Every finding on record at Thousand Oaks Post Acute, LLC

Based on observation, interview, and record review, the facility had a medication error rate of 16.67% when five medication errors occurred out of 30 opportunities during the medication administration observation for two of ten residents (Residents 86 and 23).These failures in medication administration resulted in medications not being given according to the physician's orders and had the potential for Residents 86 and 23 to experience inadequate management of conditions or side effects such as upset stomach and nausea.Findings:1. During a medication pass observation on 7/6/26, at 8:49 AM, outside of Resident 86's room, Licensed Vocational Nurse 1 (LVN 1) was observed preparing nine medications for Resident 86. The medications included eight pills, including one tablet of Ocular Vitamins (multivitamin for eye health) and one tablet of metoprolol tartrate (generic for Lopressor, a medication to treat high blood pressure) 25 milligrams (mg). LVN 1 did not give Resident 86 any liquid medications. LVN 1 gave Resident 86 a glass of water with the medications. LVN 1 did not offer food with Resident 86's medications. A review of Resident 86's Medication Review Report, dated 7/7/26, indicated Resident 86 had a physician's order, dated 6/22/26, for metoprolol tartrate 25 mg, Give 25 mg by mouth two times a day for HTN [hypertension, high blood pressure].Give with food. A review of Resident 86's Medication Review Report, dated 7/7/26, indicated Resident 86 had a physician's order, dated 6/22/26, for Ocular Vitamins, Give 2 tablet by mouth one time a day for Supplement. A review of Resident 86's Medication Review Report, dated 7/7/26, indicated Resident 86 had a physician's order, dated 6/22/26, for chlorhexidine gluconate (prescription mouthwash to treat gum disease) 0.12% solution, Give 15 ml [milliliters] by mouth two times a day for Oral [mouth] care for 1 Month. During an interview on 7/6/26, at 1:53 PM, with LVN 1, LVN 1 stated he did not give chlorhexidine oral solution to Resident 86 during the medication pass observation. LVN 1 stated he was supposed to give Resident 86 the chlorhexidine oral solution during the morning medication pass observation. LVN 1 further stated he only gave one tablet of Ocular Vitamins to Resident 86, instead of two tablets as ordered by the physician. LVN 1 stated he administered Resident 86's metoprolol tartrate after breakfast. LVN 1 stated metoprolol tartrate was supposed to be given with food. LVN 1 further stated he was supposed to offer Resident 86 a snack to take with the metoprolol tartrate to follow the orders. During a phone interview on 7/9/26, at 10:51 AM, with the Consultant Pharmacist (CP), the CP stated metoprolol tartrate was given with food to decrease gastrointestinal (GI, referring to the digestive tract, including the stomach and intestines) side effects. The CP stated the concern was the blood pressure dropping too quickly if metoprolol tartrate was given without food. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for metoprolol tartrate tablets, dated 1/31/24, retrieved from DailyMed, indicated, Metoprolol tartrate tablets should be taken with or immediately following meals. 2. During a medication pass observation on 7/6/26, at 4:12 PM, outside of Resident 23's room, LVN 2 was observed preparing five medications for Resident 23. The medications included two tablets of ibuprofen (generic for Advil, pain medication) 200 mg, total dose 400 mg, and two tablets of acetaminophen (generic for Tylenol, pain medication) 325 mg, total dose 650 mg. LVN 2 did not offer food with Resident 23's medications. A review of Resident 23's Medication Review Report, dated 7/7/26, indicated Resident 23 had a physician's order, dated 11/15/25, for acetaminophen 325 mg, Give 2 tablet by mouth every 4 hours as needed for mild pain 1-3/10. A review of Resident 23's Medication Review Report, dated 7/7/26, indicated Resident 23 had a physician's order, dated 6/30/26, for ibuprofen 200 mg, Give 200 mg by mouth every 4 hours as needed for breakthrough pain.give with food. During an interview on 7/6/26, at 4:38 PM, with LVN 2, LVN 2 stated Resident 23's ibuprofen orders indicated to give one tablet. LVN 2 stated she gave two tablets of ibuprofen to Resident 23. LVN 2 also stated Resident 23's orders indicated to give ibuprofen with food. LVN 2 stated she did not give ibuprofen with food as ordered. LVN 2 further stated Resident 23's pain score for the afternoon medication pass was five out of 10. LVN 2 confirmed the acetaminophen was supposed to be given for a pain score between one and three. LVN 2 stated she gave acetaminophen because Resident 23 did not have pain medication for a pain score of five. During an interview on 7/7/26, at 3:02 PM, with Registered Nurse 1 (RN 1), RN 1 stated pain medications were only supposed to be administered to residents with a pain score within the ordered range. During an interview on 7/7/26, at 3:05 PM, with RN 1, RN 1 stated the expectation was for nurses to administer medications correctly by checking for the right patient, the right dosage, right indication, and the right parameters. During an interview on 7/8/26, at 2:56 PM, with the Director of Nursing (DON), the DON stated Resident 23 was only supposed to get one tablet of ibuprofen during the medication pass observation. The DON stated nurses were supposed to follow the doctor's orders. Regarding the acetaminophen, the DON stated nurses were supposed to call the doctor for a pain score outside of the medication orders. The DON stated Resident 23 was not supposed to get acetaminophen for a pain score of five. During an interview on 7/8/26, at 3:00 PM, with the DON, the DON stated medications ordered to give with food needed to be given during a mealtime or with a snack. The DON also stated it was not appropriate for a nurse to omit giving medications or to give the wrong dose. The DON stated the expectation was for nurses to administer medications as ordered. During a phone interview on 7/9/26, at 10:55 AM, with the CP, the CP stated ibuprofen should be given with food to minimize gastrointestinal side effects, such as upset stomach and nausea. The CP also stated administering acetaminophen when the pain score was out of the ordered range was a medication error. During a phone interview on 7/9/26, at 10:59 AM, with the CP, the CP stated it was not appropriate for residents to miss medications or for nurses to not follow the prescriber's orders. A review of the facility's policy and procedure (P&P) titled, Medication Errors, revised January 2026, indicated, Medication Error.administration of medications or biologicals which are not in accordance with.The prescriber's order.Manufacturer's specifications regarding the preparation and administration of the medication. The P&P further indicated the following: Unauthorized medication error: Facility administers a medication dose not authorized for the resident. Dose error: Facility administers to the resident a medication dose that is greater than or less than the amount ordered by the Physician/Prescriber. Administration time error: Facility administers to the resident a medication greater than sixty (60) minutes from its scheduled administration time or if administration exceeds the time in relation to meals. and Omission error: Facility fails to administer an ordered dose to the resident. A review of the facility's P&P titled, IIA2: Medication Administration - General Guidelines, dated October 2012, indicated, FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. The P&P further indicated, Medications are administered in accordance with written orders of the prescriber. A review of the facility's P&P titled, 72313 Administration of Medications and Treatments dated December 2024, indicated, Medications and treatments shall be administered as prescribed.

Based on observation, interview, and record review, the facility failed to appropriately store food for food service safety when:1. Food was not properly labeled in two of four facility freezers (Freezer 2 and Freezer 3).2. Food was not properly labeled in two of two resident refrigerators (West Wing Refrigerator and East Wing Refrigerator).3. Employee food items were being stored inside one of two resident refrigerators (West Wing Refrigerator).These failures had the potential for expired foods to be served to the residents, which could cause illness and for residents to be exposed to foodborne disease through contamination of resident food items.Findings:1. During a concurrent kitchen observation tour and interview on 7/6/26, at 8:30 AM, with the Dietary Supervisor (DS), the following was observed inside the kitchen:a. Freezer 2: One unopened and unlabeled plastic pack of individually wrapped sliced cheese with no expiration date.b. Freezer 3: Three unopened and unlabeled plastic bags of waffles without expiration dates.The DS confirmed the unopened individually wrapped cheese and the three unopened plastic bags of waffles did not have expiration dates and needed to be labeled before placing them inside the freezer.A review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, revised 1/2025, indicated, . 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.2. During a concurrent observation tour and interview on 7/6/26, at 9:18 AM, with the DS, in a locked room in the East Wing, five unopened and unlabeled 500 milliliter (ml- volume of measurement) Pedialyte bottles were observed inside the residents' refrigerator. The DS stated all the food inside the East Wing Refrigerator must be labeled.During a concurrent observation tour and interview on 7/10/16, at 10:30 AM, with Registered Nurse 2 (RN 2), in a locked room in the [NAME] Wing, one unopened and unlabeled Ensure plus bottle was found inside the residents' refrigerator. RN 2 confirmed the Ensure plus bottle must be labeled when placed inside the [NAME] Wing Refrigerator.A review of the facility's P&P titled, Use and Storage of Food Brought to Resident, revised 6/2025, indicated, . Storage Guidelines. Perishable items may be: a. Stored in the facility's refrigerator/freezer, with resident's name and date.3.During a concurrent observation tour and interview on 7/6/26, at 9:12 AM, with the DS, in a locked room in the [NAME] Wing, one unopened and unlabeled humus food item and one unlabeled lunch bag with food inside was observed in the [NAME] Wing Refrigerator. The DS stated the items belonged to an employee and no employee food items should be placed inside the residents' refrigerator.During a concurrent observation and interview on 7/7/26, at 10:24 AM, with the RN 1, in a locked room in the [NAME] Wing, one opened container of potato salad with an employee's name was found inside the residents' refrigerator. RN1 stated the [NAME] Wing Refrigerator was for residents only and any food placed by staff must be tossed out.A review of the undated sign posted on the outside of the residents' refrigerator in the [NAME] Wing indicated, Attention Staff- supplements and resident food only! Absolutely no staff food/drinks. Food must have resident's name, room number, date food brought into facility. Food must be discarded after 72 hours. Undated/Unlabeled food will be tossed. Any staff food/drinks will be tossed! Please use staff refrigerator in break room.

Based on observation, interview, and record review the facility failed to keep the door of one of one trash compactor closed.This failure had the potential to attract pests to the exposed trash, which could then spread disease to residents and staff in the facility. Findings:During a concurrent observation tour and interview on 7/6/26, at 8:30 AM, with Kitchen Staff (KS), in the outdoor garbage collection area, the trash compactor door was left open and trash was exposed. KS confirmed the trash compactor lid must be closed all the time.During an additional observation tour and interview on 7/8/26, at 8:35 AM, with the Dietary Supervisor (DS), in the outdoor garbage collection area, the trash compactor door was left open, leaving trash at the bottom exposed. The DS stated all kitchen trash went to the compactor and confirmed the trash compactor door must always remain closed.A review of the facility's policy and procedure (P&P) titled, Dispose of Garbage and Refuse, revised 1/2025, indicated, . 1. Garbage and refuse containers are maintained in good condition (no leaks) and waste is properly contained in dumpsters or compactors with lids covered.

Based on observation, interview and record review, the facility failed to provide care in a manner that promoted residents' dignity and respect for two of 24 sampled residents (Resident 121 and 108) when:1. A Facility Staff (FS) fed Resident 121 while standing and not at eye level.2. Two unopened bottles of Ensure Plus labeled with another resident's name were found on the table of Resident 108. These failures violated residents 121 and 108's right to be treated with respect and dignity and had the potential to affect the residents' sense of self-worth and self-esteem.Findings: 1. A review of Resident 121's admission RECORD (front page of the chart that contains a summary of basic information about the resident) dated 7/7/26, indicated the resident was readmitted to the facility on [DATE] with diagnoses that included adult failure to thrive (a state of undernutrition delayed physical growth where an individual fails to gain weight at the expected rate), anemia (condition characterized by a lack of enough healthy red blood cells), and muscle weakness. A review of Resident 121's HISTORY AND PHYSICAL (H&P) dated 7/7/26, indicated the resident had the capacity to understand and make decisions. During an observation on 7/6/26, at 12:15 PM, inside Resident 121's room, Resident 121 was lying on her bed. The bed was placed in a low position with the head of bed elevated. FS was observed standing over Resident 121 while feeding her. Resident 121's neck was hyperextended (stretched beyond normal upright position) while being fed. FS stood over the resident and assisted her with her meal until Resident 121 finished her lunch at around 12:24 PM. During an interview on 7/6/26, at 12:28 PM, with FS, FS acknowledged the findings and stated staff were expected to sit and be at eye level with residents while assisting with their meals. FS also stated this was important to make the residents feel invited, comfortable, and calm while eating. FS further stated that it was not acceptable and undignified to stand over Resident 121 while feeding her. During an interview on 7/7/26, at 10:24 AM, with Registered Nurse 2 (RN 2), RN 2 stated staff were expected to feed residents at eye level. RN 2 also stated it was not acceptable to stand over the residents because it did not provide dignity and respect for the residents. During an interview on 7/7/26, at 11:30 AM, with the Director of Nursing (DON), the DON stated it was her expectation for staff to sit down and be at eye level with the residents while providing feeding assistance. The DON stated this was important to establish connections, provide a home-like environment, and promote dignity and respect for the residents. 2. A review of Resident 108's admission RECORD indicated Resident 108 was admitted to the facility on [DATE], with diagnoses which included generalized muscle weakness, difficulty in walking, and depression. A review of Resident 108's H&P, dated 6/26/26, indicated Resident 108 had the capacity to understand and make decisions. A review of Resident 108's Order Summary Report dated 7/4/26, indicated Resident 108 had a current physician's order for Ensure Plus one time a day for supplement. During an observation tour and concurrent interview on 7/6/26, at 11:00 AM, with Resident 108, inside Resident 108's room, two unopened bottles of Ensure Plus labeled with another resident's name (Resident 63) were found on Resident 108's bedside table. Resident 108 stated she was upset and confirmed the two unopened bottles of Ensure Plus did not belong to her. During an observation and interview on 7/6/26, at 11:00 AM, with Certified Nursing Assistant 1 (CNA 1), in Resident 108's room, CNA 1 confirmed the two unopened Ensure Plus bottles were labeled with Resident 63's name and were wrongly placed in Resident 108's room. During an interview on 7/6/26, at 4:11 PM, with RN 1, RN 1 stated the two unopened bottles of Ensure Plus found in Resident 108's room labeled for Resident 63 were not supposed to be there. A review of the facility's Policy & Procedure (P&P) titled RESIDENT RIGHTS, revised January 2025, indicated POLICY STATEMENT: Residents in long term care facilities have rights guaranteed to them under Federal and State law including the right to a dignified existence, self-determination, and communication with and access to persons and services.Employees shall treat residents with kindness, dignity and respect. A review of the facility's P&P titled DIGNITY AND RESPECT, revised January 2026, indicated POLICY STATEMENT: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. INTENT: To provide staff with guidelines to ensure residents are treated with kindness, respect, and dignity. Guidelines: 1. The facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.5. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self worth.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 8) was free from unnecessary psychotropic medications (medications that affect brain activities associated with mental processes and behavior) when Resident 8 received an as needed (PRN) psychotropic medication for more than 14 days.This failure resulted in Resident 8 receiving an as needed psychotropic medication for an extended time period and had a risk of medication side effects, such as drowsiness and confusion. Findings:A review of Resident 8's admission Record, dated 7/9/26, indicated Resident 8 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. The admission record further indicated diagnoses of Other Specified Anxiety Disorders with an Onset Date of 4/22/26. A review of Resident 8's Orders, dated 5/21/25, indicated Resident 8 had a physician's order for alprazolam (generic for Xanax, a psychotropic medication to treat anxiety) 0.25 milligrams (mg), Give 1 tablet by mouth every 8 hours as needed for restlessness. The alprazolam orders were discontinued on 6/17/25. A review of Resident 8's Medication Administration Record (MAR, legal document used to track the medications a patient has been given), dated 5/1/25 - 5/31/25, indicated Resident 8 received three doses of PRN alprazolam in May 2025 on the following dates and times:5/27/25 at 10:55 PM5/29/25 at 12:25 AM5/31/25 at 8:00 PM A review of Resident 8's Medication Administration Record, dated 6/1/25 - 6/30/25, indicated Resident 8 received nine doses of PRN alprazolam in June 2025 on the following dates and times:6/2/25 at 8:00 PM6/5/25 at 11:48 PM6/7/25 at 8:00 PM6/8/25 at 7:30 PM6/9/25 at 8:00 PM6/10/25 at 7:30 PM6/13/25 at 11:51 PM6/15/25 at 8:45 PM6/16/25 at 7:30 PM During a phone interview on 7/9/26, at 11:00 AM, with the Consultant Pharmacist (CP), the CP stated initial orders for PRN psychotropic medications had a 14-day limit. The CP stated the physician could re-evaluate the resident for new orders after the initial 14-day treatment. During a concurrent interview and record review on 7/9/26, at 11:17 AM, with the Director of Nursing (DON), Resident 8's Orders, dated 5/21/25, were reviewed. The DON stated initial PRN psychotropic medication orders were supposed to be for a maximum of 14 days. The DON stated the orders, dated 5/21/25, were the first time the physician ordered as needed (PRN) alprazolam for Resident 8. The DON stated the alprazolam was ordered for 27 days. During a concurrent interview and record review on 7/9/26, at 2:13 PM, with the DON, the facility's policy and procedure (P&P) titled, Dignity and Respect Psychoactive Medications, dated January 2025, was reviewed. The policy indicated, PRN orders for psychotropic drugs shall be limited to 14 days. The DON stated new PRN psychotropic medication orders, like the orders for Resident 8, needed to be limited to 14 days. The DON stated the risk of a longer time frame was overmedicating the resident. The DON stated the facility and prescriber were responsible for ensuring the 14-day limit for PRN psychotropic medications was implemented. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for alprazolam tablets, dated 5/31/24, retrieved from DailyMed (internet database operated by the U.S. National Library of Medicine providing labeling for prescription and nonprescription drugs) indicated alprazolam adverse reactions included Drowsiness.Fatigue and Tiredness .Confusional state.

Based on interview and record review, the facility failed to ensure timely completion of the Discharge Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment for one of three sampled residents (Resident 71) reviewed for Resident Assessments.This failure had the potential to result in inadequate monitoring of Residents 71's progress and decline and a lack of resident specific information to CMS for payment and quality measure monitoring.Findings:A review of Resident 71's admission RECORD (front page of the chart that contains a summary of basic information about the resident) dated 7/8/26, indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (loss of mental function such as thinking, memory, and reasoning skills), hypertension (high blood pressure), and muscle weakness.A review of Resident 71's Physician Telephone order dated 2/16/26, indicated, Order Summary: May transfer to hospital.for further evaluation.A review of Resident 71's discharge MDS assessment, with an Assessment Reference Date (ARD - a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 2/16/26, indicated, Section (Sec.) A0310F was coded 11 (Discharge assessment-return anticipated) and Sec. Z0500B (Date Registered Nurse (RN) Assessment Coordinator signed assessment as complete) was dated 4/8/26.During a concurrent interview and record review on 7/8/26, at 3:18 PM, with the Director of Nursing (DON), the DON reviewed Resident 71's MDS assessments in the electronic health record and stated the discharge MDS assessment with an ARD of 2/16/26 was completed on 4/8/26. The DON also stated the discharge MDS assessment should have been completed within 14 days of the discharge date . The DON stated it was not acceptable and should have been completed in a timely manner. The DON further stated that the Resident Assessment Instrument (RAI) submission timelines were not followed.The Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated .Chapter 2: Assessments for the RAI.Discharge Assessment-return anticipated (non-Comprehensive).MDS Completion Date (Item Z0500B) No Later Than.discharge date + 14 calendar days.A review of the facility's MDS Lead (RN) Job Description, dated December 2016, indicated, .Summary: The MDS Lead (RN) is responsible for managing the timely completion of accurate assessments and interdisciplinary care plans that meet Federal and State guidelines.Roles and Responsibilities: Oversee/complete assessments, Minimum Data Set (MDS) and care plans for residents. Monitor completion of MDS by other disciplines within timeframes prescribed by regulatory guidelines. Manage accurate, timely completion of the MDS information for residents.

Based on observation, interview, and record review, the facility failed to ensure resident's hearing status in the comprehensive admission MDS (MDS- a federally mandated resident assessment tool) assessment was accurately coded per Resident Assessment Instrument (RAI- comprehensive assessment and care planning process used by nursing home) guidelines for one of 24 sampled residents (Resident 33).This failure had the potential for Resident 33 not to receive the necessary care, treatment, and services to attain his highest practicable level of functioning.Findings:A review of Resident 33's admission RECORD (front page of the chart that contains a summary of basic information about the resident) dated 7/8/26, indicated the resident was readmitted to the facility on [DATE].During an initial tour observation and interview on 7/6/26, at 1:05 PM, inside Resident 33's room, with Resident 33 and his responsible party (RP), Resident 33 was awake and verbally responsive while lying on his bed. Resident 33 asked for the question to be repeated and stated he had bad hearing. The RP stated Resident 33 was hard of hearing for years now and had been using hearing aids.During an observation and interview on 7/8/26, at 9:11 AM, in the hallway outside Resident 33's room, with Facility Staff (FS), FS leaned forward closer to Resident 33 during their conversation. FS stated Resident 33 had hearing problems because he would ask her to repeat what she just said.During an interview on 7/8/26, at 9:21 AM, in the hallway outside Resident 33's room, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 33 could verbalize his needs but was hard of hearing. CNA 2 also stated Resident 33 verbalized he could not hear her, and she would have to repeat herself while talking to the resident.During an interview on 7/8/26, at 10:08 AM, with the Speech Language Pathologist (SLP- health care professional that diagnoses and treats conditions that affect one's ability to communicate and swallow), the SLP stated one of the challenges when working with Resident 33 was his hearing difficulties. The SLP also stated Resident 33 would ask her to speak louder because he could not hear her.During an interview on 7/8/26, at 10:13 AM, with the Certified Occupational Therapy Assistant (COTA- licensed professional that helps patients to develop, recover, and improve the skills needed for daily living), the COTA stated he had to repeat verbal cues, speak clearly, and face Resident 33 while working with him because he was hard of hearing.A review of Resident 33's admission MDS assessment with an Assessment Reference Date (ARD- a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 6/5/26, Section (Sec.) B0200 (Hearing) was coded 0 indicating hearing was adequate.During a concurrent interview and record review on 7/8/26, at 10:23 AM with the MDS Coordinator (MDSC), the MDSC reviewed Resident 33's comprehensive admission assessment with an ARD of 6/5/26, the MDSC stated Sec. B (Hearing, Speech, and Vision) was completed by the Social Services Department. The MDSC also stated that the look-back period for this section was from 6/1-5/26.A review of Resident 33's Activity Participation Review assessment dated [DATE], indicated, 5a. Ability to hear.Moderate difficulty was marked.During a concurrent interview and record review on 7/8/26, at 10:37 AM, with the Social Services Director (SSD), the SSD reviewed Resident 33's comprehensive admission assessment and stated she completed Section B of the MDS assessment. The SSD also stated the RAI guidelines should be followed when coding MDS assessments.During a subsequent interview and record review on 7/8/26, at 10:44 AM, with the SSD, the SSD reviewed the RAI guidelines in coding Section B and stated Resident 33's hearing status was not coded accurately because she only based it on her assessment. The SSD also stated that accuracy of assessments was important in the development of Resident 33's plan of care. The SSD also stated that when an assessment was not completed accurately, there was a possibility of a delay in the provision of the resident's care needs.During a concurrent interview and record review on 7/9/26, at 3:12 PM, with the Director of Nursing (DON), the DON reviewed Resident 33's Sec. B of the comprehensive admission assessment and the RAI guidelines in coding resident's hearing status and stated it was her expectation that assessments be coded accurately following the RAI guidelines. The DON also stated that the RAI manual was not followed in this case. The DON further stated that an accurate assessment of Resident 33 was important because the care plan depended on it.The Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated .Chapter 3: MDS Items (B). B0200: Hearing.Steps for Assessment 1. Ensure that the resident is using their normal hearing appliance if they have one.2. Interview the resident and ask about hearing function in different situations.3. Observe the resident during your verbal interactions and when they interact with others throughout the day. 4. Think through how you can best communicate with the resident. For example, you may need to speak more clearly, use a louder tone. The resident may need to see your face to understand what you are saying.All of these are cues that there is a hearing problem. 5. Review the medical record. 6. Consult the resident's family, caregivers, direct care staff, activities personnel, and speech or hearing specialist. Coding Instructions. Code 0, adequate.Code 1, minimal difficulty., Code 2, moderate difficulty.Code 3, highly impaired.A review of the facility's Social Services Director Job Description, dated October 2016, indicated, .Roles and Responsibilities:. Keeps abreast of current federal and state regulations, as well as professional standards.Participates in.resident assessments.A review of the facility's Policy and Procedure (P&P) titled DOCUMENTATION POLICY, revised January 2025, indicated POLICY: 1. It is the policy of this facility to document relevant findings in the clinical record.3. The facility utilizes assessment sheets, flow sheets, progress notes.and other mandated assessments as required by State and Federal Regulations.Resident Assessments.These assessments are validated and reliable in accordance with RAI standards as set forth by CMS.A review of the facility's P&P titled Resident Assessment, revised January 2026, indicated POLICY STATEMENT: Initially and periodically, the facility conducts a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. INTENT To ensure the facility uses the Resident Assessment Instrument (RAI) in accordance with specified format and timeframes in conducting comprehensive assessments.GUIDELINES: 1. The facility develops a comprehensive assessment of a resident's needs, strengths, goals, life history, and preference using the Resident Assessment Instrument (RAI) provided by CMS.3. The assessment minimally includes the following.Communication.The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Based on interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long term care) was accurately completed for one of three sampled residents (Resident 62) reviewed for PASRR.This failure had the potential for Residents 62 not to receive the most appropriate care and services for his needs.Findings:1. A review of Resident 62's admission RECORD (front page of the chart that contains a summary of basic information about the resident) dated 7/8/26, indicated the resident was admitted to the facility on [DATE] with diagnoses that included psychotic disorder (mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality), chronic kidney disease, and muscle weakness.A review of Resident 62's comprehensive admission Minimum Data Set (MDS - a federally mandated resident assessment tool) with an Assessment Reference Date (ARD- a specific date that serves as the end point of the look back or observation period for capturing a resident's clinical condition) of 4/24/26, indicated, Section I- Active Diagnoses.I5950 Psychotic Disorder. was marked X- indicating the presence of this condition.A review of Resident 62's PASRR Level 1 Screening dated 5/11/26, indicated, .11. Diagnosed Serious Mental Illness. Does the individual have a diagnosed Serious Mental Illness disorder such as.symptoms of psychosis.? This question was marked No and the diagnoses selection for Schizophrenia (a severe brain disorder in which people interpret reality abnormally)/Schizoaffective Disorder (chronic mental health condition characterized by schizophrenia and mood disorder [temporary, generalized state of feelings and emotions] symptoms), or symptoms of Psychosis was left blank.During a concurrent interview and record review on 7/8/26, at 2:10 PM, with the Director of Nursing (DON), the DON reviewed Resident 62's admission record, Sec. I of the comprehensive admission MDS assessment, and PASRR and stated that the PASRR dated 5/11/26 was inaccurately filled out. The DON stated it was her expectation for Resident 62's PASRR to be accurately completed so that further evaluations, appropriate recommendations, interventions and placement for the resident would be provided.A review of the facility's Policy and Procedure (P&P) titled Preadmission SCREENING AND RESIDENT REVIEW (PASRR), revised January 2026, indicated POLICY STATEMENT: The facility ensures each resident is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the extent possible, and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate.Mental Disorder (MD).(i) Diagnosis.This mental disorder is:.a.other psychotic disorder.Preadmission Screening and Resident Review (PASARR). PASARR requires that: 1. All applicants to a Medicaid-certified nursing facility are evaluated for a serious mental disorder.2. Are offered the most appropriate setting for their needs.3. Receive the services they need in those settings.GUIDELINES.9. Individuals who have or are suspected to have MD may not be admitted to a Medicaid-certified nursing facility unless approved based on Level II PASARR evaluation and determination.13. Level II PASARR is a comprehensive evaluation conducted by appropriate state designation authority.determines the appropriate setting for the individual, and recommends what, if any, specialized services and /or rehabilitative services the individual needs.20. The facility is required to provide all other care and services appropriate to the resident's condition.A review of the facility's MDS Lead (RN) Job Description, dated December 2016, indicated, .Summary: The MDS Lead (RN) is responsible for managing the timely completion of accurate assessments and interdisciplinary care plans that meet Federal and State guidelines.Roles and Responsibilities:.Facilitate the correction of errors immediately and retransmit the assessment. Facilitate the completion and updating of resident care plans to reflect the residents' most current needs. Lead facility staff education.and the coordination of obtaining accurate documentation from direct care staff.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for hearing impairment for one of 24 sampled residents (Resident 33). This failure had the potential to delay Resident 33's care, treatment, and services to maintain or improve his hearing abilities.Findings:A review of Resident 33's admission RECORD (front page of the chart that contains a summary of basic information about the resident) dated 7/8/26, indicated the resident was readmitted to the facility on [DATE].During an initial tour observation and interview on 7/6/26, at 1:05 PM, inside Resident 33's room, with Resident 33 and his responsible party (RP), Resident 33 was awake and verbally responsive while lying on his bed. Resident 33 asked for the question to be repeated and stated he had bad hearing. The RP stated Resident 33 was hard of hearing for years now and had been using hearing aids.During an interview on 7/8/26, at 9:21 AM, in the hallway outside Resident 33's room, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 33 could verbalize his needs but was hard of hearing. CNA 2 also stated Resident 33 verbalized he could not hear her, and she would have to repeat herself while talking to the resident.During an interview on 7/8/26, at 10:08 AM, with the Speech Language Pathologist (SLP- health care professional that diagnoses and treats conditions that affect one's ability to communicate and swallow), the SLP stated one of the challenges when working with Resident 33 was his hearing difficulties. The SLP also stated Resident 33 would ask her to speak louder because he could not hear her.During a concurrent interview and record review on 7/8/26, at 10:58 AM, with the MDS Coordinator (MDSC), the MDSC reviewed Resident 33's electronic health records and stated there was no documented evidence that a comprehensive care plan was developed for Resident 33's hearing impairment. The MDSC also stated that hearing impairment needed to be addressed, and the development of a care plan was important to monitor Resident 33's hearing progress or decline.During a concurrent interview and record review on 7/8/26, at 11:14 AM with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 33's electronic health records and acknowledged that Resident 33 had no care plan for his hearing impairment. The ADON also stated it was her expectation that when a problem existed, staff should develop a comprehensive care plan to identify, implement, and follow through with interventions to meet the needs of the residents.During an interview on 7/9/26, at 3:15 PM, with the Director of Nursing (DON), the DON stated that a hearing impairment care plan should have been developed for Resident 33. The DON also stated that care plans were important to address resident's issues so appropriate care could be provided.A review of the facility's Policy and Procedure (P&P) titled COMPREHENSIVE CARE PLANS-TIMING, revised January 2026, indicated POLICY STATEMENT: Each resident has a person-centered, comprehensive care plan, developed, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative.GUIDELINES: 1. The comprehensive care plan is completed by the interdisciplinary team.The interdisciplinary team reviews and revises the comprehensive care plan after each assessment.3. The comprehensive care plan is developed within seven days of completion of the comprehensive assessment, reviewed and revised after each assessment. 4. The comprehensive care plan must be completed no more than 21 days after admission. -Cross reference to F641

Based on observation, interview, and record review, the facility failed to ensure the appropriate use of lidocaine patches (medication to treat pain), when the nursing staff failed to remove lidocaine patches after 12 hours per manufacturer recommendations for one out of ten residents (Resident 86) during the medication administration observation.This failure had the potential for Resident 86 to receive an excessive dose of lidocaine which could result in side effects, including swelling and skin irritation.Findings:During a medication pass observation on 7/6/26, at 9:06 AM, in Resident 86's room, Licensed Vocational Nurse 1 (LVN 1) was observed administering nine medications to Resident 86. Resident 86 was lying in bed. The medications included one lidocaine 5% (percent, medication strength) patch. LVN 1 removed Resident 86's blanket to expose Resident 86's right knee. There was a patch labeled 7/5 and initialed on the right knee. LVN 1 stated this was the old lidocaine patch. LVN 1 removed the old patch before applying the new lidocaine patch. During a continued medication pass observation on 7/6/26. at 9:09 AM, in Resident 86's room, LVN 1 removed Resident 86's blanket to expose Resident 86's left knee. There was a patch labeled 7/5 and initialed on the left knee. LVN 1 removed the old lidocaine patch before applying the new patch. LVN 1 stated the left knee patch had the same initials and handwriting as the patch on the right knee. A review of Resident 86's Medication Review Report, dated 7/7/26, indicated Resident 86 had a physician's order, dated 6/29/26, for Lidoderm (brand name for lidocaine) 5% patch, Apply to each knee topically [on the skin] in the morning for knee osteoarthritis [pain in the joints] apply one patch to each knee. During a concurrent interview and record review on 7/7/26, at 8:50 AM, with LVN 1, Resident 86's Medication Administration Record (MAR, legal document used to track the medications a patient has been given), dated 7/1/26 - 7/7/26, was reviewed. The MAR indicated Resident 86's lidocaine patches were applied on 7/5/26 during the 9:00 AM medication pass. LVN 1 stated the lidocaine patches applied in the morning on 7/5/26 were left on overnight before the medication pass observation on 7/6/26. LVN 1 further stated the lidocaine patch orders were incomplete because they did not include instructions to remove the patch at night. LVN 1 stated the facility got new orders to remove the lidocaine patch after 12 hours after the morning medication pass observation on 7/6/26. During an interview on 7/7/26, at 3:02 PM, with Registered Nurse 1 (RN 1), RN 1 stated lidocaine patches were only supposed to be applied for 12 hours. RN 1 stated a lidocaine patch applied to a resident at 9:00 AM should be removed at 9:00 PM the same day. RN 1 stated orders for lidocaine patches needed to include scheduled times for application and removal. During an interview on 7/8/26, at 2:51 PM, with the Director of Nursing (DON), the DON stated the guideline was for lidocaine patches to remain on a resident for 12 hours and then 12 hours off. The DON stated the expectation was for lidocaine patches to be removed 12 hours after application even if not written in the physician's order. During a phone interview on 7/9/26, at 10:46 AM, with the Consultant Pharmacist (CP), the CP stated proper administration of lidocaine patches was to have 12 hours on the skin, followed by 12 hours off. The CP stated this was the approved manufacturer dosing. The CP stated skin irritation was a possibility if the lidocaine patch was left on for over 12 hours. The CP confirmed the expectation was for lidocaine patches to be removed after 12 hours. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Lidoderm 5% patch, dated 2/1/10, retrieved from DailyMed (internet database operated by the U.S. National Library of Medicine providing labeling for prescription and nonprescription drugs) indicated: .Apply LIDODERM to intact skin to cover the most painful area. Apply up to three patches, only once for up to 12 hours within a 24-hour period. and .Excessive dosing by applying LIDODERM to larger areas or for longer than the recommended wearing time could result in increased absorption of lidocaine and high blood concentrations, leading to serious adverse effects.Systemic [affecting the entire body] adverse effects of lidocaine.including.confusion, dizziness, drowsiness.tremors, convulsions, unconsciousness. and .the skin at the site of application may develop blisters, bruising, burning sensation.discoloration, edema (swelling).irritation. A review of the facility's policy and procedures (P&P) titled, Medication Errors, revised January 2026, indicated, Medication Error.administration of medications or biologicals which are not in accordance with.Manufacturer's specifications regarding the preparation and administration of the medication.

Based on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards of practice for one of ten residents (Resident 23) observed during the medication administration observation, when Resident 23's pain scores were incorrectly documented in the medical record.This failure resulted in inaccurate documentation of Resident 23's pain which could cause inaccurate clinical assessment of pain management medications. Findings:During a medication pass observation on 7/6/26, at 4:12 PM, at Resident 23's bedside, Licensed Vocational Nurse 2 (LVN 2) was observed administering five medications to Resident 23. The medications included two tablets of acetaminophen (generic for Tylenol, pain medication) 325 milligrams (mg), total dose 650 mg, and two tablets of ibuprofen (generic for Advil, pain medication) 200 mg, total dose 400 mg. A review of Resident 23's Medication Review Report, dated 7/7/26, indicated Resident 23 had a physician's order, dated 11/15/25, for acetaminophen 325 mg, Give 2 tablet by mouth every 4 hours as needed for mild pain 1-3/10. A review of Resident 23's Medication Review Report, dated 7/7/26, indicated Resident 23 had a physician's order, dated 6/30/26, for ibuprofen 200 mg, Give 200 mg by mouth every 4 hours as needed for breakthrough pain. During an interview on 7/6/26, at 4:38 PM, with LVN 2, LVN 2 stated Resident 23's pain score for the afternoon medication pass was five out of 10. LVN 2 confirmed the acetaminophen was supposed to be given for a pain score between one and three. LVN 2 stated she had to enter a pain score between one and three on the medication administration record (MAR, legal document used to track the medications a patient has been given). LVN 2 stated she gave acetaminophen because Resident 23 did not have pain medication for a pain score of five. A review of Resident 23's Medication Administration Record, dated 7/1/26 - 7/7/26, indicated Resident 23 received a dose of as needed (PRN) acetaminophen on 7/6/26 at 4:22 PM, with a documented pain score of two. The record also indicated Resident 23 received a dose of PRN ibuprofen on 7/6/26 at 4:21 PM, with a documented pain score of four. During an interview on 7/8/26, at 2:56 PM, with the Director of Nursing (DON), the DON stated it was not acceptable to document a pain score of two when Resident 23's actual pain score was five. The DON stated a nurse was supposed to call the doctor for a pain score outside of the medication orders. During a phone interview on 7/9/26, at 10:58 AM, with the Consultant Pharmacist (CP), the CP stated it was not appropriate for a nurse to document an incorrect pain score in Resident 23's medical record. The CP stated nurses needed to accurately document the resident's complaints of pain. The CP stated all providers were expected to accurately document the resident' s condition. The CP stated inaccurate information could affect the evaluation of Resident 23' s pain management therapy. During a concurrent interview and record review on 7/9/26, at 3:42 PM, with the DON, the facility's policy and procedure (P&P) titled, Accuracy of Assessments, revised January 2026, was reviewed. The policy indicated, The appropriate, qualified health professionals correctly document the resident's medical, functional.problems and identify resident strengths to maintain or improve medical status. The P&P titled, Services Provided Meet Professional Standards, revised January 2026, was also reviewed. The policy indicated, The services provided or arranged by the facility.meet professional standards of quality. The DON agreed accurate documentation in the medical record was a professional standard. The DON stated both policies addressed the inaccurate pain score documentation in Resident 23's medical record and verified it was not acceptable practice. A review of the facility's P&P titled, Pain Assessment and Management, revised January 2025, indicated, The facility provides pain management to residents who require such services, consistent with professional standards of practice. The policy also indicated, The ongoing evaluation of the status (presence, increase or reduction) of a resident's pain is vital, including.the response to interventions to prevent or manage pain. A review of the facility's P&P titled, IIA2: Medication Administration - General Guidelines, dated October 2012, indicated, When PRN [as needed] medications are administered, the following documentation is provided.Complaints or symptoms for which the medication was given.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), was cared for by staff (IP and CNA2) using enhanced barrier precautions (gloves and gown). This failure had the potential to result in the spread of harmful germs from contaminated uniforms to residents during the delivery of care.During a review of Resident 1's physician orders dated 3/5/26, the orders indicated Resident 1 to have Enhance Barrier Precautions due to: foot and right buttocks wounds every shit for infection control and prevention. During a review of the facilities P&P titled, Enhanced Barrier Precautions, dated January 2025, the P&P indicated, EBP are indicated for residents with any of the following: Wounds, even if the resident is not known to be infected or colonized with a Multi-Drug-Resistant Organism (MDRO). The staff will implement EBP for residents who are indicated when performing the following high contact resident care activities: providing hygiene.changing briefs . Review of the California Department of Public Health (CDPH) All Facilities Letter (AFL- information on changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) 24-15 titled, Enhanced Barrier Precautions (EBP), dated 6/13/24, the AFL indicated, California SNFs [skilled nursing facilities] should refer to the CDC website on Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs). Review of the Centers for Disease Control and Prevention (CDC) website, https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, accessed on 3/11/2026, indicated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP. for residents with. Wounds. regardless of MDRO colonization status. During a review of Resident 1's Order Summary Report (OSR), dated 3/5/26, the OSR indicated, Active Orders As Of: 03/05/2026. Enhanced Barrier Precaution due to: foot and right buttocks wounds. During an observation on 3/4/26 at 3 p.m. outside Resident 1's room was a sign posted indicating EBPs were required. Inside Resident 1's room the Infection Preventionist (IP) and a certified nursing assistant (CNA2) were changing Resident 1's brief without wearing the required PPE gowns. During an interview on 3/426 at 3:30 p.m. with IP and CNA2, IP stated IP should have been wearing a PPE gown and wasn't. IP further stated, CNA2 stated CNA2 should have been wearing a gown and wasn't. During an interview on 3/2/2026 at 4:30 p.pm. with the Administrator (ADM), ADM stated he was aware of the infection control issue because his staff told him about it.

Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided quality care when the facility failed to: Administer Glargine (insulin used for regulating blood sugar) for 3 days, on 8/21 at 9 p.m., 8/22 at 9 a.m. and 9 p.m., and 8/23 at 9 a.m. 2. Notify/Communicate to the charge nurse and physician the missed doses of Glargine. 3. Acquire insulin to meet Resident 1's needs. 4. Administer Glargine from a properly labeled medication container. 5. Clarify the order for finger stick blood sugar (FSBS- a method of monitoring blood sugar levels) with the physician. 6. Failed to monitor blood glucose (BG- blood sugar). 7. Realize the need for monitoring blood sugar. As a result of these failures, Resident 1 was transferred to an acute care hospital due to abnormally high blood sugar (593) for evaluation and treatment and ultimately died. FindingsDuring a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was 65-years-old admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (stroke, loss of blood flow to a part of the brain) and secondary diagnoses diabetes mellitus (a disorder characterized by difficulty in blood sugar control), hypertension (high blood pressure), hemiplegia (paralysis of one side of the body), chronic myelogenous leukemia (a type of cancer), anemia (inadequate number of red blood cells), drug induced polyneuropathy (a painful condition caused by medications), atrial fibrillation (irregular heart beat), dysphagia (difficulty swallowing), gastrostomy tube (G-tube- feeding tube directly into the stomach), and other psychotic disorder not due to a substance or known physiological condition (the state of the body and how its different parts and systems are working).According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 328), Standards of nursing care reflect the knowledge and skill ordinarily possessed and used by nurses to perform within the scope of practice.1. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 640), Administering medications requires unique nursing knowledge, clinical judgment, and skills. As a nurse you need to. administer medications correctly, and then closely monitor their effects.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 3/23, the P&P indicated, Medications must be administered in accordance with the orders.During a review of Resident 1's Order Summary Report (OSR- a breakdown of all the orders placed for a specific time period), dated [DATE] - [DATE], the OSR indicated, Insulin Glargine. every 12 hours for DM2 [type 2 diabetes] . Start Date. [DATE].During a concurrent interview and record review on [DATE] at 12 p.m. with the Director of Nursing (DON), Resident 1's Medication Administration Record (MAR), dated 8/25 and Progress Notes (PN), dated [DATE] - [DATE] were reviewed. The DON stated the insulin was not given on [DATE]-[DATE], the insulin was first given on [DATE]. DON stated, These were significant medication errors.During a review of Resident 1's MAR, dated 8/25, the MAR indicated, Glargine (insulin) was ordered to be administered every 12 hours for diabetes mellitus starting at 9 p.m. on [DATE]. Glargine was not administered as ordered on 8/21 at 9 p.m., 8/22 at 9 a.m. and 9 p.m., and 8/23 at 9 a.m. Each of the boxes had a number nine indicating other / see NN [progress note]. During a review of Resident 1's PNs titled, Medication Administration Note, dated:- [DATE] at 9:41 p.m., the PN indicated Glargine (insulin) was not given due to new admission. The PN did not indicate if the nurse contacted the physician or pharmacist.- [DATE] at 9 a.m. and 9 p.m., no PNs indicating why Insulin Glargine was not administered was found. - [DATE] at 9 a.m., no PN indicating why Insulin Glargine was not administered was found. - [DATE] at 8:58 p.m., the PN indicated the Glargine was not available. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), dated [DATE] at 5:57 p.m., the SBAR indicated, Situation - abnormal lab results. Glucose level 593, sent to ER per MD; Assessment - Received abnormal lab results and noted with elevated glucose level 593. MD notified and received orders to send out via regular ambulance.During a review of Resident 1's Health Status Note, dated [DATE] at 4:22 p.m., the PN indicated, Will send patient to hospital. Needs admission for fluids and diabetes control. 2. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 3/23, the P&P indicated, To provide employees with guidelines for the safe and timely administration of medications. Medications must be administered in accordance with the orders.During a concurrent interview and record review on [DATE] at 12 p.m. with the DON, Resident 1's MAR, dated 8/25 and PNs, dated [DATE] - [DATE] were reviewed. The DON stated the missed insulin doses were not reported to Resident 1's physician.During an interview on [DATE] at 1:15 p.m. with a licensed nurse (LN6), LN6 stated did not realize the physician needed to be notified when the insulin was not delivered and when Resident 1 missed doses of their medication.3. During a review of the facility's P&P titled, Medication Ordering and Receiving From Pharmacy, dated 6/16, the P&P indicated, To access medication from the emergency kit [E-Kit] secondary to a new order or when medication for which there is a current prescription is not readily available. the nurse confers with the prescriber or the pharmacy.During a review of Resident 1's PN titled, admission Summary, dated [DATE] at 9:08 p.m., the PN indicated, New patient arrived at the facility around 1915 [7:15 p.m.] . All medications have been faxed to the pharmacy.During a review of Resident 1's MAR, dated 8/25, the MAR indicated, Glargine (insulin) was not administered as ordered on 8/21 at 9 p.m.During a review of Resident 1's PN titled, Medication Administration Note, dated [DATE] at 9:41 p.m., the PN indicated Glargine (insulin) was not given due to new admission. The PN did not indicate if the nurse contacted the physician or pharmacist.During a concurrent interview and record review on [DATE] at 12 p.m. with the DON, the DON stated the E- Kit (emergency medicine supply) kept at the facility was not used. DON further stated the LNs did not know what to do and did not ask for help.During a review of the pharmacy's Packing Slip (PS- a document included in the shipment that lists the items inside the package), dated [DATE] at 12:42 a.m., the PS indicated Resident 1's Glargine (common brand name Lantus) medication was delivered to the facility [DATE] at 4 a.m.During a review of the facility's Pharmacy Services Agreement (PSA), signed by the facility Administrator (ADM) [DATE], dated effective [DATE], the PSA indicated, All new drug orders shall be available on the same day ordered unless the drug would not be started until the next day.4. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 643), An important step in safe medication administration is being sure that you give the right medication to the right patient.During a concurrent interview and record review on [DATE] at 1:15 p.m. with LN6, Resident 1's MAR dated 8/25 was reviewed. The MAR indicated LN6 administered Glargine on [DATE], for the 9 a.m. and 9 p.m. administration times and on [DATE], for the 9 a.m. administration time. LN6 stated Resident 1's Glargine was not located; another resident's Glargine was found and used for Resident 1. LN6 further stated was aware medications cannot be shared between residents.During a review of the facility's P&P titled, Medication Ordering and Receiving From Pharmacy, dated 6/16, the P&P indicated, Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency box, from the provider pharmacy or a back-up pharmacy that is determined by the provider pharmacy.During an interview on [DATE] at 12 p.m. with the DON, DON stated you can't borrow medications.5. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 271), A consultation is vital if you need to seek procedural assistance or clinical expertise for a specific problem to ensure a patient receives needed clinical interventions or insights.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's OSR, dated [DATE] - [DATE] was reviewed. The OSR indicated, on [DATE], FSBS [finger stick blood sugar] Q [every] AC [before meals] &HS [bedtime]. Call MD if < 70 or > 400, was ordered as part of the batch orders (a group of multiple orders compiled together). LN1 stated it is the facility process for the nurse to add the batch orders. If the nurse fails to add the batch orders, it gets audited and returned to the nurse to correct. The resident's physician is usually not communicated with about the batch orders and LN1 does not know how the physician finds out about them. LN1 further stated the FSBS order was not the correct order for monitoring Resident 1's blood sugar and LN1 did not clarify the order with the physician.During a concurrent interview and record review on [DATE] at 12 p.m. with the DON, Resident 1's MAR, dated 8/25, was reviewed. DON stated the FSBS was ordered incorrectly. The FSBS should have been clarified with the physician and ordered every six hours. DON further stated the new nurses were not experienced to know the FSBS was needed.During a concurrent interview and record review on [DATE] at 1:15 p.m. with LN6, Resident 1's MAR, dated 8/25 was reviewed. LN6 stated inexperience was reason for not clarifying the missing blood sugar monitoring with the physician.6. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 1220), Blood Glucose Monitoring. Review health care provider's order for time or frequency of measurement. Rationale. Health care provider determines test schedule on basis of patient's physiological status and risk for glucose imbalance.During a review of the facility's P&P titled, Diabetes Clinical Protocol, dated 2/24, the P&P indicated, The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate parameters into the Medication Administration Record.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's MAR, dated 8/25, was reviewed. The MAR indicated that the order for FSBS monitoring did not appear on it. LN1 stated no blood sugar monitoring was done.During a concurrent interview and record review on [DATE] at 12 p.m. with the DON, Resident 1's electronic medical record (eMR- digital version of patient's paper chart) was reviewed. DON stated there was no BG monitoring while Resident 1 was at the facility.During a review of Resident 1's Health Status Note (HSN), dated [DATE] at 4:22 p.m., authored by Resident 1's physician, the HSN indicated, Will send patient to hospital. Needs admission for. diabetes control.7. Review of the National Institute of Health website, https://pubmed.ncbi.nlm.nih.gov/30969870/, accessed on [DATE], indicated, All nurses should be familiar with the importance of blood glucose monitoring. Appropriate and timely monitoring of blood glucose will allow for successful management of blood glucose that is out of target range. This will ensure ongoing patient safety.During a review of the facility's policy and procedure (P&P) titled, Diabetes Clinical Protocol, dated 2/2024, the P&P indicated, The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will. note parameters as ordered to the resident's care plan.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's Medicare Skilled Charting (MSC- details of the patient's condition, their response to treatments, and any changes), dated [DATE] at 8:25 p.m. was reviewed. The MSC indicated the skilled nursing services being provided did not include diabetic care and the most recent BG result was not included in the section for vital signs. LN1 stated the BG should have been done and wasn't.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1): 1. Had a baseline care plan (BCP- initial instructions for care right after admission) developed for diabetes management. 2. Had BCP developed for abdominal binder (a wide, elastic compression belt worn around the abdomen) use. 3. Had BCP interventions (specific actions to be taken) that were applicable to Resident 1 regarding NPO (nothing by mouth) status. These failures resulted in Resident 1 being transferred to the hospital for elevated blood sugar and had the potential for choking or aspiration (food or liquids entering the lungs).During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was a [AGE] year-old admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (stroke, loss of blood flow to a part of the brain) and secondary diagnoses of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control), dysphagia (difficulty swallowing) and gastrostomy tube (G-tube - feeding tube directly into the stomach). During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, dated 1/2025, the P&P indicated, Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission. The baseline care plan includes the minimum healthcare information necessary to properly care for a resident, including. Physician orders. 1. During a review of Resident 1's Order Summary Report (OSR), dated 8/21/25 - 8/25/25, the ORS indicated, FSBS [finger stick blood sugar] Q [every] AC [before meals] &HS [bedtime]. Call MD if < 70 or >400. Monitor signs and symptoms of hyperglycemia [high blood sugar] . Monitor signs and symptoms of hypoglycemia [low blood sugar] . (Insulin Glargine) Inject 22 unit subcutaneously [under the skin] every 12 hours for DM2 [diabetes mellitus type 2]. During a review of Resident 1's Health Status Note (HSN), a late entry dated 9/2/25 at 1:24 p.m. for 8/25/25 at 4:22 p.m., the HSN indicated, Will send patient to hospital. Needs admission for fluids and diabetes control. During a concurrent interview and record review on 10/14/25 at 2:15 p.m. with the Director of Nursing (DON), Resident 1's BCPs were reviewed. DON stated there was no BCP for diabetes management and there should have been. 2. During a review of Resident 1's Wound Weekly Monitoring Assessment (WWMA), dated 8/22/25 at 3:36 p.m., the WWMA indicated, Resident wearing binder to prevent resident from pulling on peg tube [feeding tube inserted through the stomach]. During a concurrent interview and record review on 9/25/25 starting at 3:45 p.m. with a licensed nurse (LN1), Resident 1's BCPs were reviewed. LN1 stated there should have been a BCP for abdominal binder use and there wasn't. 3. During a review of Resident 1's BCP titled, Resident has the following dietary orders Resident is NPO [nothing by mouth]. Currently on G-tube [feeding tube directly into the stomach], date initiated 8/21/25, the BCP intervention indicated, Monitor meal intake. During a review of Resident 1's BCP titled, The resident is on Seroquel (Antipsychotic Medications) r/t [related to] psychosis manifested by: behaviors of agitation, date initiated 8/21/25, the BCP intervention indicated, Offer warm beverage of preference, such as warm milk or hot tea. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 265), Choosing suitable nursing interventions requires applying your nursing knowledge and the best scientific evidence for a patient's health problems. During a concurrent interview and record review on 9/25/25 at 3:45 p.m. with LN1, Resident 1's BCPs titled Resident has the following dietary orders Resident is NPO. Currently on G-tube, and The resident is on Seroquel r/t psychosis manifested by: behaviors of agitation, dated 8/21/25 were reviewed. LN1 stated the interventions were not right and should have been changed. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 399), Most computer documentation systems allow these care plans to be modified by creating individualized interventions and outcomes for each patient.

Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided care according to accepted professional nursing standards (actions that ensure safe nursing practice) when the facility failed to: Develop a baseline care plan (BCP- initial instructions for care right after admission developed by using the nursing process) for diabetes management. 2. Develop care plans (CP- a detailed outline of health needs, goals, and preferences that guides care to ensure consistent and appropriate care) with resident specific interventions. 3. Clarify conflicting orders for the way to (route) administer medication. 4. Follow physician order for monitoring blood pressure (BP). 5. To communicate with the physician to clarify PRN (as needed) Seroquel order when ordered for an excessive duration without an end date and with conflicting physician indications for its use. 6. To include an intervention for a psychiatric assessment and a review of the results of the psychiatric assessment. 7. Ensure Licensed Vocational Nurses (LVNs) worked within their scope of practice (legally permitted actions based on their education, training, and licensure). As a result of these failures, Resident 1 was transferred to an acute care hospital due to abnormally high blood sugar (593) for evaluation and treatment and ultimately died.Findings:1. During a review of the facility's policy and procedure (P&P - expected employee conduct and detailed patient care instructions) titled, Baseline Care Plan, dated 1/25, the P&P indicated, The facility develops and implements a baseline care plan for each resident. that meet professional standards of quality care. based on the resident's admission orders, information available from the transferring provider. includes the minimum healthcare information necessary to properly care for a resident.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's Baseline Care Plans (BCPs), were reviewed. A BCP for diabetes management was not found. LN1 stated there should have been a BCP developed for diabetes management and there wasn't.During a concurrent interview and record review on [DATE] at 2:15 p.m. with DON, Resident 1's BCPs, were reviewed. DON stated there should have been a care plan developed for diabetes management and there wasn't.2. During a review of Resident 1's CPs, titled:- BCP [baseline care plan] Resident has the following dietary orders Resident is NPO [nothing by mouth]. Currently on G-tube, initiated [DATE], the CP indicated, Interventions (actions to be taken) . Monitor meal intake.- The resident is on Seroquel (Antipsychotic Medications), initiated [DATE], the CP indicated, Offer warm beverages of preference, such as warm milk or hot tea.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's CPs were reviewed. The CPs indicated Resident 1 was to have nothing by mouth. The CPs also indicated interventions to monitor meal intake and offer warm beverages of preference. LN1 stated, I should have changed those, interventions.During a concurrent interview and record review on [DATE] at 2 p.m. with the DON, Resident 1's CPs were reviewed. The CPs indicated Resident 1 was to have nothing by mouth. The CPs also indicated interventions to monitor meal intake and offer warm beverages of preference. DON stated the interventions were not specific to Resident 1.3. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 648), It is essential to verify the accuracy of every medication you give to your patients with the patients' orders. If the medication order is incomplete, incorrect, or inappropriate or if there is a discrepancy between the original order and the information on the MAR, consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration.During a review of the facility's P&P titled, Administering Medications, dated 3/23, the P&P indicated, To provide employees with guidelines for the safe and timely administration of medications per physician order. Medications must be administered in accordance with the orders.During a review of Resident 1's AR, Initial admission date [DATE], the AR indicated, Diagnosis. Dysphagia [difficulty swallowing].During a review of Resident 1's OSR, dated [DATE] - [DATE], the OSR indicated:-NPO diet [nothing by mouth]During a review of Resident 1's OSR, dated [DATE] to [DATE], the OSR indicated, Order Date [DATE]. Start Date [DATE]. NPO [nothing by mouth], and Enteral [through the feeding tube directly into the stomach] Feeding Order. Every shift Flush feeding tube 30 ml [milliliter] water before and after medication administration.During a concurrent interview and record review on [DATE] at 12 p.m. with DON, Resident 1's OSR, dated [DATE] to [DATE] and MAR, dated 8/25 were reviewed. DON stated that based on the documentation all the medications were given by mouth. DON also stated it should have been clarified with the physician whether to give the medications by mouth or feeding tube. DON further stated the issues were because of the nurses' inexperience.During a review of Resident 1's BCP titled, Resident has the following dietary orders Resident is NPO. Currently on G-tube [nutrition by tube directly into the stomach], initiated [DATE], the BCP indicated Resident 1's goal was to adhere to diet as ordered.During a concurrent interview and record review on [DATE] at 1:15 p.m. with LN6, Resident 1's MAR, dated 8/25 was reviewed. LN6 stated Resident 1's medications were administered by mouth. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 640), The National Coordinating Council for Medication Error Reporting and Prevention (2021) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and /or failing to administer a medication.4. During a review of Resident 1's OSR, dated [DATE] to [DATE], the OSR indicated, Seroquel [antipsychotic]: Monitor orthostatic hypotension [a significant drop in blood pressure upon sitting from a lying position] - blood pressure [BP] while lying and sitting every day shift for 10 days. Order Date. [DATE]. Start Date. [DATE].During a review of Resident 1's BCP titled, The resident is on Seroquel (antipsychotic medications) r/t psychosis manifested by: behaviors of agitation, initiated [DATE], the BCP indicated, Monitor orthostatic hypotension [a drop in blood pressure (B/P)] - B/P while lying and sitting . Call MD for changes noted.During a record review of Resident 1's MAR, dated 8/25, the MAR indicated:- [DATE]: lying 128/72, sitting 128/72,- [DATE]: lying 128/63, sitting 128/63,- [DATE]: lying 158/83, sitting 158/83, and- [DATE]: lying 147/69, sitting 147/69.During a concurrent interview and record review on [DATE] at 1:15 p.m. with LN6, Resident 1's OSR dated [DATE] to [DATE] and MAR dated 8/25 were reviewed. LN6 stated the lying and sitting BPs are identical. The lying BP was used for the sitting BP because it was too difficult to get Resident 1 into the sitting position. LN6 further stated LN6 did not notify the physician of the difficulty in trying to sit-up Resident 1 or of the BPs recorded as sitting when they were actually lying BPs.During a concurrent interview and record review on [DATE] at 2:15 p.m. with the DON, Resident 1's OSR dated [DATE] to [DATE] and MAR dated 8/2025 were reviewed. DON stated the nurses should have notified the physician instead of duplicating the BPs.5. During a review of the facility's policy and procedure (P&P) titled, Dignity and Respect Psychoactive Medications, dated 1/25, the P&P indicated, Based on a comprehensive assessment of a resident, the facility shall ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. PRN (as needed) orders for psychotropic drugs shall be limited to 14 days. The resident's medication management plan is documented in their medical record. (such as. vital signs.) is essential to evaluate the ongoing effectiveness, benefits as well as risks of. psychotropic medications.During a review of Resident 1's OSR, dated [DATE] - [DATE], the OSR indicated, Seroquel. Give 0.5 tablet by mouth every 24 hours as needed for psychosis m/b [manifested by] agitation. Order Date. [DATE]. Start Date. [DATE]. End Date. [not indicated].During a review of Resident 1's New Prescription Summary (NPS), dated [DATE], the NPS indicated, Seroquel. Give 0.5 tablet by mouth every 24 hours as needed for psychosis m/b agitation.Refills: 99.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's OSR, dated [DATE] - [DATE] and NPS, dated [DATE] were reviewed. LN1 stated, Yes, the Seroquel PRN order was for three months. During a concurrent interview and record review on [DATE] at 2:15 p.m. with DON, Resident 1's OSR, dated [DATE] - [DATE] and NPS, dated [DATE] were reviewed. DON stated there should have been a stop date at 14 days. DON also stated all consultation notes, including the Psychiatric Intake Note (PIN), should have been reviewed and communicated to the ordering physician. DON further stated these issues are because of the nurses' inexperience.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's NPS, dated [DATE], OSR, dated [DATE] - [DATE], and PIN, dated [DATE] were reviewed:- The NPS indicated, Seroquel [antipsychotic] Oral Tablet 25 MG [milligram]. Give 0.5 tablet by mouth every 24 hours as needed for psychosis m/b [manifested by] agitation. Refills: 99. Start Date: [DATE].- The OSR indicated, Seroquel Oral Tablet 25 MG. Give 0.5 tablet by mouth every 24 hours as needed for psychosis m/b agitation . Order Date [DATE]. Start Date [DATE]. End Date [none indicated].- The PIN indicated, History of Present Illness. According to sister [Resident 1's sister's name], Resident had no history of mental illness. Mental Status Examination. Thought Content: (Hallucinations) Denied. Delusions: Denied. Hx [history] of Aggression: No. Treatment Plan/Recommendation. Continue Seroquel 12.5 mg qhs [every bedtime] for psychosis w/o [without] agitation.During a concurrent interview and record review on [DATE] at 3:45 p.m. with LN1, Resident 1's PIN, dated [DATE] and OSR, dated [DATE] - [DATE] were reviewed. LN1 stated LN1 does not know who receives the PIN or who reviews it. LN1 further stated that the PIN indicated Resident 1 did not have agitation and the OSR was for agitation. LN1 added they are the opposite of each other.6. During a review of the facility's P&P titled, Baseline Care Plan, dated 1/2025, the P&P indicated, The facility develops a baseline care plan. intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events most likely to occur right after admission.During a review of Resident 1's BCP titled, The resident is on Seroquel (antipsychotic medications) r/t psychosis manifested by: behaviors of agitation, initiated [DATE], the BCP indicated there was no intervention for a psychiatric assessment or a review of the assessment results.During a review of Resident 1's PN titled, Social Service Progress Note, dated [DATE] at 11:58 a.m., the PN indicated, This patient was seen by psychiatrist [name], NP on Saturday [DATE].During a review of Resident 1's Psychiatric Intake Note (PIN- a detailed document of the first session with a new patient), dated [DATE], the PIN indicated, According to sister [name], Resident has no history of mental illness. Medications. Seroquel 12.5 mg [milligrams] qhs [every night at bedtime] . Hx [history] of Aggression: No. continue Seroquel 12.5 mg qhs for psychosis w/o [without] agitation.During a concurrent interview and record review on [DATE] at 2:15 p.m. with DON, Resident 1's PIN, dated [DATE] and OSR, dated [DATE] - [DATE] were reviewed. DON stated all consultant notes should be reviewed and communicated to the physician.7. Review of the California Association of Long Term Care Medicine (CALCM) website, https://www.caltcm.org/index.php?option=com_dailyplanetblog&view=entry&year=2024&month=10&day=14&id=268:why-is-there-confusion-about-whether-a-licensed-vocational-nurse-can-assess-residents-in-california-nursing-homes, accessed on [DATE], indicated, The nursing process (Assessment, planning, implementing, and evaluating), otherwise known as problem-solving or critical thinking, and the care plan document, were identified as the unique domains of RNs. The RN is to perform the nursing process, which includes a clinical assessment. Similarly, the LVN has the authority to conduct basic patient assessments. The limitation is that, in California, the LVN is not allowed to conduct comprehensive health assessment. The responsibility of developing care plans is the responsibility of the RN and physicians.During a review of California Code of Regulations (CCR), Title 16 Professional and Vocational Regulations, Section 2518.5 Scope of Vocational Nursing Practice, the CCR indicated, The licensed vocational nurse performs services requiring technical and manual skills which include the following. Provides direct patient/client care by which the licensee. Contributes to the development and implementation of a teaching plan related to self-care for the patient/client.During a review of Resident 1's CPs titled:- At risk for hypo[low]/hyperglycemia [high blood sugar] . Diabetic Neuropathy [nerve damage], the CP indicated, it was initiated and created on [DATE] and revised on [DATE] by a Licensed Vocational Nurse (LN12), goals initiated and created on [DATE] and revised on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- Hypoglycemic Medications / Insulin, the CP indicated, it was initiated and created on [DATE] and revised on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- The resident has hemiplegia [paralysis on one side of the body]/Hemiparesis [weakness or paralysis on one side of the body], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] and revised on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- The resident has potential for complications, s/sx [signs and symptoms] r/t [related to] Dx [diagnosis] of Anemia [blood condition], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- The resident is at nutrition risk secondary to: Dysphagia [difficulty swallowing], pain, stroke, enteral feeding [tube feeding into the stomach], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- Alteration in musculoskeletal [muscles and bones], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12. The resident requires Enteral Feeding, the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.- The resident has GERD [stomach contents flow back up the throat], the CP indicated, it was initiated and created on [DATE] by LN12, goals initiated and created on [DATE] by LN12, interventions initiated and created on [DATE] by LN12.During a current interview and record review on [DATE] at 2 p.m. with the DON, Resident 1's CPs were reviewed. The CPs indicated they were initiated and created by LVNs. DON stated there are Registered Nurses in the assigned areas who should be developing the care plans.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1):1. Had appropriate alternatives to bed rails identified and tried.2. Was adequately assessed for bed rail use. 3. Had their bed and mattress assessed for bed rails (metal bars attached to the bed) prior to the bed rail installation. 4. Had the appropriately trained staff install the bedrails.These failures had the potential to result in an increased risk of entrapment (caught, trapped, entangled, or strangled in the space in or about the bed rail).Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (type of stroke- brain cells die) and secondary diagnoses including flaccid (floppy and weak) hemiplegia (paralysis of one side of the body), muscle weakness, drug-induced polyneuropathy (nerve damage that occurs as a side effect of certain medications), dysphagia (swallowing difficulties) with gastrostomy (surgical opening in the abdomen to insert a feeding tube directly into the stomach for nutrition). During a review of the facility's policy and procedure (P&P) titled, Siderail-Bedrail Safety Evaluation, dated 3/23, the P&P indicated, The facility attempts to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails. 1. During a review of Resident 1's progress note (PN) titled, admission Summary, dated 8/21/25 at 9:08 p.m., the PN indicated, New patient arrived to the facility around 1915 [7:15 p.m.]. During a review of Resident 1's Bed/Side Rail Entrapment Risk Assessment (BSRERA), dated 8/21/25 at 7:52 p.m., the BSRERA indicated, Alternative Interventions. Low Bed. Upper body mechanics. During a review of Resident 1's Devices / Physical Restraint Assessment/ Re-evaluation (DPRAR), dated 8/28/25 for effective date 8/21/25 at 8:15 p.m., the DPRAR indicated, Less restrictive measures / alternatives attempted. No. During a concurrent interview and record review on 9/25/25 at 3:45 p.m. with a licensed nurse (LN1), Resident 1's BSRERA, dated 8/21/25 at 7:52 p.m. and DPRAR, dated 8/28/25 for effective date 8/21/25 at 8:15 p.m. were reviewed. LN1 stated No alternatives were attempted. LN1 also stated Resident 1's family requested the bed rails and LN1 complied to keep the family from complaining. During a review of the facility's P&P titled, Respect and Dignity - Physical Restraints, dated 3/23, the P&P indicated, The facility does not implement the use of a restraint at the resident or resident representative request in the absence of an evaluation and identification of a medical symptom that must be treated and includes the practitioner in the review and discussion. 2. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 433), Side rails also can lead to patients becoming caught, trapped, entangled, or strangled, especially in those who are frail, elderly, or confused (FDA, 2017). Therefore, an assessment of a patient's mobility and responsiveness to instructions helps determine whether using a side rail is safe. During a review of Resident 1's PN titled, Health Status Note, dated 8/25/25 at 4:22 p.m., the PN indicated, A&OX0 [alert but not oriented to person, place, time, or situation]. Non-verbal. Unable to follow commands. During a review of Resident 1's PN titled, IDT [interdisciplinary team] Progress Note, date 8/22/25 at 4:08 p.m., the PN indicated, AOx0, cannot follow simple commands, does not follow with eyes, left facial droop, resident grips hard onto staff. Review of the U.S. Food and Drug Administration (FDA) website, https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-consumers-and-caregivers-about-adult-portable-bed-rails#:~:text=Some%20people%20are%20at%20a,Recommendations%20for%20Health%20Care%20Providers)., accessed on 11/7/25, indicated, Some people are at high-risk for entrapment, falls, or other injury from adult portable bed rails. High-risk people include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, or a combination of these factors. Additionally, people who are cognitively impaired. from a medical condition, such as. stroke. are at a higher risk of entrapment and injury. Consider other alternatives when bed rails are not appropriate. Alternatives include roll guards, foam bumpers. using concave mattresses that can help reduce rolling off the bed. During a review of Resident 1's Bed / Side Rail IDT (BSRIDT), dated 8/21/25 at 7:52 p.m., the BSRIDT indicated, Why is a bed/ side rail being considered? . Patient / Resident request. During a review of Resident 1's Section GG - Functional Abilities - admission (SGGFAA), dated 8/25/25, the SGGFAA indicated, Resident 1 was dependent (resident does none of the effort to complete the activity) on staff to be able to roll left and right in bed, to move from sitting on the side of the bed to lying, to move from lying in bed to sitting, to move from sitting to standing, and to transfer to and from the bed to a chair. During a review of Resident 1's BSRERA, dated 8/21/25 at 7:52 p.m., the BSRERA indicated, Is the resident dependent for bed mobility [no response] . Does the resident display poor bed mobility or difficulty in moving? [no response] . Does the resident have difficulty with balance or poor trunk control (e.g. leans forward, leans sideways, slides down)? [no response] . Reason for device use [no response] . RECOMMENDATIONS. Use of bed/side rail [no response]. 3. During an interview on 10/14/25 at 2 p.m., with the Director of Nursing (DON), DON stated the nurse is not supposed to assess the bed, mattress or bed rail. It's maintenance that should. During a concurrent interview and record review on 10/14/25 at 4:50 p.m. with the Maintenance Director (MD), MD stated no request for bed rail installation was made between 8/21/25 and 8/25/25. During an interview on 9/25/25 at 3:45 p.m. with LN1, LN1 stated Resident 1's bed was not measured or assessed. 4. During an interview on 9/25/25 at 3:45 p.m. with LN1, LN1 stated the Maintenance Department (MD) usually installs the bed rails and MD goes home around 6 p.m. LN1 also stated the side rails were not installed by MD because they had gone home. LN1 additionally stated LN1 installed the bed rails, was not trained to install the bed rails, and LN1 should not have installed them.

Based on interview and record review, the facility failed to have competent nurses who possessed the knowledge, skills, and judgment required to provide safe care for one of two sampled residents (Resident 1), when the facility failed to ensure: Licensed nurses knew to contact the physician when they did not administer Glargine (insulin- medicine used to regulate blood glucose levels) as ordered. 2. Licensed nurses knew to communicate to the charge nurse the missed doses of Glargine. 3. Licensed nurses knew to contact the physician when the medication administration record did not include blood glucose monitoring. 4. Licensed nurses knew to clarify conflicting orders for how to (route) administer medication. For Resident 1, these facility failures resulted in unsafe nursing care and admission to the hospital for an avoidable decline.1. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 640), Administering medications requires unique nursing knowledge, clinical judgement, and skills. Medication errors include. failing to administer a medication . When an error occurs, the patient's safety and well being are the top priorities. notify the health care provider of the incident as soon as possible. During a review of Resident 1's Medication Administration Record (MAR), dated 8/2025, the MAR indicated, Insulin Glargine. every 12 hours for DM2 [diabetes mellitus type 2] . start date 08/21/2025 2100 [at 9 p.m.]. The MAR also indicated 8/21/25 at 9 p.m., 8/22/25 at 9 a.m. and 9 p.m., and 8/23/25 at 9 a.m. and 9 p.m. to See Nurses Notes. During a review of Resident 1's progress notes (PN) titled, Administration Note, dated:- 8/21/25 at 9:41 p.m., the PN indicated, Insulin Glargine. New admission.- 8/22/25 no PNs were found for 9 a.m. or 9 p.m. missed doses.- 8/23/25 no PN was found for 9 a.m. missed dose.- 8/23/25 at 8:58 p.m., the PN indicated, Insulin Glargine. not available. During a concurrent interview and record review on 10/14/25 at 12 p.m. with the Director of Nursing (DON), Resident 1's MAR, dated 8/2025 and PNs, dated 8/21/25 - 8/25/25 were reviewed. DON stated the insulin was not given 8/21/25-8/23/25. DON next stated Resident 1's physician was not notified about the missed insulin doses. DON further stated the LNs did not know what to do. During an interview on 10/14/25 at 1:15 p.m. with a licensed nurse (LN6), LN6 stated LN6 did not realize they should have called the physician when Resident 1 missed doses of the insulin when it was not delivered from the pharmacy. 2. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 271), A consultation is vital if you need to seek procedural assistance or clinical expertise for a specific problem to ensure a patient receives needed clinical interventions or insights. During a concurrent interview and record review on 10/14/25 at 12 p.m. with DON, Resident 1's MAR' was reviewed. The MAR indicated Glargine insulin was ordered to start on 8/21/25 at 9 p.m. DON stated the insulin was not given to Resident 1 until 8/24/25. DON also stated the new nurses did not know what to do and did not ask for help from the charge nurse. 3. Review of the National Institute of Health website, https://pubmed.ncbi.nlm.nih.gov/30969870/, accessed on 11/6/25, indicated, All nurses should be familiar with the importance of blood glucose monitoring. Appropriate and timely monitoring of blood glucose will allow for successful management of blood glucose that is out of target range. This will ensure ongoing patient safety. During a concurrent interview and record review on 10/14/25 at 12 p.m. with DON, Resident 1's MAR, dated 8/2025, was reviewed. The MAR indicated the order for FSBS monitoring did not appear on it. DON stated no blood sugar monitoring was done. During a concurrent interview and record review on 10/14/25 at 12 p.m. with the DON, Resident 1's Order Details (OD), dated 8/21/25 at 7:08 p.m., and MAR, dated 8/2025, were reviewed. The OD indicated, FSBS [finger stick blood sugar] Q [every] AC [before meals] & HS [at bedtime]. Call MD [physician] if < [less than] 70 or > [greater than] 400. The MAR indicated the FSBS order did not appear on the document. DON stated the FSBS was ordered incorrectly. DON also stated for Resident 1, the FSBS should have been clarified with the physician and ordered every six hours. DON next stated the OD computer entry for the FSBS did not indicate the scheduling details which would have made the order appear on the MAR. DON further stated the new nurses were not experienced to know the FSBS was needed. During a concurrent interview and record review on 10/14/25 at 1:15 p.m. with LN6, Resident 1's OD, dated 8/21/25 at 7:08 p.m., and MAR, dated 8/2025 were reviewed. LN6 stated inexperience was her reason for not clarifying the missing FSBS order with the physician. During the review of the Administrator's explanation letter (EL) titled, Training Competencies, undated, the EL indicated the LN's training competencies dated prior to 8/21/25 were unable to be located. During a review of Resident 1's PN titled, Health Status Note, a late entry dated 9/2/25 at 1:24 p.m. for 8/25/25 at 4:22 p.m., authored by Resident 1's physician, the PN indicated, Will send patient to hospital. Needs admission for fluids and diabetes control. 4. According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 648), It is essential to verify the accuracy of every medication you give to your patients with the patients' orders. If the medication order is incomplete, incorrect, or inappropriate. consult with the health care provider. During a review of Resident 1's Order Summary Report (OSR), dated 8/21/25 to 8/25/25, the OSR indicated, Order Date 8/21/25. Start Date 8/21/25. NPO [nothing by mouth], and Enteral [through the feeding tube directly into the stomach] Feeding Order. Every shift Flush feeding. before and after medication administration. During a review of Resident 1's MAR, dated 8/2025, the MAR indicated:- Enteral Feed Order every shift Flush feeding tube with 30 ml [milliliter] water before and after medication administration. The MAR also indicated the nurses acknowledged this order on 8/21 through 8/25.- Asciminib [cancer treatment] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22, 8/24, and 8/25.- Aspirin [lowers the risk of heart attack or stroke] . give.by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22 through 8/25.- Esomeprazole [stomach acid reducer] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22, 8/24, and 8/25.- Gabapentin [nerve pain treatment] . give. by mouth. The MAR also indicated it was administered at 9 p.m. on 8/22 through 8/24.- Lipitor [treats high cholesterol] . give. by mouth. The MAR also indicated it was administered at 9 p.m. on 8/22 through 8/24.- Losartan [treats high blood pressure] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22 through 8/25.- Plavix [blood clot prevention] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22, 8/24, and 8/25.- Pyridoxine [vitamin] . give. by mouth. The MAR also indicated it was administered at 9 a.m. on 8/22, 8/24, and 8/25.- Acyclovir [treats infection] . give. by mouth. The MAR also indicated it was administered at 9 a.m. and 5 p.m. on 8/22, 8/24, and 8/25 as well as 5 p.m. on 8/23.- Carvedilol [blood pressure treatment] . give. by mouth. The MAR also indicated it was administered at 9 a.m. and 5 p.m. on 8/22 through 8/25.- Ursodiol [gallstone treatment] . give. by mouth. The MAR also indicated it was administered at 9 a.m. and 5 p.m. on 8/22, 8/24,8/25 and at 5 p.m. on 8/23. During a concurrent interview and record review on 10/14/25 at 1:15 p.m. with LN6, Resident 1's MAR, dated 8/2025 was reviewed. LN6 stated LN6 administered Resident 1's medications by mouth. During a concurrent interview and record review on 10/14/25 at 12 p.m. with DON, Resident 1's OSR, dated 8/21/25 to 8/25/25 and MAR, dated 8/2025 were reviewed. DON stated that based on the documentation, all the medications were given by mouth. DON also stated it should have been clarified with the physician. During an interview on 10/14/25 at 2:15 p.m. with DON, DON stated that the issues were because of the nurses' inexperience.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had complete and accurate documentation in their health record.This failure resulted in the planning and delivery of care based on inaccurate resident assessments.According to Fundamentals of Nursing ([NAME] et al; Elsevier: 2023, p. 389), Information in a patient's record provides a detailed account of the level of quality of care delivered. The quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the health care system, and legal guidelines make documentation and reporting an extremely important nursing responsibility. During an interview on 9/25/25 at 3:45 p.m. with a licensed nurse (LN1), LN1 stated LN1 texted the physician to clarify Resident 1's route of medication administration. LN1 stated there is no record of this text in Resident 1's medical record. During a concurrent interview and record review on 9/25/25 at 3:45 p.m. with LN1, Resident 1's:- Medicare Skilled Charting (MSC- details of the patient's condition, their response to treatments, and any changes), dated 8/21/25 at 8:25 p.m., was reviewed. The MSC indicated, Skilled Nursing Services. [none indicated]. LN1 stated it should have indicated diabetic care and enteral feeding care (nutrition through a tube into the stomach).- Bed / Side Rail Entrapment Risk Assessment (BSRRA), dated 8/21/25 was reviewed. The BSRRA indicated, alternatives attempted prior to bed/ side rales were a low bed and upper body mechanics. LN1 stated LN1 marked them as having been attempted when no alternatives were attempted. During a concurrent interview and record review on 10/14/25 at 1:15 p.m. with LN6, Resident 1's Medication Administration Record (MAR), dated 8/25 was reviewed. The MAR indicated, on 8/22 to 8/25/25 for the day administration time, Resident 1 had the same lying and sitting blood pressure recorded. LN6 stated the blood pressures were not accurate because the same blood pressure was used for lying and sitting. During a concurrent interview and record review on 10/14/25 at 2:15 p.m. with the Director of Nursing (DON), Resident 1's MSC, dated 8/21/25 at 8:25 p.m., BSRRA, dated 8/21/25, and MAR, dated 8/25 were reviewed. DON stated, Inaccurate charting documented. During a review of the facility's policy and procedure (P&P) titled, Documentation Policy, dated 3/23, the P&P indicated, It is the policy of this facility to document relevant findings in the clinical record.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had an accurate diagnosis recorded on their Minimum Data Set Assessment ([MDS] a tool for implementing standardized assessment and for planning care). This facility failure resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS). Findings: During a concurrent interview and record review on 5/28/25 at 3:34 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS 3.0 Section I - Active Diagnoses was reviewed. The section indicated, an active diagnosis of benign prostatic hyperplasia ([BPH], condition in older men where the prostate gland enlarges but is not cancerous). MDSC stated that MDS Section I - Active Diagnoses for BPH should not have been marked yes and acknowledged that MDS Section I was incorrectly coded, as Resident 1 did not have this diagnosis. During a review of the facility 's MDS manual titled, CMS's RAI Version 3.0 Manual, dated 10/2024, the MDS manual indicated, Active Diagnoses Intent: The items in this section are intended to code disease that have a direct relationship to the resident's functional status . One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status.

Based on observation, interview, and record review, the facility failed to promptly notify the physician of the x-ray results for one of two sampled residents (Resident 1). This failure resulted in a delay in treatment for Resident 1's dislocated hip and increased the potential for Resident 1 to experience unnecessary pain or worsening of her condition. Findings: During a review of Resident 1's admission Record (AR), dated 5/28/25, the AR indicated, Resident 1 was admitted in the facility on 2/24/25 with diagnoses including but not limited to, midcervical fracture of right femur (a break in the upper bone near the hip) and aftercare following joint replacement surgery. During a review of Resident 1's Radiology Results Report (RRR), dated 5/19/2025 at 7:13 p.m., the RRR indicated, postsurgical changes from a right hip hemiarthroplasty with superior dislocations (the femoral component of the hip implant had moved upward out of place). During a review of Resident 1's Change of Condition (COC), dated 5/20/25 at 7:41 p.m., the COC indicated, Resident 1 was sent out to [hospital name] via regular transport per physician order. [physician's name] called nurse with an order to send resident out. During an interview on 5/28/25 at 4:07 p.m. with Nurse Supervisor (NS), NS stated they received the RRR on 5/19/2025 around 7 p.m. NS stated that the findings were communicated to [physician's name] via text message at 10:44 p.m., but the physician did not respond or contact the facility until the afternoon of 5/20/25. During an interview on 6/16/25 at 5:08 p.m. with Director of Nursing (DON), DON stated that the staff should have continued attempting to contact [physician's name] and if there was no response after three call attempts, the staff should have escalated the radiology report by notifying the medical director to avoid delays in care. During a review of the facility's policy and procedure (P&P) titled, Notifying Clinicians Diagnostic Results, dated 3/2023, the P&P indicated, Abnormal test results outside of the accepted range or the physician's documented range for the resident are reported promptly to the ordering provider to address potential concerns including but not limited to: diagnose or treat the resident's condition.

Based on observation, interview and record review, the facility failed to ensure 1 of 6 sampled residents (Resident 1) was free from neglect when the facility failed to: 1. Develop a plan of care to prevent maggot (a soft-bodied legless larva, especially that of a fly found in decaying matter) infestation of Resident 1's right foot wound, 2. Keep Resident 1's right foot wound site clean, dry, and sanitary to prevent maggot infestation, 3. Perform wound care as ordered by the physician. These failures resulted in maggots infestation of Resident 1's right foot wound. Findings: Review of complaint from a wound clinic dated [DATE], indicated on three separate occasions patient (Resident 1) presented for (wound) treatment with maggots in the right foot wound, most recently on [DATE] and [DATE]. Patient has presented on multiple occasions with wet dressings A review of the wound clinic notes dated on [DATE] indicated, upon removal of Resident 1's wound dressing, the clinic noted maggots in the resident's wound, and notified the facility's director of nursing (DON). A second note from the clinic dated [DATE], indicated Resident 1 arrived at the clinic again with maggots in right foot wound bed and area sprayed with [MEDICATION NAME] (antibiotic wound cleanser) spray, maggots removed with forceps and area soaked with [MEDICATION NAME] spray for 15 minutes. Area cleansed thoroughly until all evidence of maggots were removed. Record review on [DATE] indicated Resident 1 was admitted with [DIAGNOSES REDACTED]. Record review on [DATE] of the significant change in status assessment dated [DATE] indicated Resident 1 had memory problems and required extensive assistance with dressing, toilet use, transfer, and limited assistance with personal hygiene. Resident 1 was assessed as frequently incontinent of bowel and bladder. Review of a physician's orders [REDACTED]. A review of the Resident 1's wound evaluation form indicated there was no wound evaluation done for Resident 1 on [DATE] as ordered. The facility was unable to provide documentation to indicate the wound care/treatment was done for two consecutive days, on [DATE] and [DATE]. Review of a physician's orders [REDACTED]. However, a review of the facility's Treatment Administration Record (TAR) revealed the wound was not treated on [DATE], [DATE], and [DATE]. A review of the facility's plan of care for Resident 1's right dorsal foot wound dated [DATE] did not include a plan of care to address Resident 1's right dorsal foot wound related to maggot infestation and wound being soaked with urine to prevent infection and delayed wound healing. During an interview on [DATE] at 2:30 p.m., the licensed nurse (LN 1), she was the treatment nurse, stated the wound clinic wanted the dorsal foot wound to be left open to the air, but LN 1 preferred the wound covered with sock. LN 1 stated, she applies compression wrap from Resident 1's right knee to his foot and changes it two times weekly. During an observation accompanied LN 1 on [DATE], at 2:45 p.m., Resident 1 was in his room, seated on a wheelchair with sweat pants on, wet from the waist down to the socks on both feet. Resident 1 smelled with strong urine odor. LN 1 removed Resident 1's sock with strong urine odor from the right foot, and several maggots fell out from the sock to the floor. Resident 1 was also noted with a wound on the right dorsal foot with maggots on the wound bed. During an interview with a certified nursing assistant (CNA 1) on [DATE], at 3:10 p.m., CNA 1 indicated he observed Resident 1's right sock seeping with brown liquid that morning, but did not remove it. CNA 1 stated, I told the nurse about the seepage. During an interview with restorative nursing aide (RNA 1) on [DATE], at 3:20 p.m., RNA 1 confirmed being made aware by CNA 1 about the drainage from Resident 1's right sock on [DATE], and stated, I did not report the information to the nurse, I'm not a nurse, I figured (CNA 1) would tell somebody else. During an observation and concurrent interview with the Director of Nursing (DON) on [DATE], at 3:30 p.m., Resident 1 was out of the room propelling self at the hallway with socks on both feet touching the carpeted floor. The DON instructed a staff to assist Resident 1 back to the room. The DON stated, (Resident 1) should not be in the hallway. During an interview on [DATE] at 3:50 p.m., an environmental services personnel stated, (Resident 1's) clothing and socks are always soaked with foul smelling urine every day.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions and prevent the potential for food borne illness (illness caused by ingestion of contaminated food or beverages) when the dietary department staff failed to: 1. Maintain the chemical sanitizer for the dishwasher at the correct concentration ppm (parts per million). 2. Wash hands correctly before coming in contact with food and food surfaces. 3. Donn hairnets so they completely cover hair and prevented exposure to residents food. 4. Take food temperatures accurately to ensure proper food temperatures. These facility failures placed all residents at high risk for food borne illnesses and transmission of diseases. 1. Immediate jeopardy (IJ) was called on 2/8/16 at 10:45 a.m., with the facility Administrator (AD) and Dietary Manager (DM). On 2/8/16 at 1:30 p.m., the facility provided an acceptable plan of correction. The plan of correction is as follows: a. Staff provided residents with food items/snacks on paper plates, bowls, and utensils temporarily. b. The facility contacted EcoLab to inspect the dishwashing machine to ensure appropriate functioning. c. The Maintenance Supervisor (MS) inspected the dishwashing machine and chemical dispenser lines and made necessary corrections. The dishwasher machine chemical sanitizer was tested by the MS in the presence of the DM and the reading was at the appropriate level. d. Upon completion of fixing the dishwasher machine by EcoLab, the dietary department will rewash pots, pans, utensils, plates and items used to prepare and place eating items for the residents. e. The EcoLab specialist will validate the proper functioning of all aspects of the dishwasher prior to the rewashing of the equipment. f. Staff retested dishwasher machine chemical to ensure compliance. g. DM and/or designee will test the dishwashing chemical after each load to ensure compliance. The Facility will: a. Document the ppm (parts per million; concentration of chemical sanitizer) concentration reading and continued deficient finding(s) will be reported to the DM, MS and/or AD for corrective action(s) and follow-up. b. DM and /or designee will review the dishwasher chemical test readings daily to ensure compliance. c. Conduct daily random testing of the dishwasher chemical by the DM and/or designee. d. Monthly for 90 days, have the DM report results of any deficient finding(s) to the QAPI(Quality Assurance and Performance Improvement )/UR Committee. e. Committee shall make additional recommendations to the plan as determined by the review of the results of the finding(s) and reevaluate for continued compliance. Reevaluation will be continued if non-compliant. f. The DM is responsible to ensure compliance is achieved and sustained. Findings: During an observation on initial tour with the Dietary Manager (DM) on 2/8/16 at 8:45 a.m., a dietary aid (DA 1) was observed loading dirty dishes into a dishwashing machine. When DA 1 tested , the chemical concentration of the sanitizer for the dishwashing machine with an EcoLab test strip, the concentration was 10 ppm (concentration required to be 50 ppm - for proper sanitation). Dietary aid (DA 2), tested the chemical concentration two more times using Ecolab test strips. Once in the retained water inside the dishwasher and a second time in the retained water in the bottom of a blender, and the chemical concentration was 10 ppm both times. During an observation and concurrent interviews on 2/8/16, at 10 a.m., DA 1 and DA 2 retested the chemical concentration, with EcoLab test strips, of the sanitizer in the dishwasher three times in the presence of the DM. Each time, the test resulted in a concentration of 10 ppm. DA 1 and DA 2 indicated that a result of 10 ppm for the chemical sanitizer was not acceptable to properly clean dishes. The DM confirmed 10 ppm was too low to correctly sanitize dishes. On 2/8/16 at 10:51 a.m., DA 1 tested the chemical concentration of the sanitizer with EcoLab test strips in the dishwasher with the DM and the AD. The concentration was 10 ppm. On 2/8/16, at 12:56 p.m., the EcoLab specialist (expert in dishwasher machine) confirmed that the chemical concentration of the dishwasher sanitizer was supposed to be between 50-100 ppm to ensure proper sanitation. Review of EcoLab's manufacturers instructions for the test strips used by the facility to measure the chemical sanitizer in the dishwasher revealed that the required chlorine concentration for the dishwasher was 100 ppm. The facility policy titled Dish Machine FB-6111 revised 8/6/12, indicated, The chemical sanitizer in the dishwasher machine was to be checked to ensure utensils and dishes washed by a mechanical dishwasher will be clean and sanitized. The facility policy titled Sanitation and Infection Control in Food Service FB-6100 dated 8/6/12, indicated, The Dietary Manager assumes responsibility for the food safety and sanitation of the Dietary Services Department, and that infection control and sanitation practices are followed to minimize the risk of contamination of food and prevent food-borne illness. The Dietary Manager monitors the food safety and sanitation of the Dietary Services Department on a daily basis. 2. During an observation of trayline for residents lunch on 2/9/16, at 11:56 a.m., a dietary staff (DS 1) was observed to enter the kitchen, wash his hands for ten seconds and go directly to trayline. During an interview on 2/10/16, at 9:18 a.m., the dietary manager (DM) indicated that dietary staff are trained and required to wash their hands for twenty seconds. The undated facility policy and procedure titled Hand Washing indicated, For preventing the spread of infection, proper hand hygiene is required and the method is to include wetting hands, wrists and lower forearm; soap thoroughly and lather all areas and rub hands together for 20 seconds. 3. During an observation of trayline on 2/9/16, starting at 11:50 a.m., two dietary cooks (DC 1 and 2) were observed preparing food for residents lunch. DC 1's hairnet did not cover the hair below his ears to his neck line. DC 2's hairnet did not cover all of her hair leaving long strands of hair exposed. During an interview on 2/10/16, at 9:18 a.m., the DM indicated that hairnets must fully cover all hair. The facility policy titled Sanitation and Infection Control in Food Service FB-6100 dated 8/6/12, indicated The Dietary Manager assumes responsibility for the food safety and sanitation of the Dietary Services Department. 4. During an observation and concurrent interview of trayline on 2/9/16, starting at 11:50 a.m., two dietary cooks (DC 1 and 2) were observed taking the temperatures of food to be served to residents for lunch. The following practices were observed: DC 2 inserted the thermometer into the regular chicken and obtained the temperature, then pulled the thermometer out and immediately inserted the thermometer into the ground chicken, then pulled the thermometer out and immediately inserted the thermometer into the pureed chicken. No wipe down with alcohol or recalibaration of the thermometer was performed. When asked about this practice, DC 2 said if its the same type of food just a different texture, they don't have to wipe down the thermometer. During an interview on 2/9/16, at 1:21 p.m., the registered dietician (RD, expert in nutrition) indicated that she had trained dietary staff to wipe the thermometer after each stick or dip even if it was the same food as this was the proper method of temping foods to prevent inaccurate readings. During an interview on 2/10/16, at 9:18 a.m., the DM confirmed that dietary staff are supposed to wipe the thermometer with an alcohol wipe between each test. A review of the facility inservice dated 2/9/16 indicated dietary staff are to make sure they clean/sterilize the thermometer between each food item. 5. During an observation on initial tour of the kitchen on 2/8/16, starting at 8:45 a.m., the following food items were stored without labeling: a large tube of brown meat, a black trash bag with brown meat, an open zip lock bag of hotdogs, two bags of fish, and one bag of sausages. During an interview on 2/10/16, at 9:18 a.m., DM stated that all food items must be labeled. The facility policy and procedure titled Food Safety FB-6049 dated 1/1/01, indicated, All stored food items will be labeled.

Based on record review, interview, and observation, the facility failed to provide the necessary care and services to two of four sampled residents, (Residents 1 and 2) to attain the highest physical and mental well being, based on their assessments. 1. The facility failed to: a) assess Resident 1 for injuries, including a bruise to the right hand, b) implement precautionary measures to prevent further injuries when it assessed Resident 1 as having a bruise to left leg. c) use two persons to transfer Resident 1 as identified in the resident's plan of care. As a result of these failures, Resident 1 suffered a tibia and fibular (bones in the lower leg) shaft fracture, and severe pain. 2. Resident 2 was improperly transferred by a certified nursing assistant (CNA 4) who roughly pulled the resident's left arm. The CNA's failure to properly transfer Resident 2 resulted in a tear in the resident's pectoral major (upper chest) muscle resulting in a hematoma (solid swelling of clotted blood) and pain. Additionally, Resident 2 experienced a decline in her progress towards discharge because she had difficulty participating in rehabilitation therapy due to the pain from the trauma. These failures placed Residents 1 and 2 at risk for complications of their injuries, including [MEDICAL CONDITION] and fat embolism, deformities, and death. Findings: According to the American Academy of Orthopedic Surgeons (AAOS.org) under Fractures of the Shinbone, the tibia and fibula are the two long bones in the lower leg forming the shin and calf bone. Fractures of these bones are usually due to major trauma such as a direct blow or fall, or due to a twisting injury. A review of the clinical record for Resident 1 on 7/28/15, revealed [DIAGNOSES REDACTED]. On 7/20/15 at 2:30 p.m., Resident 1 was transferred to an acute care hospital's emergency room for evaluation of a bruise to her left leg. A review of the facility's comprehensive assessment, dated 7/1/15, indicated Resident 1 required extensive assistance of two staff for toileting and transferring. The resident's balance was not steady when moving from seated to standing position, or moving between the bed and the wheelchair. Resident 1 had severely impaired cognition (intellectual activity such as thinking, remembering and reasoning), ability to express herself and to be understood was impaired, and highly impaired vision. Review of the facility care plan dated 4/14/15, indicated Resident 1 had a history of [REDACTED]. The facility's care plan measures included reminding Resident 1 not to ambulate or transfer without assistance; placing a safety mat next to the bed; and a pressure alarm pad. A review of a complaint to the Department alleging quality of care and treatment issues at the facility indicated the facility called the complainant on 7/16/15 to inform her of an injury to Resident 1's left leg. Four days later, on 7/20/15 the complainant received another call from the facility stating Resident 1 had a change of condition regarding the left leg injuries. A review of the clinical record for Resident 1, (SBAR communication form and progress note - a facility form used by nurses to document changes in resident condition) dated 7/18/15, at 1:30 p.m., indicated Resident 1 had a left shin faint green oval shaped discoloration. A licensed nurse (LN 1) documented: monitor the discoloration daily for 30 days. On 7/20/15, at 9:30 a.m., LN 1 documented on a SBAR form Resident 1 was up in a wheelchair and there was an increase in the purplish reddish discoloration and swelling of the resident's left lower leg. The note further indicted Resident 1 complained of pain upon touch to the lower leg. During an interview on 7/27/15, at 5:00 p.m., Resident 1's family member and responsible party (RP) stated LN 1 called and left her a message on 7/20/15 stating there was a change in condition in regarding Resident 1. The RP stated she went to the facility, and LN 1 said there was fluid in Resident 1's leg, not sure what was going on, and that the doctor had ordered x-rays. The RP went to Resident 1's room and found the resident up in a wheelchair next to the bed, complaining of pain and holding onto her head, and complaining of a headache and leg pain, stating, my leg, my leg. The RP stated Resident 1's left leg was bruised from ankle to shin, dented in, and swollen so she called the facility for help. According to the complainant, CNA 2 went into the room and attempted to transfer Resident 1 from a wheelchair to bed by standing the resident up. When the CNA 2 stood up Resident 1, the resident began screaming in severe pain so the CNA sat the resident back down and left the room and brought another CNA, (a male CNA). The two CNA's lifted the resident by her arms and legs into bed. Resident 1 continued to screaming in pain. The RP stated at that point, she told the facility staff not to touch the resident, but rather, call 911. The RP stated LN 1 came into the room and told her since there was no respiratory distress it would be 40 minutes before the ambulance would arrive. The RP stated she told LN 1 the resident was in severe pain, but the ambulance did not arrive until 50 minutes later. The ambulance personnel (EMT's) helped her to take pictures of Resident 1's left leg, and applied a cardboard splint to the resident's left leg. During a concurrent interview and record review on 7/29/15 at 11 a.m., the Director of Nursing (DON) confirmed the facility used one CNA to transfer Resident 1, and was unable to provide documentation to indicate the facility used two staff members to transfer Resident 1 as identified in the resident's care plan. A review of the ambulance assessment and transfer document, dated 7/20/15 revealed the Emergency Medical Services (EMS) personnel initial assessment of Resident 1 at the facility indicated the resident had a bruise to her right hand in addition to the left leg discoloration and deformity. The EMS notes indicated: facility staff noted the patient had a bluish coloration to her skin three days ago. Today when family visited they noted the appearance of the leg. They contacted EMS for further evaluation. The EMS notes further reflected an initial assessment indicated Resident 1 had ecchymosis to distal leg, swelling to the foot, deformed distal leg, tenderness to the lower leg with, crepitus (a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone) to LLE .bruise of approx. equal age to the right dorsal hand. During a concurrent interview and record review on 7/29/15 at 11 a.m., the Director of Nursing (DON) was unable to provide documentation to indicate the facility assessed Resident 1 for additional injuries, including the bruise to her right hand. A review of the an acute care hospitals emergency room assessment dated [DATE], at 3:21 p.m. indicated Resident 1 was drowsy, disoriented and her left lower leg had ecchymosis (ruptured blood vessels causing livid black, blue and purple spots) discoloration with a fracture deformity. An x-ray of the left leg on 7/20/15, at 4 p.m., revealed a tibia and fibular (bones in the lower leg) shaft fracture. A CT (computerized tomography) scan of the head on 7/20/15, at 5:04 p.m., showed a small right frontal scalp hematoma. The impression documented by the physician on 7/20/15 at 5:48 p.m. was Resident 1 had a [MEDICAL CONDITION] tibia and fibula, and a closed head injury with a right scalp hematoma. Resident 1 was admitted to the hospital for surgery to repair the left tibia fracture. During an observation on 7/28/15 at 2:30 p.m., Resident 1 was observed at the acute hospital lying in bed asleep. The left leg was splinted and wrapped in an ace bandage. A brownish purple discoloration approximately 6 cm circular was observed on top of the right hand. During an interview on 7/29/15, at 10:00 a.m., CNA 1 confirmed she had taken care of Resident 1 in the past, and she (CNA 1) transfers Resident 1 without assistance from another staff. During an interview on 7/30/15, at 11:00 a.m., a Certified Nurses' Assistant, (CNA 2), confirmed she was assigned to Resident 1 on 7/20/15 prior to the hospital transfer. CNA 2 indicated during a transfer, Resident 1 screamed in pain when she was lifted to her feet. Resident 1 could not stand any longer when she attempted to transfer the resident to a wheelchair. CNA 2 stated she sat Resident 1 back down into a wheelchair and requested assistance from another staff. CNA 2 indicated she noted a big bruise on the left leg of Resident 1 and was instructed by LN 1 to leave the resident up in a wheelchair. 2. Record review, on 7/27/15, revealed Resident 2's [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE], revealed the resident could make herself understood and clearly understood others. Resident 2 required the extensive assistance of one staff member for transferring and using the toilet. The admission nursing assessment revealed Resident 2 had no complaints of pain, and a nursing note for 7/18/15 at 1:40 p.m. indicated the resident was without complaints of pain. Review of Resident 2's Medication Administration Record [REDACTED]. The resident showed no evidence of pain on 7/17, 7/18 or 7/19/15. However, complaints of pain were noted on 7/20 and 7/21/15. Review of Resident 2's pain assessment record revealed the resident received 650 milligrams of Tylenol on 7/20/15 at 2:30 a.m. and 4 p.m. for complaints of left upper arm pain. Review of an occupational therapist (OT) initial assessment, dated 7/18/15, revealed Resident 2 was oriented to person, place, time and had one hundred percent normal range of motion in both arms. The resident required moderate assistance for transfers. Resident 2 required minimal assistance for upper body dressing and reported no complaints of pain. An OT treatment note, dated 7/20/15, revealed Resident 2 complained of left shoulder soreness, required moderate assistance for clothes management and moderate to maximum assistance for transfers. The increased need for assistance with dressing and transferring due to pain correspond with a change in Resident 2's condition from the initial OT assessment on 7/18/15. Review of physician's orders [REDACTED]. Additionally, a CT (computerized tomography in which a three dimensional image of a body structure is made) scan of the resident's chest was ordered due to pain and discoloration. Review of Resident 2's CT report of the left upper extremity, dated 7/23/15, revealed a tear in the lateral aspect of the pectoralis major muscle with a hematoma measuring 6.3 centimeters (cm) by 3.1 cm. During a concurrent interview and observation, on 7/28/15 at 10:25 a.m., Resident 2 indicated in the middle of the night on Sunday, 7/19/15, a male CNA got her up to the bathroom and was rough causing pain and bruising to her left arm. Resident 2 indicted the football player size CNA pulled her up by the arm and it hurt very badly right away. Observation of Resident 2's left upper arm revealed an eight inch by five inch solid dark purple discoloration surrounding the biceps. The resident's left side revealed a solid dark purple bruise extending from underneath the arm to the hip, was nine inches wide and covered the entire lateral side of the resident's breast. Resident 2 stated, They (facility staff) want to say it happened before I came here (the facility), but it didn't. Resident 2 indicated she felt angry because the facility staff didn't believe her, saying, It's not true. I had nothing like this before. Resident 2 indicated the male CNA who'd been rough had not taken care of her since that night. Resident 2 said the pain in her chest limited her ability to lift up her left arm and kept her from participating fully in occupational therapy. During an interview, on 7/28/15 at 3:15 p.m., Resident 2's family member indicated on 7/20/15, she was assisting Resident 2 with dressing and observed bruising to the resident's left shoulder, arm and side. When she inquired about the bruising the resident said the night before a big male CNA came to provide assistance in going to the bathroom and grabbed her by the arm causing pain. During an interview, on 7/28/15 at 4:30 p.m., the physical therapist (PT) confirmed performing the initial assessment for Resident 2 on 7/18/15. The PT stated Resident 2 was able to fully participate with therapy and had full range of motion (ROM), without pain, in both arms. Resident 2 was able to push up using her arms to a standing position with no assistance to minimal assistance. Resident 2 had no complaints of pain or facial grimacing when using her arms. The PT stated it would have been apparent if Resident 2 had any problem with her shoulder or muscles in the axillary or chest area. During a concurrent interview and observation, on 7/29/15 at 9:45 a.m., the occupational therapist (OT) confirmed performing the initial assessment for Resident 2 on 7/18/15. The OT stated at that time the resident had no complaints of pain or limitations in ROM of the left upper arm. On 7/20/15, the OT indicated she began working with Resident 2 and the resident could not lift any weight due to pain in the left chest. The OT indicated she assessed Resident 2's left arm and noted purplish bruising on the left upper arm. The resident told the OT a big tall male CNA lifted her by the arm and was rough. The OT indicated the resident displayed restriction in the ROM for her left arm due to the pain. The OT stated therefore, compared to the initial assessment on 7/18/15, when therapy was attempted on 7/20/15, Resident 2 needed more help with transfers and couldn't push up with her left arm because of pain. During a concurrent interview and demonstration, on 7/29/15 at 11:15 a.m., the director of staff development (DSD) and the director of rehabilitation services (DRS) indicated a resident should never be pulled by the arm or lift from underneath the arm when one person was transferring a resident from the bed to a sitting or standing position. The DRS indicated Resident 2 was mostly independent and required staff assistance to make sure the resident is stable and doesn't lose her balance. Review, on 7/30/15, of an undated facility interview revealed, CNA 4 transferred Resident 2 to the bathroom at 2 a.m. and after the resident was done using the bathroom she complained of pain in her arm. During a concurrent interview and record review, on 7/30/15 at 9:45 a.m., acute hospital licensed nurse (LN 5) confirmed she prepared Resident 2 for discharge on 7/17/15. LN 5 indicated at the time of discharge she assisted Resident 2 to the bathroom and the resident showed no signs of pain or discomfort. During an interview, on 7/30/15 at 10:15 a.m., the physician (MD 1) confirmed reading the CT scan of Resident 2's chest and left shoulder. MD 1 indicated a tear in the pectoral muscle was a stress injury and could be caused by over abduction (movement away from the midline of the body) of the arm. MD 1 indicated it would take an abrupt trauma, not a normal movement to cause the tear. During a concurrent interview and record review, on 7/30/15 at 12 p.m., the director of nursing (DON) confirmed Resident 2 had not complained of pain prior to 7/20/15. The DON indicated after the resident complained of pain due to rough handling training was conducted for CNAs on 7/21/15, on how to gently handle residents and for CNAs to communicate before performing care.

Based on interview and record review, the facility failed to assess and implement fall prevention interventions for one of five sampled residents (Resident 5). As a result of these failures, Resident 5 fell on [DATE], and sustained a fracture of the odontoid process of C2-cervical spine (neck fracture). Findings: Review of the clinical record for Resident 5 on 2/6/15 revealed [DIAGNOSES REDACTED]. A review of the facility care plan dated 11/11/13 indicated Resident 5 was identified by the facility as a high risk for falls due to Dementia, and confusion. The facility comprehensive assessment (Material Data Set-(MDS) dated [DATE] indicated Resident 5 required extensive assistance with transfers. A review of the clinical record (nurses ' notes) for Resident 5 on 3/4/15 revealed on 8/12/14 Resident 5 was found face down on the carpet/floor and noted with forehead and nose abrasion. On 10/7/14 Resident 5 was found on the floor (fell ) and was transferred to an acute care hospital for evaluation of a possible fracture. On 10/23/14 Resident 5 was found laying on the floor on left side and complained of left shoulder pain. On 11/07/14 Resident 5 was seen by facility staff falling forward from a wheelchair to the ground, and sustained skin tear on the left check and abrasions and redness on the left frontal area of the forehead. Resident 5 sustained bruises on the left hand and complained of pain. During an interview on 3/4/15 at 10:36 a.m. a licensed nurse (LN 2) stated on 11/21/14 she and another nurse found Resident 5 laying on the ground on her right side and blood was splattered on the floor around her. During an interview on 3/4/15 at 2:55 p.m. a licensed nurse (LN 3) confirmed Resident 5 would constantly try to reach and pick things off the floor, was constantly moving in her wheelchair and trying to get up. During an interview on 2/4/15, the Director of Nursing (DON) was unable to provide documentation to indicate the facility re-assessed Resident 5 and implemented interventions to prevent Resident 5 from falling from the wheelchair due to constantly reaching and picking things from the floor. A review of the facility ' s nurses ' notes indicated On 11/21/14, Resident 5 was seen by a licensed nurse (LN 2) falling forward from her wheelchair, and landing on her forehead. Resident 5 complained of pain to her neck and was transferred to an acute care hospital for evaluation. In an interview on 2/4/15 at 2:30 p.m., a Medical Records Assistant/Clerk stated on 11/21/14, Resident 5 was in a wheelchair by the Medical Record office and dropped a paper tissue on the floor. Resident 5 fell forward and hit her head as the resident attempted to pick up the tissue from the floor. During an interview on 2/6/15 at 11:25 a.m. the DON stated we don't do fall risk assessments. If they are a new admit we give them the alarm, (devices to alarm the staff of the residents ' unsafe transfer) the pads (foam pad) and bed in lowest position and we have Director of Physical Therapy evaluate them. During an interview on 3/4/15 at 2:10 p.m., the DON and the Director of Physical Therapy (PT) both confirmed the facility did not identify the actual and potential causes for Resident 5's falls and continued to use the same intervention (alarms and pads) for fall precautions after each fall.

Based on interview and record review, the facility failed to assess and implement fall prevention interventions for one of five sampled residents (Resident 5). As a result of these failures, Resident 5 fell on [DATE], and sustained a fracture of the odontoid process of C2-cervical spine (neck fracture). Findings: Review of the clinical record for Resident 5 on 2/6/15 revealed [DIAGNOSES REDACTED]. A review of the facility care plan dated 11/11/13 indicated Resident 5 was identified by the facility as a high risk for falls due to Dementia, and confusion. The facility comprehensive assessment (Material Data Set-(MDS) dated [DATE] indicated Resident 5 required extensive assistance with transfers. A review of the clinical record (nurses ' notes) for Resident 5 on 3/4/15 revealed on 8/12/14 Resident 5 was found face down on the carpet/floor and noted with forehead and nose abrasion. On 10/7/14 Resident 5 was found on the floor (fell ) and was transferred to an acute care hospital for evaluation of a possible fracture. On 10/23/14 Resident 5 was found laying on the floor on left side and complained of left shoulder pain. On 11/07/14 Resident 5 was seen by facility staff falling forward from a wheelchair to the ground, and sustained skin tear on the left check and abrasions and redness on the left frontal area of the forehead. Resident 5 sustained bruises on the left hand and complained of pain. During an interview on 3/4/15 at 10:36 a.m. a licensed nurse (LN 2) stated on 11/21/14 she and another nurse found Resident 5 laying on the ground on her right side and blood was splattered on the floor around her. During an interview on 3/4/15 at 2:55 p.m. a licensed nurse (LN 3) confirmed Resident 5 would constantly try to reach and pick things off the floor, was constantly moving in her wheelchair and trying to get up. During an interview on 2/4/15, the Director of Nursing (DON) was unable to provide documentation to indicate the facility re-assessed Resident 5 and implemented interventions to prevent Resident 5 from falling from the wheelchair due to constantly reaching and picking things from the floor. A review of the facility ' s nurses ' notes indicated On 11/21/14, Resident 5 was seen by a licensed nurse (LN 2) falling forward from her wheelchair, and landing on her forehead. Resident 5 complained of pain to her neck and was transferred to an acute care hospital for evaluation. In an interview on 2/4/15 at 2:30 p.m., a Medical Records Assistant/Clerk stated on 11/21/14, Resident 5 was in a wheelchair by the Medical Record office and dropped a paper tissue on the floor. Resident 5 fell forward and hit her head as the resident attempted to pick up the tissue from the floor. During an interview on 2/6/15 at 11:25 a.m. the DON stated we don't do fall risk assessments. If they are a new admit we give them the alarm, (devices to alarm the staff of the residents ' unsafe transfer) the pads (foam pad) and bed in lowest position and we have Director of Physical Therapy evaluate them. During an interview on 3/4/15 at 2:10 p.m., the DON and the Director of Physical Therapy (PT) both confirmed the facility did not identify the actual and potential causes for Resident 5's falls and continued to use the same intervention (alarms and pads) for fall precautions after each fall.

Based on observation, staff interview, and document review, the facility failed to prevent cross contamination (harmful substances or disease-causing microorganisms passed to food by hands, food contact surfaces, or utensils that are not maintained cleaned after washing), and potential of food borne illness (illness caused by ingestion of contaminated food or beverages) (unintended presence of potentially harmful substances, including microorganisms, chemicals or physical objects in food) when the dietary department staff failed to prevent cross contamination and prevent potential of food borne illness when: 1. Staff caused dirty dishwater to be sprayed on to clean dishware, 2. Staff loaded dirty dishware into clean side using the counter designated for clean dishware, thereby contaminating the counter and then unloading clean dishes from dish machine back onto the same contaminated counter, 3. Staff carried dirty pots and pans from the three-compartment sink area through the clean dish area, These failures placed residents at high risk to be served food on dirty dishes when clean sanitized (free from filth or pathogens (microorganisms like bacteria causing disease) (that endanger health) dishes were contaminated. Therefore the facility placed residents at increased risk of spreading bacteria causing illness to the residents. Cross Reference F361, F362, F363, F364, F366, F367, F441, F500, F520. Immediate jeopardy (IJ) was called on 1/29/14 at 4:05 p.m., with the facility Administrator, Division Director of Operations, and Division Director of Healthcare. On 1/29/14 at 7 p.m., the facility provided an acceptable plan of correction. On 1/30/14 the facility submitted a revision to the plan of correction submitted on 1/29/14 and was accepted by the Department. The plan of correction was as follows: 1. Staff isolated all dirty dishes, equipment and utensils to the designated dirty area for washing. 2. The facility designated the north entrance, into the kitchen, as the dirty area that extends from the entrance to the mid area of the dishwasher. The area was defined by a yellow tape line on both ends. 3. Also, the space for drying of dishes, utensils, equipment, etc. has been increased. The area extending from the dishwasher is no longer used for dirty items. 4. The three compartment sink will only be used during emergencies if the dish machine is not functioning. Otherwise, the three compartment sink area will be clean and sanitized and designated as a clean area. 5. The dishwasher machine will be used by staff to clean and sanitize the kitchen equipment and utensils. The facility will assign 2 staff members on the dishwashing lines, so the dishwashing can start soon after the tray line is completed. One individual will be assigned to the dirty side, while the other shall work on the clean side. Facility will: 1. Maintaining of infection control practices to minimize and decrease risks for actual and /or potential cross contamination of food, equipment and/or dishes whole cleaning dirty equipment/dishes. This will include reviewing with staff practices for ensuring clean to clean: dirty to dirty. 2. On proper utilization of the three-compartment sink area to prevent cross contamination of dirty and clean and ensure proper sanitation of dirty equipment and utensils. 3. The revision to the dishwashing area includes reviewing with the staff the designated dirty area as you enter the north door of the kitchen, extending to the dishwasher, and the utilization of the three compartment sink. 4. All staff, non-dietary shall be in-serviced to the new procedure of the north door as the designated dirty area for receiving dirty items; while the south door shall be utilized for the delivery of clean items/food to the floor. Staff that is not present on site during this time shall be in-serviced upon return to work. The facility has hired a full-time consultant RD that shall provide oversight to ensure the plan of action is in place and being maintained. This shall be done via ongoing visual observation of the systems and processes for ensuring food, equipment and dishes are not contaminated. The IJ was abated on 1/30/14 at 8:00 p.m., with the Administrator, and Division Director of Healthcare, and Consultant Registered Dietitian 2. Findings: The dishwashing area was observed concurrently with the Dietary Services Director (DSD) interview on 1/27/14 at 3:10 p.m. There was a mechanical dishwasher at one end of the wall and a three compartment sink at the other end of the wall. Both the dishwashing machine and the three-compartment sink (sink containing three compartments for washing, rinsing, and sanitizing dishes, pots, utensils, and equipment) used the same clean table to air dry dishware/cooking equipment. There were 4 rolling racks with approximately 20 bowls and one metal rack containing clean sanitized dishware including pots, glassware, and plastic pitchers on the wall directly opposite wall that was in the dirty dishwashing area by approximately 3 to 4 feet. The dishwashing area was not organized to maintain a clean area for air drying and storing the clean sanitized dishware. This failure had the potential of cross-contamination of the dirty dishware to the clean sanitized dishware used by residents. The DSD concurrently stated while viewing the clean sanitized dishware stored and dried with the dirty dishware stated, "Is this OK? We have nowhere else to put them (indicating the clean sanitized bowls and dishware on the metal rack)." Observation on 1/27/2013 at 3:30 p.m., showed Cook 1 putting dirty cooking equipment on the clean dishwashing counter area and putting the dirty cooking equipment into the dish machine from the clean side. At the end of the dishwashing cycle Cook 1 removed the clean and sanitized cooking equipment back on the counter that had food debris (discarded garbage) which appeared to be green items and not further identified. Cook 1 confirmed there was food debris on the counter. Cook 1 stated concurrently that "We do not use the three compartment sink, we store the dirty pots and pans there and then put them into the dishwashing machine from the three compartment sink end." Cook 1 was observed on 1/27/2013 at 3:30 p.m., taking the dirty cooking equipment across the clean area to be put into the dirty end of the dishwashing machine. She confirmed concurrently that the cooks would transport the dirty cooking equipment to the dirty end of the dish machine. This transport of dirty dishware was through the clean dishes. DSD concurrently stated "this is not OK for the cooks to do this (transport dirty pots to through the clean dishware), "during observation of the cooks transporting dirty dishware. The potential of the above cooks' actions of transporting of dirty pots was cross-contamination of the clean dishware. On 1/28/14 at 9:15 a.m., dishwasher 1 (person employed to wash dishes) (DW 1) was scrapping food waste from dirty plates into a trash can was adjacent (approximately 4 inches-6 inches) from the clean storage rack containing approximately 20 sanitized bowls. DW 1 stated that "the space had always been this way," when he was asked about how close the trash can was located to the clean dishware. He did not demonstrate knowledge that there was a problem with cross-contamination of the clean sanitized bowls located 4 inches from to the trash barrel. On 1/28/14 at 9:25 a.m., dirty cooking equipment (pots, pans and serving tongs and ladles) was observed in the rinse and sanitized sinks of the three-compartment sink which was connected to the clean area and exposing the clean sanitized dishware to dirty dishware with the potential for cross contamination of the clean cooking equipment with dirty cook ware. On 1/28/14 at 4:27 p.m., the consultant (experienced individual giving professional advice) Registered Dietitian (RD 1) stated she was responsible for the clinical nutrition review and a one time a month sanitation check list which she gave to the administrator. The RD 1 stated that "I have not done anything training for the dietary staff." She did not state that she had had findings on the sanitation check list that she had been doing since October 2013 when she started at the facility. The RD 1 failure to provide guidance to the DSD and food service workers through observation of the sanitary practices and in-services for proper dishwashing procedures and storage of sanitary dishware were a potential for the residents to receive meals on contaminated dishware (plates, glasses, pitchers, and bowls.) Review of Monthly Standards and Sanitation Inspection Report provided by the Administrator on 1/30/14 at approximately 2:00 p.m., and dated from February 20, 2013 to December 31, 2013 showed these inspection reports were all completed by the Food Service Director (FSD). All of the areas concerning the dishwasher and proper cleaning procedure in the area were marked as full compliance. The deficient practice of cross-contamination in the dishwashing and storage was not identified and acted upon. The cross-contamination practices continued. Review of the policy titled Dish Machine FB-6111 dated 8/6/2012, stated "to ensure proper techniques when washing service ware i.e., dishes silverware, glasses and cups. Utensils and dishes washed by a mechanical dishwasher will be clean and sanitized." A review of the policy Manual Cleaning and Sanitizing with Three-Compartment Sink FB 6112 dated 8/6/2012 stated "Equipment and utensils are cleaned and sanitized appropriately after use." There were no procedures defined in either dishwashing or three-compartment sink policy to direct staff to maintain clean storage of service ware after washing and sanitizing. There were no procedures defined to prevent cross-contamination. Review of 7 in-services presented by the DSD dated from 6/30/13 to 1/20/14 covered hand washing, infection control and hairnets. The 7 in-services provided only general topic title and did not contain a detailed description of the material covered. There were no in-service topics describing the mechanical or three compartment sink process to prevent cross contamination or maintain sanitized dishware, bowls and other equipment clean and sanitized. The policy titled Sanitation and Infection Control in Food Service FB6100 dated 8/6/2012 stated "The Dietary Services Director (DSD) assumes responsibility for the food safety and sanitation of the Dietary Services Department. Section 1. Infection control and sanitation practices are followed to minimize the risk of contamination of food and prevent food-borne illness. The DSD monitors the food safety and sanitation of the Dietary Services Department on a daily basis." During the interviews and concurrent observations of staff dishwashing practices and storage of clean service ware, starting on 1/27/14 at 3:10 p.m., the DSD did not demonstrate knowledge of the storage or washing procedures to prevent the cross-contamination of clean service ware. These failures put the residents at risk of food-borne illness with the continuing unsafe lack of maintaining service ware in a sanitary condition. During an observation in the kitchen, with the Administrator, Division Director of Operations, and Division Director of Healthcare, on 1/29/2014 at 6:00 p.m., the dishwashing system was observed. There was no dishwashing activity at this time. There was cooking equipment stacked at the end of the dishwashing machine waiting to be washed. During an observation of the kitchen with the contract Registered Dietitian 2 (RD 2) on 1/30/2014 at 4:30 p.m., the implementation of the IJ plan to wash, maintain clean and dirty areas and prevent cross contamination was observed. The plan was implemented and dietary dishwashing staff interviewed confirmed knowledge of the correct process to ensure separation of the clean and dirty dishware and air drying all utensils. There was a delineation tape on the floor to separate the clean area from the dirty area. Patients' dishware and food production cook equipment were observed in operation.