNA 1 opened a blue pad and white pad, rolled them together and placed them under Resident 7. Video number 10 lasted one minute. The undated video number 11 showed Resident 7 lying in bed, positioned on her left side, facing towards CNA 2, who was standing next to the bed. CNA 2 replaced the pad and brief from under Resident 7. Resident 7 ' s right leg was crossed over the left leg and CNA 2 separated Resident 7 ' s legs open in a forceful manner and pushed Resident 7 ' s right leg with (CNA 2 ' s) right hand to keep Resident 7 ' s legs open. Resident 7 screamed Ahhhh and was crying out loud. Video number 11 lasted 39 seconds. A review of Resident 7 ' s care plans were conducted. Resident 7 ' s care plan for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) indicated .LTC [Long-term Care] ADL Function Rehab .Last Updated on 2/22/24 .Interventions .Provide Assistance to Support Level of Need .Assist With Oral Care/Grooming .Assist With Toileting/Peri Care .Assist With Dressing in Appropriate Clothes .Assist With Bathing to include Shower per Schedule . The care plan regarding Resident 7 ' s behavior indicated .LTC Behavioral Symptoms .Last Updated 9/30/22 .Interventions .Provide Care With Smile, Gentle Touch, Soft Reassuring Voice . During an interview on 9/25/24 at 10:12 A.M. with the DON, the DON acknowledged the abuse of Resident 7, and stated that the videos were devastating and shocking. The DON stated that Resident 7 .looked terrified and experienced pain as it was heard on the video. The DON further stated that CNA 1 and CNA 2 ' s employment at the facility were terminated on 9/18/24. During an interview on 10/1/24 at 12:52 P.M. with the DON, the DON stated LN 3 ' s employment at the facility had been terminated but did not recall exact date. Interviews of CNA 1, CNA 2 and LN 3 were not conducted due to CNA 1, CNA 2 and LN 3 were no longer employed at the facility. A review of facility records for CNA 1 titled, Evaluation Report, signed by CNA 1 and the DON on 10/21/23 was conducted. The evaluation report indicated, .Join Date: 1/5/2004 .Status .Active Full-Time . A facility letter addressed to CNA 1 dated 9/18/24 indicated, . After review and consideration of the information, it remains the decision . to terminate your employment effective, 9/18/24 . A review of facility records for CNA 2 titled, Evaluation Report, signed by CNA 2 and the DON on 11/13/23 was conducted. The evaluation report indicated, .Join Date: 9/8/2014 .Status .Active Full-Time . A facility letter addressed to CNA 2 dated 9/18/24 indicated, . After review and consideration of the information, it remains the decision . to terminate your employment effective, 9/18/24 . A review of facility records for LN 3 titled, Evaluation Report, signed by LN 3 and the DON on 11/17/23 was conducted. The evaluation report indicated, .Join Date: 8/30/2004 .Status .Active Full-Time . A facility letter addressed to LN 3 dated 9/5/24 indicated, .This letter is to notify you .to terminate employment .effective, 9/5/24 . A review of the facility ' s policy and procedure (P&P) titled, Abuse Prohibition - Alleged, revised on 10/22/22 was conducted. The P&P indicated, .to protect residents as dependent adults from abuse, neglect, involuntary seclusion, and misappropriation of property for all residents .Physical abuse includes .Assault, battery . Assault with . force likely to produce great bodily injury .Psychological/mental abuse includes fear, agitation .and other forms of serious emotional distress . If a photograph or recordin [sic] of a resident . that it is used demeans or humiliates a resident (s) . regardless of the residents [sic] cognitive status will be considered abuse .

Based on observation, interview and record review, the facility failed to implement policies and procedures for abuse when: a licensed nurse (LN) did not report a witnessed abuse of one resident. (Resident 7). This failure resulted in an incomplete investigation and protection of residents from the perpetrators. Findings: Resident 7 was admitted to the facility on [DATE], per Resident 7 ' s face sheet. The Physician Progress Note, dated 8/8/24, indicated Resident 7 ' s diagnoses included senile dementia (a progressive decline leading to loss of memory, language, problem solving, other thinking abilities and loss of independence in daily activities). Resident 7 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/31/24, section C0700 through section C1000, indicated that Resident 7 had short and long-term memory problem, memory/recall problem, and had severely impaired daily decision making. An interview with certified nursing assistant (CNA) 5 was conducted on 9/4/24 at 10:50 A.M. CNA 5 stated that a witnessed physical abuse of a resident should be reported to the Director of Nursing (DON) and the Administrator right away. During an interview on 9/4/24 at 11:15 A.M. with licensed nurse (LN) 1, LN 1 stated that any physical abuse should be reported to the DON and the Administrator as soon as possible. On 9/4/24 at 12:07 P.M., an interview was conducted with the DON in the facility ' s conference room. The Administrator was present during this interview. The DON stated that on 1/26/24 she received a call from an attorney who represented Resident 7 ' s family. The DON stated that the attorney informed the DON and Administrator that Resident 7 ' s family had placed a hidden camera in Resident 7 ' s room from 11/29/23 through 1/26/24. The DON stated the attorney informed her that there were videos which showed staff ' s lack of compassionate care and abusive behavior. A review of the videos from Resident 7 ' s room was conducted on 9/25/24 at 8:56 a.m. in the facility ' s conference room with the Administrator. The Administrator provided a laptop computer to view the 11 recorded videos. The video footage did not include dates or times that indicated when the abuse incidents occurred. One undated video showed Resident 7 lying in bed wearing a long sleeve shirt and purple pants that were pulled up to Resident 7 ' s thigh. CNA 1 put pants on Resident 7, turned Resident 7 towards her, then grabbed and pulled Resident 7 ' s long hair up to elevate Resident 7 ' s head, and pulled Resident 7 ' s hair and head towards her (CNA 1). LN 3 entered Resident 7 ' s room and was talking (unable to determine what LN 3 was saying) to CNA 1. LN 3 was facing CNA 1 and Resident 7. The video only showed LN 3 ' s back and part of the left side of LN 3 ' s face. As LN 3 was speaking with CNA 1, Resident 7 ' s head was still being pulled with resident ' s head raised up to CNA 1 ' s upper body. CNA 1 quickly lowered Resident 7 ' s head and fixed (straightened/smoothed over) Resident 7 ' s clothing. Resident 7 was frowning and speaking in Spanish during this video footage (unable to determine what the resident was saying). A telephone interview was conducted on 10/1/24 at 12:52 P.M. with the DON. The DON acknowledged that LN 3 witnessed abuse of Resident 7, as shown in the video. The DON stated LN 3 was a mandated reporter and expected LN 3 to have reported the incident to her, the supervisor, or to the compliance hotline immediately. The DON further stated she expected all staff to report abuse immediately, per the facility ' s abuse policy. A review of the facility ' s policy and procedure (P&P) titled, Abuse Prohibition - Alleged, revised on 10/22/22 was conducted. The P&P indicated, . SUMMARY/INTENT .to protect residents as dependent adults from abuse . [Mandated Reporter] Any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult . including administrators, supervisors, and any licensed staff .that provides care or services for elder or dependent adults . Reports can be made by anyone having knowledge of abuse or information regarding a resident ' s safety and/or well-being. An employee who has knowledge of resident abuse shall report this to their immediate supervisor .If the . abuse occurs within the facility, the facility will contact the California Department of Public Health within 24 hours .

Based on observation, interview, and record review, the facility failed to ensure staff reported a witnessed physical abuse of a resident (Resident 7) who was cognitively impaired (problem with the ability to think, learn, remember, use judgement, and make decisions) to the facility's administration. This deficient practice had the potential for actual and/or alleged abuse incidents to be unreported and not investigated. In addition, this failure had the potential for residents to be unprotected from abuse. Findings: A review of Resident 7 ' s clinical record was conducted. Resident 7 was admitted to the facility on [DATE], per Resident 7 ' s face sheet. The Physician Progress Note, dated 8/8/24, indicated Resident 7 ' s diagnoses included senile dementia (a progressive decline leading to loss of memory, language, problem solving, other thinking abilities and loss of independence in daily activities). Resident 7 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 7/31/24, section C0700 through section C1000, indicated that Resident 7 had short and long-term memory problem, memory/recall problem, and had severely impaired daily decision making. An interview with certified nursing assistant (CNA) 5 was conducted on 9/4/24 at 10:50 A.M. CNA 5 stated that a witnessed physical abuse of a resident should be reported to the Director of Nursing (DON) and the Administrator right away. An interview with licensed nurse (LN) 1 was conducted on 9/4/24 at 11:15 A.M. LN 1 stated that any physical abuse should be reported to the DON and the Administrator as soon as possible. On 9/4/24 at 12:07 P.M., an interview was conducted with the DON in the facility ' s conference room. The Administrator was present during this interview. The DON stated that on 1/26/24 she received a call from an attorney who represented Resident 7 ' s family. The DON stated that the attorney informed the DON and Administrator that Resident 7 ' s family had placed a hidden camera in Resident 7 ' s room from 11/29/23 through 1/26/24. The DON stated the attorney informed her that there were videos which showed staff ' s lack of compassionate care and abusive behavior. The DON stated that she ended the call and directed the issue to the facility ' s risk management (department; the facility ' s process of identifying and controlling threats to an organization). The DON stated that on 8/22/24, the Chief Nursing Officer (CNO) notified her of videos that included Resident 7. The DON stated she first viewed the video footage on 8/22/24. The DON stated that she and the Administrator identified two CNAs in the video footage. The DON stated that in one video, a third staff member was observing (the abusive behavior toward Resident 7) in the room. The DON identified the third staff member as LN 3. A review of the videos from Resident 7 ' s room was conducted on 9/25/24 at 8:56 a.m. in the facility ' s conference room with the Administrator. The Administrator provided a laptop computer to view the 11 recorded videos. The video footage did not include dates or times that indicated when the abuse incidents occurred. One undated video showed Resident 7 lying in bed wearing a long sleeve shirt and purple pants that were pulled up to Resident 7 ' s thigh. CNA 1 put pants on Resident 7, turned Resident 7 towards her, then grabbed and pulled Resident 7 ' s long hair up to elevate Resident 7 ' s head, and pulled Resident 7 ' s hair and head towards her (CNA 1). LN 3 entered Resident 7 ' s room and was talking (unable to determine what LN 3 was saying) to CNA 1. LN 3 was facing CNA 1 and Resident 7. The video only showed LN 3 ' s back and part of the left side of LN 3 ' s face. As LN 3 was speaking with CNA 1, Resident 7 ' s head was still being pulled with resident ' s head raised up to CNA 1 ' s upper body. CNA 1 quickly lowered Resident 7 ' s head and fixed (straightened/smoothed over) Resident 7 ' s clothing. Resident 7 was frowning and speaking in Spanish during this video footage (unable to determine what the resident was saying). A telephone interview was conducted on 10/1/24 at 12:52 P.M. with the DON. The DON acknowledged that LN 3 witnessed Resident 7 being abused, as shown in the video. The DON stated that LN 3 was a mandated reporter and expected LN 3 to have reported the incident to her, the supervisor, or to the compliance hotline immediately. The DON further stated she expected all staff to report abuse immediately. A review of the facility ' s policy and procedure (P&P) titled, Abuse Prohibition - Alleged, revised on 10/22/22 was conducted. The P&P indicated, .Reports can be made by anyone having knowledge of abuse or information regarding a resident ' s safety and/or well-being. An employee who has knowledge of resident abuse shall report this to their immediate supervisor .If the . abuse occurs within the facility, the facility will contact the California Department of Public Health within 24 hours .

Based on interview and record review, the facility failed to ensure a person-centered care plan was updated for one of three residents (Resident 1) reviewed with osteoporosis (bone disease; weak, brittle bones). This failure had the potential to miscommunicate care related to Resident 1 ' s health and safety when providing care, assistance, and repositioning for Resident 1. Findings: A record review of Resident 1's face sheet (contains demographic information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (a serious health condition; difficulty breathing). A record review of Resident 1's Minimum Data Set (MDS; nursing assessment tool), section B0100, dated 11/14/23, indicated .comatose . persistent vegetative state /no discernible consciousness (individual does not show signs of awareness). This section was coded as yes. A record review of Resident 1's portable chest x-ray, signed by the medical doctor (MD), dated 1/5/23, indicated .Probable small bilateral pleural effusions (build-up of fluid in the tissues that line the lungs and chest). Bones are osteopenia (condition that occurs when the body does not make new bone) . A record review of Resident 1's x-ray of the left toe, signed by the MD, dated 8/3/23, indicated .osteopenia and flexion deformity of the toes . A record review of Resident 1's document titled Physician Progress Note, dated 1/15/24, indicated .The patient's left humerus fracture was most likely related [to] staff moving his left arm while turning, dressing, shifting in bed in combination with osteoporosis . An interview was conducted on 1/22/24 at 11:59 A.M. with CNA (certified nursing assistant) 3, in the conference room. CNA 3 stated that he worked with Resident 1 on 1/15/24, the morning of when the fracture was first discovered. CNA 3 stated that Resident 1 required two-person assistance with transfers, repositioning, and all care. CNA 3 stated Resident 1 was bed-bound (no longer able to move easily; confined to a bed). An interview was conducted on 1/22/24 at 12:21 P.M. with CNA 4, in the conference room. CNA 4 stated that Resident 1 used to transfer to a wheelchair with a Hoyer lift (mechanical lift that assisted with resident transfers) but stated that he has not seen Resident 1 out of bed, as of date. CNA 4 stated that after the incident with Resident 1's left arm fracture, that an in-service (education/training) was conducted by the rehabilitation (rehab) team. CNA 4 stated that if he was not familiar with Resident 1's care, that he would seek the information from the licensed nurses (LN) to provide safe care. A concurrent interview and record review of Resident 1's medical record was conducted on 1/22/24 at 2:10 P.M., with the MDS nurse (MDS). The MDS nurse confirmed Resident 1 ' s chest x-ray with noted osteopenia by the MD on 1/5/23. The MDS nurse stated that Resident 1 was at risk for fractures and injuries due to brittle bones associated with osteopenia. The MDS nurse stated that Resident 1's care plan did not address the risks for injuries or fractures when assisting the resident with activities of daily living (ADL) care, and did not reflect rehab recommendations from the in-service. The MDS nurse stated that Resident 1's care plan should have been updated when there was a medical change, as noted in the chest x-ray dated 1/5/23, to ensure safety precautions were in place, due to osteoporosis risk factors. An interview was conducted on 1/22/24 at 2:59 P.M. with LN 1, in station C. LN 1 stated that it was important to include any new diagnosis such as osteoporosis, in a care plan. LN 1 stated that the care plan was important because it helped to communicate risk factors related to preventing injury of fragile bones and ensure safe care practices for the residents. An interview was conducted on 1/22/24 at 3:12 P.M. with LN 2, in the hallway outside of Resident 1's room. LN 2 stated it was important to know resident ' s change of conditions to help prevent injuries and provide safe care. LN 2 stated that risk factors should be personalized for Resident 1, due to Resident 1 ' s risk factors associated with osteoporosis, so that gentle care may be provided during ADL care. An interview was conducted on 1/22/24 at 4:30 P.M. with the DON, in the conference room. The DON stated it was her expectation that care plans were updated and personalized to provide a safe plan of care for Resident 1, and to help prevent future fracture injuries. Per the facility policy and procedure titled, Procedure: Care Planning and Assessment, revised 10/24/18 Rev 4 indicated .IV. Steps of procedure . F. The plan of care will be kept current during the patients stay and will be updated . if there is a medical change of condition, the members of the IDT will update and modify interventions .

Based on observation, interview and record review the facility failed to implement transmission based infection control measures when Licensed Nurse (LN) 2 entered the room of a resident (Resident 1) who tested positive for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) without the required personal protective equipment (PPE, equipment worn to minimize exposure to infection and injury in the workplace). This failure had the potential to increase the risk of COVID-19 transmission to all residents, staff, and visitors at the facility. Findings Include: Resident 1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, per the residents admission record. On 12/5/23 at 11:31 AM an interview was conducted with LN 1 in the hallway outside Resident 1's room. LN 1 stated Resident 1 had tested positive on the routine rapid antigen test for COVID-19 this morning. On 12/5/23 at 11:53 AM an observation and interview were conducted with LN 2 outside of Resident 1's room. LN 2 was observed entering Resident 1's room wearing a gown, gloves, N95 respirator (a respiratory protection device worn over the mouth and nose that filters viruses and particles). LN 2 was not observed wearing a face shield or eye protection upon entering Resident 1's room. LN 2 was observed exiting Resident 1's room at 11:59 AM. LN 2 stated she should have worn eye protection or a face shield in Resident 1's room because Resident 1 tested positive for COVID-19 and had been placed on enhanced droplet precautions (PPE that includes a mask, gown, gloves, eye protection). LN 2 stated not wearing the required PPE while providing care for a COVID-19 positive resident was a problem because it increased the risk of transmission to others. On 12/5/23 at 12:53 PM an interview was conducted with Infection Preventionist (IP) 1 and IP 2. IP 1 stated anyone entering a resident room with COVID-19 was expected to wear goggles, a face shield, gown, gloves and an N95. Stated if staff are observed not wearing the required PPE when entering a COVID-19 positive patient room they increased the risk of COVID-19 transmission to other residents in the facility. On 12/28/23 at 12:57 an interview was conducted with the Director of Nursing (DON). The DON stated staff were expected to wear a gown, gloves, N95 mask, face shield or goggles when caring for COVID-19 positive residents. The DON stated the goal of wear the proper PPE is to prevent COVID-19 positive transmission to other coworkers and susceptible residents. A review of Resident 1's orders, dated 12/5/23 at 11:43 AM, indicated, .Patient Isolation: Enhanced Droplet, Resident is Covid Positive by Antigen Test . A review of the facility document titled, The [NAME] at Poway COVID-19 Surveillance Plan, undated, indicated, I. SUMMARY/INTENT All long term care residents are considered high risk of severe illness, hospitalization and death from COVID-19 infection . C. Care for Residents with Suspected or Confirmed COVID-19 Infection . 4. Staff caring for residents with confirmed or suspected COVID-19 infection should use an N95/PAPR respirator wherever available (if unavailable, a facemask), eye protection (face shield or goggles), gloves, and gown .

Based on interview and record review the facility failed to offer bed hold for two residents who were transferred to the acute hospital. (Resident 5 and Resident 6) This failure had the potential for the residents to not be aware of their choice to hold a bed at the facility when transferred to the hospital. Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses including wound care, leaking colostomy (an opening for the colon or large intestine through the abdomen) according to the facility ' s Patient Information. On 9/14/23, at 11:36 A.M., a concurrent review of Resident 5 ' s nursing note with the Director of Nursing (DON) was conducted. The DON stated Resident 5 was transferred to the hospital on 3/23/23 due to shortness of breath, with cold and clammy skin. During an interview and concurrent record review on 9/14/23, at 12:10 P.M., with the nursing supervisor (NS), the NS stated if a resident was transferred to the hospital, the nursing staff called the resident or the responsible party to inquire if a bed hold was requested. The NS stated the form titled, Notice of Resident Transfer and Discharge, was used for bed holds. The NS reviewed the form from Resident 5 ' s chart and stated she did not know why the form was blank. The NS further stated she was not sure if bed hold was offered. Resident 6 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition in which the heart does not pump or fill blood as well as it should) according to the facility ' s Patient Information. On 9/14/23, at 11:36 A.M., a concurrent review of Resident 6 ' s nursing note with the Director of Nursing (DON) was conducted. The DON stated Resident 6 was transferred to the hospital on 3/22/23 due to chest pain. Further concurrent review of Resident 6 ' s records was conducted with the DON on 9/14/23, at 12:15 P.M. A form titled, Notice of Resident Transfer and Discharge was in Resident 6 ' s chart. The DON confirmed that the form was blank. The DON stated she was unsure what the facility policy was regarding bed hold. An interview was conducted on 9/14/23 at 1:41 P.M. with the DON. The DON state she checked with the business office if they kept bed hold forms for residents who were transferred to the hospital. The DON stated if the resident had Medi-Cal insurance, a bed hold form would not be completed. The DON stated if the resident had other insurances, the staff would notify the business office to hold a bed. The DON further stated the facility practice did not follow their policy and procedure which needed updating. A review of the facility ' s policy and procedure (P&P) titled, Procedure: Bed Hold Policy (7 day), dated 5/4/23 was conducted. The P&P indicated, .Any resident that is transferred to the emergency room or Acute Hospital will be asked whether they would like a bed to be held .

Based on observation, interview and record review, the facility failed to ensure: 1. Loading dock, dumpster cart, and area in front of the dumpster were free of kitchen waste. 2. Food and Nutrition department floor sink drains were free from food waste. These failures provided an unsanitary environment in the kitchen that harbored pests and had the potential to contaminate resident food. The nursing home census was 109 residents. Cross reference F812, F925 Findings: 1. During a kitchen observation of the garbage disposal and concurrent interview on 03/20/23 at 2:34 P.M., Food Service Worker 1 (FSW1) demonstrated the trash removal process from the kitchen. FSW1 brought trash bags in garbage can to dock. FSW1 went down service lift to get dumpster cart. Food debris and garbage from kitchen was observed between lift and dock. FSW1 put the trash bags in the trash cart from the dock. FSW1 then climbed down from the loading dock and then he pushed trash cart to dumpster lift, which put the cart contents into dumpster and compressed contents. Foul smelling kitchen waste was observed at base of the lift where the cart was dumped. FSW1 stated he was not sure who was responsible for cleaning up the area. Dumpster cart was observed to have waste residue inside it. FSW1 returned the cart to storage area on the dock and walked to back kitchen door entrance. On the wall next to the back kitchen door entrance, there was a large electronic bug zapper neon light with dozens of dead flies, spider webs, and other insects. There were noticeable flies and gnats that flew inside the kitchen after FSW 1 entered the back door. The Food Service Director (FSD) and Food Service Manager (FSM) acknowledged the bug zapper light device was dirty with dead insects and spider webs and both stated it should be clean. 2. During the initial kitchen tour on 3/20/23 8:32 A.M., an observation of three floor sink drains was conducted. The one under a hand wash sink had pasta noodles and other debris inside, and the other two drains had visible food debris in them. On 3/21/23 at 9:10 A.M., during a kitchen observation there were seven (7) additional floor sink drains found with large amounts of kitchen waste inside them including food scraps, mildew, trash, and other debris. Some drains contained used tea bags, smashed individual ice cream containers, and substances that resembled mold. One floor sink drain in the cooking area under a food prep sink sign that read Food Prep Only had a mound of indistinguishable rotting food scraps filled to the top of the drain. On 3/21/23 at 10:14 A.M., an interview with Cook 3 (CK3) was conducted. CK3 stated his process for cleaning cooking area after cooking was complete was as follows: use soap and water to clean area first, sanitize with sanitizer after every time they were done cooking in the areas, including mopping the floor of that area. CK3 stated that he cleaned under the cook's prep counter table every day. CK3 further stated he cleaned the food prep sink basin but did not clean sink the floor sink drains. On 3/21/23 at 4:07 P.M., an interview with Food Service Worker 2 (FSW2) was conducted. The FSW2 stated she was designated to clean area 41 which was the area around tray line. FSW2 stated her cleaning process was to first sweep the floors, then mop, next clean the steam table with soap first, then sanitizes it with sanitizer. FSW2 stated she does clean food prep sink basins but not the floor sink drains. On 3/21/23 at 4:15 P.M., an interview was conducted with Executive Chef (EXC). EXC stated that with regards to cleaning the kitchen Each person is responsible for their area. On 3/22/23 at 10:53 A.M., a concurrent interview with the FSM, FSD, and Environmental Services Director (EVD), observation of the sink drains, and record review of facility's pest control maintenance invoices, was conducted. The EVD stated that his staff doesn't clean the kitchen floor sink drains, they only clean the kitchen restroom. EVD stated his team is responsible for overseeing the pest control in the facility. FSM, FSD, and EVD stated they were unaware of how dirty the floor sink drains were in the kitchen. The FSD and FSM acknowledged the kitchen floor sink drains were unacceptably dirty. During a review of the pest control invoices on 3/23/23 from January 2023- March 7, 2023, the invoice dated March 7, 2023, indicated, 5/19/2019 .Accumulated debris in floor drain .Clean and remove debris in or around drains to prevent possible pest infestation The FSD, FSM, and EVD all stated their expectation was for the kitchen and nursing home to be pest free and to have the kitchen floor sink drains cleaned regularly to prevent a potential pest infestation, and contamination of the food. According to the 2022 FDA Federal Food Code, section 4-601.11, It is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris (FDA Food Code, 2022). Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (FDA Food Code Annex 4-602.13). According to the 2022 FDA Federal Food Code, section 4-602.13, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. A review of the facility's policy titled Procedure: FANS Environmental Sanitation dated 12/05/22, indicated .2. Cleaning responsibilities .a. Daily .i. Clean and sanitize trash and waste bins .xi. High power spray and dry large and small trash bins/lids .xiii. Clean and sanitize hand sinks throughout kitchen .

Based on observations, interviews, and document reviews, the facility failed to ensure the menu was designed to meet the nutritional needs of the residents on pureed diets. This failure led to twelve (12) residents on pureed diets to receive fewer calories and nutrients which had the potential to further impair their nutrition and health status. Cross reference F804 Findings: During a review of the facility's undated therapeutic menu spreadsheet titled Week 2, Tuesday, 3/21/23, the Regular Diet lunch meal was 3 ounces (oz.) oven fried chicken breast, 1/2 cup mashed potatoes, 1/2 cup sauteed green beans and cherry tomatoes, 8 ounces (oz.) 1% milk, 6 oz. creamy lentil soup, 2 saltine crackers, and 1 iced brownie. The Dysphagia Pureed Diet lunch meal included a 3 oz. turkey puree with 1 oz. chicken gravy, 3 oz. corn puree, 3 oz. green beans puree, 8 oz. 1% milk, and 1 orange jello gelatin cup. During an observation and interview on 3/21/23 at 10:03 A.M. of the lunch meal food production in the main kitchen, the A.M. Cook (CK) 1 prepared 15 pre-packaged pureed food items, entrees, and side item each, and placed them in the steamer oven. CK 1 was asked did he prepare any pureed meals, and CK 1 stated No because we use prepacked pureed foods for the pureed diets. CK 1 further stated he did not prepare soup for the pureed diets. The FSM acknowledged CK 1 did not prepare soup for the pureed diets and stated, the pureed don't get soups according to therapeutic menu spreadsheet. During a review of the facility's undated therapeutic menu spreadsheet titled Week 2 Wednesday, 3/22/23, the Regular Diet indicated the lunch meal was 3 ounces (oz.) braised pork loin with 1 oz. brown sauce, 1/2 cup mashed potatoes, 1/2 cup steamed broccoli, 1 bread roll, 1 slice butter, 8 ounces (oz.) 1% milk, 6 oz. cream of mushroom soup, 2 saltine crackers, and 1 blondie bar. The Dysphagia Pureed Diet lunch meal included 4 oz. pork puree mold with 1 oz. brown sauce, 3 oz. mashed sweet potatoes puree, 3 oz. broccoli puree, 8 oz. 1% milk, and 1 tapioca pudding cup. During an interview on 3/22/23 at 4:15 P.M. with the FSM, the FSM stated the pureed diet included prepackaged foods because it was easier preparation for the Cooks because they are pre- portioned with adequate nutrition. The FSM acknowledged the therapeutic menu for Dysphagia Puree did not include pureed soups and bread rolls. The FSM stated the pureed diet should get soups and bread if it is tolerable for the puree diet. During an interview on 3/23/23 at 10:56 A.M. with the FSM, the FSM stated her expectation was for the puree diets to meet the same nutritional standards as the regular diet. The FSM acknowledged the weekly average nutrient analysis of the pureed diet had less calories and protein than the regular diet but stated they should be closer to equal because fewer nutrients could impair the resident's nutrition and health status. The FSM further stated the weekly menu should have been posted in the dining room and provided to the residents so they know what meals will be served. Review of facility undated document titled Nutritional Analysis: Average for Week 2 Cycle, indicated the Regular diet provided 2810 calories, 123 grams of protein, and 28 grams of fiber. The Pureed diet provided 2415 calories, 122 grams of protein, and 17 grams of fiber. Review of facility's Diet Manual document titled Pureed Diet page A-39 indicated .Soups .FOODS ALLOWED .All smooth cream soups or broth type soups with pureed . ingredients . Review of the facility's procedure dated 1/11/23 titled Menu Planning and Nutritional Standards indicated, .A. 90% of RDAs and DRIs will be provided daily .2. The 7 day .menu cycle is submitted for nutritional analysis. 3. Based on the results of the nutritional analysis, recipes, or products are adjusted or substituted to ensure nutrients meet standards . Review of the facility's policy dated 7/14/21, titled Food and Nutrition Services (FANS) indicated, .B. All patient meals are produced according to standardized recipes and are analyzed to the meet RDAs of the base population and approved by a Registered Dietitian .C. The primary goals of the Food and Nutrition Services .necessary to: 1. Prepare and serve attractive, satisfying .meals under high standards .2. Contribute significantly .by planning menus that meet the nutritional and therapeutic needs of patients in accordance with physicians' orders . 43518

43518 Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation protocols were maintained in the kitchen according to standards of practice and facility policy when: 1. Loading dock area, dumpster cart, and area in front of the dumpster were not free of kitchen waste. 2. Ten (10) kitchen floor sink drains were dirty and filled with food waste. 3. An Ice Machine was not properly maintained and cleaned per manufacturer guidelines. 4. An expired supplement was found in a nourishment room refrigerator in the facility nursing station. These failures exposed residents to unsanitary practices in the kitchen, which had the potential to contaminate the food and place residents at risk of developing a foodborne illness. Cross reference F814, F908, and F925 Findings: 1. During a concurrent observation and interview on [DATE] at 2:34 P.M. with Food Service Worker 1 (FSW1), FSW 1 demonstrated how he removed trash from the kitchen. There were several foul soiled kitchen wastes observed at base of the dumpster lift area where the trash from the large trash cart was dumped. FSW1 stated he was not sure who was responsible for cleaning up the area. Dumpster cart was observed to have residual wastes inside it. The Foodservice Manager (FSM) and Foodservice Director (FSD) acknowledged the wastes outside the garbage disposal area and stated it should be cleaner. According to the 2022 FDA Federal Food Code, section ,d+[DATE].11, It is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris (FDA Food Code, 2022). Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (FDA Food Code Annex ,d+[DATE].13). A review of facility procedure dated [DATE] titled FANS Environmental Sanitation, indicated, the purpose of the procedure is to .maintain a clean environment, which is essential for food safety .a. Daily: i. Clean and sanitize waste bins .d. Three times weekly: .ix. Clean and sanitize main entrance door and surrounding wall . 2. During the initial kitchen tour, an observation of three (3) of the kitchen's floor sink drains was conducted. On [DATE] at 9:10 A.M., an observation of seven (7) kitchen sink drains was conducted. Food and kitchen waste was observed in 6 of 7 drains. Some items observed in drains included: used tea bags, small individual ice cream containers, and pasta. Mold and food debris were observed in the 7 sink drains. The Cook's food prep sink labeled Food Prep Only in the center of the main kitchen had a mound of rotted food scraps collected on top of the drain. On [DATE] at 10:14 A.M., an interview with Cook 3 (CK3) was conducted. CK3 stated his cleaning process in the cooking area was to first use soap and water to clean area, then sanitize with sanitizer after every time they were done cooking in the areas, and this included mopping floor area. CK3 stated he also cleaned food prep sink basin but did not clean floor sink drains. On [DATE] at 4:07 P.M., an interview with FSW2 was conducted. FSW2 stated she was designated to clean area 41 which was the area around tray line. She stated her daily cleaning process was to sweeps floors, mop the area, then clean the steam table with soap then sanitize it. FSW2 stated she does clean food prep sink basins but does not clean the floor sink drains. On [DATE] at 4:15 P.M., an interview was conducted with Executive Chef (EXC). EXC stated in regard to cleaning the kitchen .Each person is responsible for their area. On [DATE] at 10:53 P.M., a concurrent interview with the FSM, FSD, and Environmental Services Director (EVD), observation of kitchen floor sink drains, and record review of pest control invoices was conducted. EVD stated that his staff doesn't clean the kitchen except for the restroom in the kitchen. The FSM, FSD, and EVD stated they were unaware of the dirty condition the floor sink drains were in inside the kitchen. The FSD and FSM stated the drains were unacceptably dirty. The FSD, FSM, and EVD stated their expectation was for the kitchen and SNF to have clean drains on a regular basis in the kitchen to prevent contamination of food and possible pest infestation. According to the 2022 FDA Federal Food Code, section ,d+[DATE].13, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. A review of the facility's policy titled Procedure: FANS Environmental Sanitation dated [DATE], indicated .2. Cleaning responsibilities .a. Daily .i. Clean and sanitize trash and waste bins .xi. High power spray and dry large and small trash bins/lids .xiii. Clean and sanitize hand sinks throughout kitchen . 3. On [DATE] at 10:48 A.M., an interview with Maintenance Director (MND) was conducted. The MND stated that skilled nursing facility (SNF) ice machine was cleaned 3 times a year by vendor and he and his staff performed weekly and monthly cleanings. MND stated that his staff emptied the ice bin out and cleaned the interior and exterior of machine with half to half household bleach and water diluted solution. On [DATE] at 11:50 A.M., a concurrent observation of the SNF Ice machine and interview with FSD, FSM, and MND was conducted. The MND opened ice machine and removed door to access the ice chute. A surveyor wiped a white paper towel along the interior areas of the bin door and along the bottom of the ice chute. The white paper towel was soiled with brown grainy dirt substances. MND was not familiar with how to remove the ice curtain of the machine. The MND, FSM, and FSD acknowledged the soiled white paper towel with the dark brown grainy substances on it. During a concurrent observation, interview, and record review with the MND on [DATE] at 9:32 A.M., the MND showed the surveyors the cleaning chemicals his staff used to clean the SNF ice machine. The cleaning chemicals were Super Sani Cloth, Zep Stainless Steel Cleaner, and household Clorox Bleach. A review of the Super Sani Cloth directions indicated, .May be harmful if swallowed .; the Zep Stainless Steel Cleaner directions indicated, .Do not take internally . and the Clorox Bleach bottle stated, .Harmful if swallowed . On [DATE] at 8:15 A.M., a concurrent observation of SNF Ice Machine and interview with the ice machine cleaning vendor Technician (VT), FSM, FSD, and MND were conducted. VT described his cleaning process as follows: 1. Open ice machine cover, 2. Remove top of machine, 3. Remove the curtain in front of ice grid, 4. Turn ice evaporator off, 5. Put descaler into reservoir, 6. Circulate the descaler, 7. Clean the internal pipes and tubes individually, disconnecting them and submerging them in separate buckets of descaler, water, and sanitizer and scrubbing them with pipe cleaners. VT stated he used CLR Descaler every 4 months, and Scotsman brand cleaner to clean internal components. VT removed the curtain covering the ice grid, and a brownish gray substance resembling mold was observed on the interior of the curtain. A Surveyor took a white paper towel and wiped the inside area of the ice chute and tray attached to the ice grid. The paper towel had dark brown crusty, semi-grimy pink substances on it resembling mold. The MND stated the ice machine cleaning done by his staff did not entail cleaning the ice machine curtain. The VT, FSM, FSD, and MND acknowledged the dirt and grime substances on the paper towel. VT, FSM, FSD, and MND stated it should not be there and the machine should be visibly clean. The MND stated the staff should use cleaning chemicals recommended by the manufacturer's guidelines in the future. During an interview with the FSM on [DATE] at 10:56 A.M., the FSM stated that the expectation for the facility's ice machines was that they should be operational and cleaned on a regular schedule using cleaning chemicals that follow the manufacturer's guidelines. The FSM further stated ice is food and should not be contaminated with mold or harmful chemicals because it could affect the health of the facility residents. According to the 2022 US FDA Food Code, Section ,d+[DATE].17, titled Warewashing Equipment, Cleaning Agents; Failure to use detergents or cleaners in accordance with the manufacturer's label instructions could create safety concerns for the employee and consumer .chemical residues could find their way into food if detergents or cleaners are used carelessly. Equipment .may not be cleaned if inappropriate or insufficient amounts of cleaners or detergents are used. According to the 2022 US FDA Food Code, Section ,d+[DATE].11, titled Ice Used as Exterior Coolant, Prohibited as Ingredient, Ice that has been in contact with un-sanitized surfaces .may contain pathogens and other contaminants if this ice is then used as a food ingredient, it could be contaminated . According to the 2022 US FDA Food Code, Section ,d+[DATE].17, titled Ice Units, Separation of Drains, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines .The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. A review of the facility's undated policy titled [NAME] Hospital-Poway Ice Machine Operations and Maintenance Program indicated, .Scotsman Weekly Ice maker Cleaning and Sanitation, the cleaning and sanitizing solution to be used per this policy is '200 ppm chlorine solution' and 'Cleaning solution A' . A review of the ice machine's manufacturer's guidelines, dated [DATE], located on the inside door of the ice machine in the SNF, indicated .sanitizer to be used for this machine is Nucalgon IMS and Scotsman Clear One for cleaning internal parts . A review of facility policy [DATE], titled Procedure: FANS Environmental Sanitation indicated, .G. All sanitizing agents used in accordance with the manufacturer's recommendation. 4. On [DATE] at 3:15 P.M. an observation of Nourishment room [ROOM NUMBER] was conducted. One container of Med Pass 2.0 was passed the expiration date [DATE]. The FSM, FSD, and Clinical Nutrition Manager (CNM) were present and acknowledged the expired supplement on the shelf. The FSM and FSD stated there should not be any expired supplements in the nourishment rooms because it could be given to residents, and this may increase their chance of getting a foodborne illness. According to the 2022 Federal FDA Food Code, section ,d+[DATE].11, titled Food Labels .(A) Food packaged .shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . Review of facility policy entitled Procedure: Patient Nourishment Rooms indicates, .I. Discarding of expired items is the responsibility of Nutrition Services and is done according to established guidelines .