Every finding on record at Ukiah Post Acute

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents reviewed from resident-to-resident abuse (Resident 2) by another resident (Resident 1). The facility failed to implement effective interventions after identifying an escalating pattern of accusations, threats, and aggressive behaviors directed by Resident 1 toward Resident 2.This finding resulted in Resident 1 striking Resident 2 in the arm on June 1, 2026. This finding had the potential to result in physical and psychosocial harm to Resident 2.A review of Resident 1's admission record (facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included vascular parkinsonism (a neurological disorder affecting movement) and major depression. A review of Resident 1's Minimum Data Set (MDS), a federally required resident assessment, dated 5/04/26 indicated a Brief Interview for Mental Status (BIMS, a cognitive screening tool), score of 15, indicating Resident 1 was cognitively intact.A review of Resident 2's admission record (facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses which included chronic obstructive pulmonary disease (a chronic lung disease that causes airflow blockage and difficulty breathing), peripheral vascular disease (a circulatory disorder that reduces blood flow to the arms and legs), major depression (a mood disorder characterized by persistent feelings of sadness, hopelessness, or loss of interest), anxiety disorder (a mental health condition characterized by excessive worry, fear, or nervousness), and schizophrenia (a psychiatric disorder that may affect a person's thinking, perception, emotions, and behavior). Resident 2's most recent MDS dated [DATE] documented a BIMS score of 7, which indicated his cognition was moderately impaired.A review of Resident 1's nursing progress note dated 5/25/26 at 1:58 p.m. indicated Resident 1 accused Resident 2 of stealing soft drinks from him. The progress note documented staff investigated the allegation and later located the soft drinks in Resident 1's room. According to the progress notes, despite the allegation being determined unfounded, Resident 1 continued accusing Resident 2 of stealing from him.A review of physician orders dated 5/25/26 at 1:31 p.m. and behavioral monitoring records dated 5/25/26 at 1:31 p.m. revealed that on 5/25/26, the facility initiated behavior monitoring every shift for accusations that residents or staff were stealing Resident 1's belongings. Nursing documentation from 5/25/26 through 5/29/26 reflected ongoing accusations, fixation on theft, redirection by staff, and continued monitoring.A review of a nursing progress note dated 5/30/26 at 5 p.m. indicated Resident 1 verbally threatened to fight Resident 2 and raised his fist toward Resident 2 while accusing him of stealing soft drinks. The note documented management and the physician were notified.During an interview on 6/09/26 at 2:02 p.m., the Director of Nursing stated that following the 5/30/26 incident, the physician ordered Resident 1 and Resident 2 be kept apart. The Director of Nursing showed surveyor a social media communication between facility leadership and nursing staff documenting awareness of the escalating conflict and directing staff to monitor the residents and keep them separated.A review of the facility's Five-Day Report dated 6/01/26 indicated that at approximately 3:20 p.m., Resident 1 again confronted Resident 2 regarding alleged stolen soft drinks. The report documented Licensed Nurse A observed Resident 1's wheelchair positioned extremely close to Resident 2's wheelchair and intervened to separate the residents. The report documented that although staff did not directly witness physical contact, Resident 2 reported that Resident 1 struck him in the arm.During an interview on 6/09/26 at 11:40 a.m., Licensed Nurse A stated Resident 2 reported on 6/01/26 that Resident 1 had struck him in the arm. Licensed Nurse A further stated staff had been aware of the ongoing conflict between the residents before the incident.During an interview on 6/09/26 at 12:51 p.m., the Social Services Director stated she re-interviewed Resident 2 following the surveyor interview. The Social Services Director stated Resident 2 reported Resident 1 struck him in the right upper arm and stated he was not injured.A review of the Interdisciplinary Team note dated 6/02/26 at 4 p.m. documented that Resident 2 reported being struck in the arm by Resident 1 during the June 1, 2026 incident.During an interview on 6/09/26 at 12:15 p.m., when asked whether he struck Resident 2 during the incident, Resident 1 stated, I tried.A review of the facility policy titled Abuse, Resident-to-Resident, Revised 11/2023, indicated the facility is responsible for protecting residents from harm, including abuse by other residents, and requires implementation of measures necessary to prevent additional incidents.A review of the facility policy titled Behavioral Health Services, dated 4/2019, indicated residents exhibiting behavioral concerns shall be assessed, monitored, care planned, and provided appropriate interventions to address identified behavioral needs.

Based on observations, interviews, and record reviews, the facility failed to implement a comprehensive person-centered fall care plan for one resident (Resident 1) of three sampled residents reviewed after fall incidents. This failure had the potential to result in additional falls with injury to Resident 1. A review of Resident 1's Face Sheet, indicated her medical diagnoses included difficulty in walking, unsteadiness on feet, need for assistance for personal care, muscle weakness, and abnormalities of gait and mobility. A review of Resident 1's Order Summary Report, indicated she did not have the capacity to make her own decisions. Her daughter was her decision maker. A review of Resident 1's Progress Notes, dated 5/24/26, at 3:47 p.m., indicated Resident 1 was sitting in her wheelchair in hallway at Station 1and fell asleep. This progress note indicated Resident 1 fell face forward to the floor and was sent to the ER (Emergency Room) for evaluation.A review of Resident 1's Comprehensive Person-Centered Care Plan, indicated, Resident 1 had a fall on 5/24/26 and sustained nondisplaced fracture of left nasal bone. The goal for this care plan indicated, Will resume usual activities without further incident through the review date. Target date 8/16/2026. One of the interventions on this care plan indicated, Bed in lowest position.During a concurrent observation and interview with CNA 1 (Certified Nursing Assistant 1) on 5/29/26, at 3:40 p.m., she stated Resident 1's bed was not in the lowest position. CNA 1 used the bed control for Resident 1's bed to demonstrate that the bed was not in the lowest position. Pictures of the different bed positions were taken during this observation. During an interview on 5/29/26, at 4 p.m., with LN (Licensed Nurse) 1, she stated it was her expectation that if Resident 1's care plan intervention for falls was to have her bed on the lowest position, it should be followed. During an interview on 6/1/26, at 10:30 a.m., with the DON (Director of Nursing), she stated she created the fall care plan for Resident 1 on 5/24/26. The DON stated she, the IDT (Interdisciplinary Team), Nurses, and CNAs were responsible for implementing the interventions on Resident 1's fall care plan. The DON stated if Resident 1's fall care planned interventions were not implemented, Resident 1 might fall again and could potentially sustain an injury from another fall. A review of the facility's policy and procedure (P&P) titled, Falls and Accident Prevention, dated 11/2020, indicated the purpose of the P&P, To investigate the circumstances surrounding each resident fall or other significant accidents and implement actions to reduce/prevent the incidence of additional falls/accidents and minimize potential for injury. A review of a facility P&P titled, Comprehensive Person-Centered Care Planning, dated 12/2023, indicated, Interventions are actions, treatments, procedures, or activities, designed to meet an objective.

Based on observations, interviews, and record reviews, the facility failed to ensure that one resident (Resident 31) of three sampled residents received a shower and nail trimming to maintain good grooming and personal hygiene.This failure decreased the facility's potential to prevent skin breakdown and other health related issues related to poor hygiene among residents.Findings:A review of Resident 31's face sheet indicated admission to the facility in September 2016 with diagnoses which included Cerebral Infarction (type of stroke characterized by the death of brain cells due to a prolonged lack of oxygen and nutrients, caused by blocked or severely restricted blood flow to the brain), hemiplegia (severe paralysis of one side of the body) and hemiparesis (weakness of one side of the body) which affected the left side of her body, cognitive communication deficit (an impairment in communication which affects starting, maintain, or following conversations), Type 2 Diabetes Mellitus (a chronic condition where the body is unable to properly use sugar in the blood for energy which can lead to tiredness, slow-healing sores or cuts in the skin, and complications to nerves, the heart, and kidney), and schizophrenia (a serious mental health condition that affects how people think, feel and behave).A review of Resident 31's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool) dated 12/8/25 indicated she had a Brief Interview for Mental Status (BIMS) score of 14 which meant her ability to think, process information, and understand was intact. This MDS also indicated Resident 31 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for transfers to the tub/shower.A review of Resident 31's Care Plan, initiated on 9/24/16, indicated, [Resident 31] has ADL [ADLs- essential, routine tasks required for basic personal care and independent living such as bathing, eating, dressing, etc.] self-care performance deficit [a loss, shortage, or abnormal functioning] related to hemiplegia, fatigue, impaired balance, pain. Staff were expected to implement the following interventions for this focused problem, [Resident 31] is dependent on staff assistance with bathing/shower.Check nail length and trim and clean on bath day and as necessary.A review of Resident 31's care plan initiated on 12/24/25 indicated, Resistive to care (resist to shower) related to schizophrenia. One of the interventions for this focused problem indicated, Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible.During a concurrent observation and interview with Resident 31 on 2/10/26 at 2:47 p.m., Resident 31 stated she had been asking staff to trim her nails for a month now. This surveyor observed that Resident 31's fingernails were long and needed to be trimmed.During a follow-up observation and interview with Resident 31 on 2/12/26 at 12:01 p.m., this surveyor observed that Resident 31's fingernails were still untrimmed, and she was growing facial hair on her chin. Resident 31 stated her last bed bath was a week ago. Resident 31 stated she did not want a bed bath; she wanted a shower so she could have her hair washed.On 2/12/26 at 12:05 p.m. a review of Resident 31's documents titled, CNA (Certified Nursing Assistant) Skin Observation and dated January and February 2026 was conducted. A review of these CNA skin observation sheets dated 1/27/26, 1/30/26, 2/3/26, and 2/6/26 indicated Resident 31 was only given a sponge bath in her bed. CNA 1, CNA 2, nor CNA 3, had not indicated if Resident 31 refused a shower or bath in the shower room. On 1/27/26, 1/30/26, and 2/3/26, CNA 1 and 2 indicated Resident 31's nails need clipping.During an interview on 2/12/26 at 12:11 p.m. with CNA 4 who was assigned to Resident 31 for the day CNA 4 acknowledged Resident 31 was dependent on staff to shave her and trim her nails. CNA 4 stated Resident 1 was able to state her needs. CNA 4 stated she noticed Resident 31had facial hair on her chin. CNA 4 stated she did not ask Resident 31 if she needed to shave even though other CNAs have shaved her. CNA 4 stated she believed Resident 31 had her own personal shaver but was unable to use it by herself.During a concurrent record review and interview on 2/12/26 at 3:11 p.m., Licensed Nurse 1 (LN 1) reviewed Resident 31's CNA skin observation sheets and stated she would not know if the resident refused the shower because it was not documented. LN 1 stated if the CNA notified her that the resident refused a shower, she would offer the resident a shower 1 to 2 more times and document if she still refused. During an interview on 2/12/26 at 3:35 p.m., LN 2 stated resident refusal of a shower should be documented on the CNA skin observation sheet (shower sheet) or the progress notes. LN 2 stated Resident 31 was dependent on staff for activities of daily living. LN 2 stated Resident 31 had a history of refusing showers and preferred to have showers by certain CNAs.A review of Resident 31's progress notes dated 2/1/26 to 2/9/26, indicated no documented evidence regarding Resident 31's refusal of showers nor education given to Resident 31 about the consequences of refusing showers.During a concurrent record review and interview on 2/12/26 at 3:57 p.m., the Director of Nursing (DON) reviewed Resident 31's CNA skin observation sheets and electronic medical record and acknowledged that Resident 31's refusal to have a shower were not documented on her records. The DON was also acknowledged Resident 31's CNA skin observation sheets indicated Resident 31's nails needed to be clipped and the surveyor's observation that her fingernails were untrimmed. The DON stated that she will conduct an in-service with the staff to ensure residents' needs were met.

Based on interview and record review, the facility failed to provide nursing services to one of three sampled residents (Resident 1), according to professional nursing standards of practice when:1. Licensed Nurse 1 (LN 1) clocked out for her meal period, leaving Resident 1 unattended by licensed nursing supervision, while she (Resident 1) was in uncontrolled pain, and performing a risky procedure, 2. LN 1 failed to recognize Resident 1's change in condition and notify a facility physician.3. LN 1 failed to notify Resident 1's facility physician, and family she was transferred to a General Acute Care Hospital (GACH) emergency department.4. LN 1 failed to report to the oncoming Licensed Nurse, the need to notify Resident 1's family that she had been transferred to the hospital emergency department during her shift.As a result, Resident 1 called 911 herself to obtain emergency medical services to assess her condition, and transfer her to a GACH, where she was admitted for emergency life-saving treatments. These findings had the potential to result in serious harm to Resident 1, up to and including death. A review of Resident 1's facility admission record (Facility demographic) indicated she was admitted to the facility on [DATE], with a primary diagnosis of Acute Post Hemorrhagic Anemia (a sudden incident of excessive bleeding causing a condition in which the blood cannot deliver enough oxygen to the body), Ulcerative (Chronic) Proctitis with Rectal Bleeding (a persistent condition of inflammation at the very end of the large intestine that causes tiny sores that swell and cause bleeding) and Gastro Intestinal Hemorrhage (bleeding in the digestive tract).A review of Resident 1's Nursing Care Plan initiated on 10/10/25 indicated Resident 1 was at risk for constipation (difficulty passing stools) related to reduced mobility and medication side effects. A nursing intervention listed under this focus area indicated, Monitor/Document Report to MD [Medical Doctor], as needed. This care plan indicated the signs and symptoms of complications related to constipation included, agitation .abdominal distention .vomiting .abdomen: tenderness .fecal compaction.During an interview on 12/10/25 at 1:32 p.m., LN 1 stated on 11/28/25, she was working the night shift as the Charge Nurse, and around 11 p.m., Resident 1 complained of abdominal pain and requested pain and bowel-care medication (medication to treat constipation) thinking she might need to have a bowel movement. LN 1 stated she administered Acetaminophen (an over-the-counter medication used to treat mild to moderate pain) and Milk of Magnesia (an antacid to relieve heartburn and indigestion, and saline laxative to treat occasional constipation). LN 1 stated Resident 1 was dissatisfied with the intervention and requested a suppository (a rectal medication), enema (a procedure in which liquid is introduced into the rectum to stimulate a bowel movement), and the performance of fecal disimpaction (a medical procedure in which a healthcare provider uses a gloved, lubricated finger to manually break up and remove a large, hardened mass of stool [fecal impaction] from the rectum) by LN 1. LN 1 stated she explained to Resident 1 that she could not fulfill her requests and asked to allow time for the medication to take effect. According to LN 1, Resident 1 replied that she would perform fecal disimpaction on herself and started to do it. LN 1 stated she left Resident 1, while she was performing this procedure, and clocked out for her meal period, without having another Licensed Nurse check on Resident 1 during her break. LN 1 stated that during her lunch period, a Certified Nursing Assistant (CNA) alerted her Resident 1 had blood on her fingers and hands. LN 1 stated she told the CNA that she was not surprised because Resident 1 has been doing fecal disimpaction on herself for about 30 minutes with her long fingernails. LN 1 stated the CNA told her (LN 1) Resident 1 was going to call 911 to get help, but by the time she clocked back from lunch and was about to check on Resident 1, the CNA told her Resident 1 had already called 911 herself. LN 1 stated emergency medical services arrived at the facility and took Resident 1 to the GACH. LN 1 then stated that she, totally dropped the ball on facility protocol, and did not notify Resident 1's family or attending physician that she had been transferred to a GACH by emergency services. LN 1 also admitted that she did not report to the next shift's charge nurse that Resident 1's family had not been notified of her emergency transfer to the hospital. A review of Resident 1's Medication Administration Record (MAR) for the month of November, 2025, indicated a documented pain level assessment of four out of ten (a pain scale from zero to ten, in which zero indicates no pain, and ten is the worst pain experienced during a person's lifetime), followed by an administration of two tablets of Acetaminophen 325 mg (mg = milligram; a unit of measure) to Resident 1 at 11:31 p.m. which resulted in ineffective, pain control as documented by LN 1. Resident 1's MAR also indicated LN 1 administered the medication Zofran (a prescription medication used to prevent nausea and vomiting) 4 mg tablet to Resident 1 at 11:39 p.m. The Zofran order indicated it was ordered by Resident 1's physician on 11/10/2025 for nausea and vomiting. Resident 1's MAR did not contain a physician order for the medication Milk of Magnesia, or any documentation it was administered to Resident 1.A review of a progress noted dated 11/29/25 at 2:11 a.m., documented by LN 1 indicated, pt [patient] c/o [complained of] abd [abdominal] discomfort, stated she had been nauseous all day administered PRN [as needed] APA [acetaminophen] 325 x2 tabs, prn [as needed] ondansetron [generic name for Zofran], pt c/o [complained of] constipation and requested a suppository this nurse explained 2 bm's [bowel movements] charted and administered MOM [milk of magnesia], pt requested bowel sweep [fecal disimpaction] LN [licensed nurse] explained cannot perform that request, pt then self-administered bowel sweep stating it's right there. LN advised to drink more water and allow the medication to work, pt now stating that she's going to call an ambulance, will notify MD. call light within reach.A review of a facility document provided by the Director of Nursing (DON) indicated LN 1 clocked out for her meal period on 11/29/25 at 2:46 p.m. and clocked back in after her meal period at 3:17 a.m.A review of a progress note dated 11/29/25 at 3:31 a.m., documented by LN 1 indicated, pt called 911 for herself, pt left facility in fire department ambulance/transport on transfer from bed to gurney without complications/4 medics present/via ambulance to [name of GACH].During an interview on 12/10/25 at 10:19 a.m., the DON acknowledged it was a failure on the facility's part to not notify Resident 1's family when she was transferred to the hospital by emergency medical services, and not to communicate this information to the charge nurse on the next shift.During a second interview on 12/10/25 at 3:30 p.m., the DON stated that when LN 1 saw Resident 1 performing a fecal disimpaction on herself, she (LN 1) should have told her (Resident 1) to stop, educated her, explained the risks, assessed her, stayed with her, and called the doctor. The DON confirmed in this instance, it was not appropriate for LN 1 to clock out for a meal period while she knew Resident 1 was having this issue with constipation and attempting to disimpact herself. The DON acknowledged that during the time LN 1 was clocked out for her meal period, there was no other licensed nurse to cover, and continue the responsibility of caring for Resident 1. The DON confirmed the process for notifying the attending physician of a resident's change in condition, or to obtain a new physician order in the middle of the night, was to simply call the physician. The DON stated the people LN 1 was supposed to notify in this situation were, the doctor, the family, the hospital to call and give report, the administrator, the DON, and to endorse the information to the next shift charge nurse. Additionally, according to the DON, due to Resident 1's follow up pain level assessment of six out of ten on 11/29/25, after the administration of Acetaminophen for pain, LN 1 should have called the doctor to report the worsening pain, or to request an order for an alternate pain medication to treat Resident 1's high pain level.During a phone interview with Resident 1's family member (FM) on 12/16/25 at 2:01 p.m., FM confirmed there was no notification made to Resident 1's emergency contacts, her spouse, her daughter, or her family that she was emergently transferred to the hospital from the staff at the facility on 11/29/25. FM stated the first notification Resident 1's family received regarding her GACH admission on [DATE], was from a GACH physician calling Resident 1's daughter, to obtain an emergency consent for Resident 1 to undergo a surgical procedure.A review of Resident 1's GACH emergency department report dated 11/29/25, documented by Emergency Physician 1 (EP 1) indicated, [Resident 1] Presented with abdominal pain and constipation .tachycardic [heart rate greater than 100 beats per minute; normal heart rate is 60-100 beats per minute] on arrival .Found to have emphysematous cystitis [a serious rare urinary tract infection where gas producing bacteria create bubbles in the bladder wall] and an obstructing left ureteral stone [A kidney stone inside the tube that connects the kidney to the bladder] .Blood cultures [tests used to detect bacteria or other organisms growing in a person's blood] positive for Klebsiella Pneumoniae [a type of bacteria that can cause infection] .Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to sepsis [a life threatening medical emergency where the body's overwhelming response to an infection damages its own tissues and organs], hypotension [lower than normal blood pressure] requiring pressor [emergency medication used to increase blood pressure] support.A review of the facility policy and procedure (P&P) titled, Significant Change in Condition, Response, undated, indicated, The nurse will perform and document the assessment and identify the need for additional interventions considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR (Situation, Background, Assessment, Recommendation: a standardized communication tool used for clear, concise handoffs and critical patient updates) or similar process to obtain new orders or interventions .The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report .There will be certain circumstances where immediate attention will be warranted and nursing will be responsible for notifying the appropriate department for evaluation. The nurse will use .her clinical judgment and shall contact the physician based on the urgency of the situation .The resident representative will be notified of the change in condition and any changes in the resident's medical or nursing care.

Based on interview and record review, the facility failed to provide scheduled showers for one resident (Resident 1) of three sampled residents when Resident 1 received one shower or bed bath of nine scheduled opportunities while in the facility. This failure increased the potential for delayed wound healing of Resident 1's wounds due to poor personal hygiene (the practice of maintaining cleanliness of the body to promote comfort, health, and well-being). Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility in January 2025 with diagnoses including fracture of right femur (bone in upper part of leg), orthopedic (related to bones or muscles) aftercare, contusion (bruise) of scalp, pain in right knee, presence of right artificial knee joint, weakness, and need for assistance with personal care. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Section GG - Functional Abilities, dated January 11, 2025, indicated Resident 1 was fully dependent (staff does all of the effort and resident does none of the effort to complete the activity) for showering/ bathing and personal hygiene. A review of Resident 1's care plan dated 1/6/25, indicated, has actual impairment to skin integrity related to surgical wound . ADL [Activities of Daily Living] self-care performance deficit related to weakness, impaired balance, pain, and poor endurance .[Interventions included] .requires one staff participation with bathing. During an interview on 3/25/25 at 4:25 p.m., Resident 1 stated he received only one shower during his six weeks in the facility. Resident 1 stated he did not receive any bed baths during that time. During a concurrent interview and record review on 3/27/25 at 10:50 a.m., Certified Nurse Assistance (CNA) A stated a binder which stored resident shower sheets (documentation of skin assessments and shower/bed bath refusals) was located at each nurse station. A review of the shower schedule, located at the nurse station in a binder, indicated each resident was scheduled for a shower twice per week. CNA A stated residents received a shower at least twice per week unless they requested a third shower day. During an interview on 3/27/25 at 3:05 p.m., the Medical Records Director (MRD) stated she was unable to locate any shower sheets for Resident 1. During a concurrent interview and record review on 3/27/25 at 3:40 p.m., the MRD stated a facility record titled ADL indicated what type of bathing was completed for Resident 1 from 1/6/25 through 2/7/25. The ADL record indicated Resident 1 received a shower on 1/12/25, refused a bath on 1/17/25, 2/4/25, and 2/7/25, and was unavailable for bath on 1/21/25 and 2/7/25. The ADL record indicated Resident 1 was scheduled to receive a shower/bath on Tuesdays and Fridays. The ADL record indicated NA (Not Applicable) for Resident 1's scheduled shower dates of: 1/7/25, 1/10/25, 1/14/25, 1/24/25, 1/28/25, and 1/31/25. During a concurrent interview and record review on 3/27/25 at 3:45 p.m., CNA B confirmed the document titled, ADL indicated Resident 1 was given one shower on 1/12/25, refused bathing on 1/17/25, 2/4/25, and 2/7/25 in the morning, and was unavailable for bathing on 1/21/25 and 2/7/25 in the afternoon. CNA B stated he charted NA if it was not an assigned resident's shower day, or they were unavailable for a shower. CNA B reviewed the abbreviations used for the ADL sheet and indicated the following were used when CNAs charted what type of bathing activity was completed: SH for a shower given, FB for a full body bath, SB for sponge bath, RU for resident unavailable, RR for resident refused, and NA for not applicable. The charting on the ADL document included only the abbreviations for the bathing type completed and did not include any details. During a concurrent interview and record review on 3/27/25 at 4:30 p.m., the Director of Nursing (DON) verified the document titled, ADL indicated Resident 1 was given one shower on 1/12/25, refused bathing on 1/17/25, 2/4/25, and 2/7/25 in the morning, and was unavailable for bathing on 1/21/25 and 2/7/25 in the afternoon. During a concurrent interview and record review on 4/7/25 at 1:43 p.m., the Director of Staff Development (DSD) stated the residents in the facility were scheduled to receive showers at least two times per week. Residents could have requested more showers, but the minimum had been two times per week. The DSD stated the facility had a policy and procedure for baths and showers, but it did not indicate the frequency of baths or showers. The DSD stated the scheduling of twice per week bathing was a standard of care at the facility. The DSD also stated cleanliness was very important for wound healing.

Based on observation, interview and record review, the facility failed to maintain essential patient care equipment in safe operating condition when: 1. The air conditioner in dry storage room is soiled. 2. The walk-in refrigerator condenser fans are dripping soiled water on food box. 3. Freezer number 2 had frozen ice drips on ceiling. 4. Ice machine and ice chest cleaning process is unsafe. 5. Resident refrigerator in nourishment room had a damaged gasket. These failures have the potential to contaminate food and pose a risk for food borne illness for 46 of 46 residents that reside in the facility. Findings: 1. During an observation on 1/21/25 at 10:48 a.m., in the dry storage area, the air conditioner had black and brown grime and matter underneath the vent and on the locking mechanism. During the same observation, food was stored beneath the air conditioner. A sign was placed across from air conditioner that stated Do not place objects on shelf under air conditioning unit. During an interview on 1/21/25 at 2:25 p.m., Maintenance Director (MND) stated he was responsible for maintaining and cleaning vents, sprinklers, refrigerator and freezer components. He confirmed the air conditioner could be cleaner. According to FDA Food Code 2022, Section 4-601.11, Food Contact Surfaces, Nonfood Contact Surfaces and Utensils (A) Equipment shall be clean to sight and touch. Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. According to FDA Food Code 2017, FDA Food Code 2017 - 6-202.12 Heating, Ventilating, Air Conditioning System Vents; Heating ventilating and air conditioning systems shall be designed and installed so that make-up air intake and exhaust vents do not cause contamination of food, food-contact surfaces, equipment or utensils. 2. During an observation on 1/21/25 at 10:28 a.m., water was dripping from condenser fans in walk in refrigerator making a box bottom of sliced cheese wet. Upon closer observation, the blades of the condenser fans have brown colored grime. During an interview on 1/21/25 at 2:27 p.m., MND acknowledged condenser fan leaking water and soiled areas of fans. According to FDA Food Code 2022, Section 4-601.11, Food Contact Surfaces, Nonfood Contact Surfaces and Utensils (A) Equipment shall be clean to sight and touch. Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. 3. During an observation on 1/21/25 at 10:38 a.m., in the kitchen, ice was observed hanging from the ceiling of freezer #2. During an interview on 1/21/25 at 2:29 p.m., MND stated the filters in the freezer needed to be changed or cleaned. MND acknowledged the presence of ice hanging from the ceiling. 4. During a concurrent observation and interview on 1/21/25 at 2:10 p.m., MND demonstrated and stated the process for cleaning the ice machine. MND provided surveyor with instructions and stated he follows these instructions exactly. MND brought chemical Manitowoc Ice Machine Sanitizer which he stated he uses for entire process, and stated The sanitizer also cleans. MND confirmed he used no other chemicals. He stated after following the cleaning process is completed, he dilutes the sanitizer solution with water and sprays on every inch of ice machine. After machine has air dried, he will spray water on the machine to rinse off the sanitizer. Prior to cleaning process, he stated the current ice is removed into sanitized ice chests. Ice chests are cleaned with facility wide multipurpose sanitizer from Ecolab by first spraying with water, spraying with facility wide sanitizer, then air dry. The final step to clean the ice chests was to rinse off. During a record review of document titled Section 4 Maintenance. Cleaning and Sanitizing dated 4/2014, step 3 indicated when water trough refills, the proper amount of ice machine cleaner is to be added prior to sanitizer solution in step 9. Step 11 of the same document indicated Do not rinse sanitized areas. 5. During an observation on 1/21/25 at 2:50 p.m., resident refrigerator gasket located in nutrition room was pulling away from door at top outer portion of door. During an interview on 1/21/25 at 3:55 p.m., MND stated he was not aware of damaged gasket and will replace soon. According to FDA Food Code 2022, Section 4-501.11, (A) Equipment shall be maintained in a state of repair and condition (B) Equipment components such as doors, seals .shall be kept intact, tight and adjusted in accordance with manufacturer's specifications.

Based on observation, interview and record review the facility failed to ensure that food was prepared by methods that preserved nutrition, palatability and served at an appetizing temperature when eight out of 46 residents (Resident 4,Resident 11, Resident 253, Resident 29, Resident 35, Resident 154, Resident 36, Resident 1) received meals that were cold, flavorless and overcooked. This failure had the potential to decrease nutritive content and decrease meal intake by the residents eating meals served by the kitchen and adversely affecting their health. Findings: During a concurrent observation and interview on 1/21/25 at 11:59 a.m., in the dining room, Resident 4 stated the chicken served for lunch was too dry, she couldn't chew it and didn't want it. Chicken was observed partially cut up on Resident 4's plate and appeared dry. Resident 4 stated they do not provide gravy for chicken. She asked for some refried beans in place of chicken. During a concurrent observation and interview on 1/22/25 at 11:53 a.m., in residents' room, Resident 11 was just served her lunch tray. Resident 11 had only eaten approximately 25% of her lunch. She stated that lunch was cold and that meals were frequently delivered cold, and that she would not be eating a lot of the food that was served to her for lunch. She also stated the eggs are terrible. She had informed the RD of the issues with the food but had not seen any changes. She further stated she liked everything about the facility except the food. During a concurrent observation and interview on 1/22/25 at 12:05 p.m., in residents' room, Resident 253 was just served her lunch tray. Resident 253 had only taken a few bites and stated she was finished. She stated the food was bland and cold and she was not interested in any of the alternate meal choices. During an interview on 1/21/25 at 9:56 a.m., Resident 29 stated the meals were not like home cooking. During an interview with Resident 35 on 1/21/25 at 12:10 p.m., she stated her meals were not like home cooking. She stated the food was bland and did not taste as good as it could. She stated cold food was Not very appetizing. During an interview with Resident 4, on 1/21/25 at 12:22 p.m., she stated she was the president of the Facility Resident Council, and consistent issues brought up by residents was dissatisfaction with meal menus and the temperature of food. She stated her meals are never served hot and were warm at best. During an interview on 1/21/25 at 3:54 p.m. , Resident 154 stated the food at the facility was not very good. She stated substitutions were limited to cheese based options that did not taste good and was served cold. She stated too much cheese created a constipation problem. Cold food is not appetizing and not like home cooking. She stated it made her feel like the food was from an institutional cafeteria. During an observation and interview on 1/22/25 at 8:21 a.m., Resident 154 and Resident 36 both stated the room felt cold. Resident 154 stated breakfast was French Toast, and it was cold and tough. She stated she did not finish her breakfast, and her plate was observed to have 25% of her French Toast not eaten. She stated she lost her desire to eat when food is cold and tough. Resident 36 stated her French Toast was cold and tough. She stated she did not have teeth, and it was difficult to chew. She pointed to her breakfast plate that indicated she had eaten 25% and stated she missed hot food, and the meals were not like being at home. She was observed to be tearful when she stated she was not able to enjoy her breakfast but all the meals in general. During an observation and interview on 1/22/25 at 8:24 a.m., Certified Nurses Aid (CNA) N was observed to exit Resident 1's room with a breakfast tray that indicated the resident had not eaten anything. He stated Resident 1 had told him the breakfast was cold and tough. He stated he did not ask her if she wanted a substitute breakfast tray or if she wanted him to heat it up for her. During an interview on 1/22/25 at 8:28 a.m., Resident 29 stated her breakfast was French Toast that she never ordered. She stated I have no teeth, and the French Toast was cold and tough. During an interview on 1/23/25 at 9:10 a.m., Resident 29 stated she was very upset about her breakfast. She stated she had requested oatmeal, and they served her cold cream of wheat. She had refused another tray because they told her there was no oatmeal and they would have to cook it for her. She stated she needed her breakfast in the morning because she needed it to take with her morning medications because she could not take them on an empty stomach. She stated when dietary did not serve her food that she requested and that was hot, it made her feel unimportant. She stated this is my home and it is not right. During an observation on 1/23/25 at 9:45 a.m., in the kitchen, carrots were boiling on the stove in a large amount of water. During an observation on 1/23/25 at 10:44 a.m., in the kitchen, carrots were drained. Carrots were pale in color. During a concurrent observation and interview on 1/23/25 at 11:05 a.m., small portions of boneless, skinless chicken breast were removed from the oven. They appeared dry. When [NAME] (CK) D was asked what time they were placed in the oven, he stated I placed the chicken in the oven at 9:45 a.m. During a record review of document titled Recipe: Baked Chicken, dated 2024, indicate that chicken breasts should be placed in the oven for 30-40 minutes. During a concurrent observation and interview on 1/23/25 at 10:09 a.m., all three steam wells were off. Registered Dietitian (RD) stated that they were usually kept on at a low temperature to keep them warm. During an observation on 1/23/25 at 10:23 a.m., temperature on the wall clock above the window in the kitchen reads 57.3 degrees Fahrenheit (F). Following observations of time and temps follow: 10:57 a.m.: 57.7 degrees F, 11:12 a.m.: 57.9F 11:29 a.m.: 58.2 F 11:43 a.m.: 58.6 F 11:56 a.m.: 59 F. Fans and vents are running the entirety of lunch plating. During an observation on 1/23/25 at 11:43 a.m., plate warmer had 5 plates standing above rim on both sides during trayline service. This left the higher plates to be exposed to the cold air in the kitchen. During an observation of temperatures during test trays on 1/23/25 at 12:15 p.m., the following foods were tested for temperature by RD using facility thermometer: Pureed Regular Roast Beef RD 100.2F RD 118 F Carrots RD 94.6 F RD 107.4 F Rice & Beans RD 95.1 F RD 104.5 F Survey team observed the test trays for taste, palatability and appearance. Pureed carrots and pureed rice and bean dishes spread across plate due to the thin consistency. Test trays for both regular and pureed meals were lukewarm. Survey team members stated carrots had very little flavor. The carrots are watery. RD stated Our recipes don't use much salt. During a record review of document titled Meal Service dated 2023, food items are recommended to be delivered to the residents at the following temperatures: Hot entree at or above 120F Starch at or above 120F Vegetables at or above 120F Record review of Resident Council Meeting Minutes, dated 1/20245 to 10/2024, revealed residents voicing concern over vegetables being either overcooked or undercooked, tough meat, and meals that are often served cold. During a record review of Food & Nutrition: Test Tray Evaluation Log, completed independently by RD on 10/16/24, 10/17/24, 10/23/24, 10/31/24 and 1/14/25 indicated a temperature drop from trayline to resident delivery ranging from a 38-degree temperature drop to a 70- degree. Comments from residents included toast was cold.; Weird seasoning on broccoli.; My meat was dry and tough. 38088 During an interview on 1/23/25 at 10:40 a.m., Operations Manager stated the Quality Assurance Performance Improvement (QAPI) Committee met in January and had had discussed resident dissatisfaction with meals. He stated QAPI had a plan to test meal trays and audit resident meals. He stated QAPI had not started the process yet and there were no performance improvement projects that included resident food palatability, temperature of food or temperature of the ambient temperature of facility areas. A review of the Resident Council meeting minutes from 10/24 indicated resident grievances included the resident rooms temperatures were cold for rooms 1, 2, 3, 9, 11, 15, 19, 24, 27, 28, 30. Grievances from resident included complaints that food temperatures were cold. The Resident Council meeting minutes from 11/24 did not indicate follow up from the facility administration for the grievances that included cold resident rooms and cold meals. Review of the minutes for the last year indicated resident complaints about their rooms being cold were discussed at Resident Council on 1/24, 2/24, 4/24, 6/24, 10/24, 11/24 and 12/24.

Based on observation, interview and record review, the facility failed to ensure that food was stored, prepared and served safely in accordance with professional standards of food service when: 1. Kitchen staff improperly restrained facial hair and hair net use. 2. Kitchen staff Improperly used gloves. 3. Dietary staff observed to wear jewelry while at work in the kitchen. 4. Kitchen staff did not monitor ambient food cooling. 5. Expired food found in the reach in refrigerator and dry storage area. 6. Condiment containers found with drip residue in caps and along sides of containers. 7. Soiled equipment observed in a food prep area. 8. Resident refrigerator did not have a cleaning process. 9. Cross contamination of products in the resident refrigerator in the nutrition room. These failures posed the risk for food borne illness for 46 of 46 residents that resided in the facility and consumed food prepared in the kitchen. Findings: 1. During an observation on [DATE] at 11:06 a.m., in the kitchen, Dietary Aide (DA) A wore a baseball cap with hair restraint underneath that did not cover the entirety of his hair. During an observation on [DATE] at 2:00 p.m., in the kitchen, [NAME] (CK) B wore a hair restraint on his beard. His mustache was not covered. During an observation on [DATE] at 7:15 a.m., in the kitchen, CK D wore a baseball cap with no hair restraint underneath. His hair was curling up over the bottom of the cap. During an observation on [DATE] at 2:48 p.m., in the kitchen, CK B wore a baseball cap with no hair restraint underneath. The hair at the back of the head was exposed. A beard restraint was worn. His mustache was exposed. During an observation on [DATE] at 8:30 a.m., in the kitchen, DA F had hair protruding from the bottom of the hair restraint around her entire head. During an interview on [DATE] at 3:01 p.m., Registered Dietitian (RD) stated she would look at the policy regarding hair restraint use. During an observation on [DATE] at 9:44 a.m., in the kitchen, a sign posted by the handwashing sink stated that hairnets and beard coverings must be worn while in the kitchen. During a record review facility policy titled Dress Code, dated 2023, indicated that if hair is short, staff may wear a hat that completely covers the hair. If hair is long, use hair restraint. Staff with beards and mustaches (any facial hair) must wear beard restraint. According to FDA Food Code 2022 ,d+[DATE].11 (A) showed Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. 2. During an observation on [DATE] at 2:00 p.m., in the kitchen, CK B opened the kitchen entry door with gloved hand and resumed cooking without washing hands and changing gloves. During an observation on [DATE] at 7:15 a.m., DA E retrieved an item from freezer #2 with gloved hands. Did not change gloves or wash hands before resuming plating items for trayline. During a record review of facility policy titled Glove Use Policy dated 2023, employees need to wash their hands and change their gloves when starting a different task and/or when touching non-food items. According to the FDA Food Code 2022, Section ,d+[DATE].14 Food employees shall clean their hands and exposed portions of their arms .(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms and (E) After handling soiled equipment or utensils. 3. During an observation on [DATE] at 8:30 a.m., in the kitchen, DA C wore nose piercings, ear piercings, necklace and a large, loose ring during meal prep and trayline. During an interview on [DATE] at 3:12 p.m., RD stated that she would have to review the policy regarding jewelry in the kitchen. During a record review of document titled Dress Code, dated 2023, indicated no facial jewelry no excessive jewelry. According to FDA Food Code 2022, Section ,d+[DATE].11, Jewelry indicates that except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. 4. During a concurrent observation and interview on [DATE] at 10:28 a.m., in the walk-in refrigerator, prepared tuna salad was observed in a container labeled made on [DATE]. When asked for a cooling logs, Registered dietitian (RD) stated the facility did not use cooling logs for ambient foods. We pull everything from the can at room temp and stick it right in the refrigerator. During an interview on [DATE] at 2:55 p.m., Dietary Services Supervisor (DSS) confirmed that no ambient cooling logs were kept because mayonnaise and pickles were pulled from the refrigerator. He acknowledged tuna is pulled from dry storage and is at room temp when made. During a record review of facility policy titled Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023, indicated, PHF (Potentially Hazardous Food) or TCS (Time/Temperature Control for Safety) food shall be cooled within 4 hours to 41 degrees or less, if prepared from ingredients at ambient temperature, such as reconstituted food and canned tuna. According to FDA Food Code 2022, ,d+[DATE].14 Cooling. (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna. 5. During a concurrent observation and interview on [DATE] at 10:28 a.m., in the reach in refrigerator 2 bowls of soup were found, labeled Prepared [DATE]. Use by [DATE]. RD confirmed these were expired and should have been thrown out. During a concurrent observation and interview on [DATE] at 10:48 a.m., in the dry storage area, a container of sesame oil with expiration date of ,d+[DATE] was seen. RD confirmed this was expired and should have been thrown out. The facility did not have a policy regarding expired foods. 6. During an observation on [DATE] at 10:25 a.m., in the kitchen, a container of BBQ sauce had dried drips of sauce on the outside of the container. The cap of the container had residue on the outside of the container rim. During a concurrent observation and interview on [DATE] at 10:26 a.m., in the dry storage area, a container of vanilla had dried drips of contents on the outside of the container. RD confirmed risk of bacteria growth and stated she would clean off the container. According to the FDA Food Code 2022, ,d+[DATE].11 (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. 7. During an observation while on initial tour of kitchen on [DATE] at 10:15 a.m., the following equipment was observed to be soiled: grill has black residue; slotted compartment under griddle has debris and dust; stovetop has black residue and debris in burner wells; ovens have black residue; blender base was not clean; top of dishwasher has tan, flaky debris; dishwasher has hard, white buildup on corners and crevices; silverware dispenser was not clean; can opener was not clean. During an interview on [DATE] at 10:15 a.m., CK D stated he cleans the grill portion of the stove after every use. During a record review of document titled Food Nutrition Department: Cleaning Schedule dated from [DATE] to [DATE], indicates all equipment named above is listed and assigned to dietary staff. According to the FDA Food Code 2022, Section ,d+[DATE].11, Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A) Equipment, food contact surfaces, and utensils shall be clean to sight and touch, (B) The food contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.(C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 8. During an observation on [DATE] at 2:50 p.m., the resident refrigerator in nutrition room had brown residue in crevices of door gasket. During an interview on [DATE] at 9:18 a.m., Housekeeping Tech (Hskg) M stated that she does not clean the resident refrigerator in the nutrition room. She only mops the floor in the nutrition room. She stated the kitchen clean the resident refrigerator. During an interview on [DATE] at 2:50 p.m., RD stated that the cooks spot clean the resident refrigerator and monitors the temperatures. Housekeeping helps with cleaning and deep cleaning of the refrigerator. On [DATE] at 3:50 p.m., a schedule or a log of cleaning and deep cleaning the resident refrigerator in the nutrition room was requested from RD and Maintenance Director (MND). During an interview on [DATE] at 12:45 p.m., MND stated there was not a deep cleaning or cleaning schedule for the resident refrigerator in the nutrition room, and that it was done on an as needed basis only. According to the FDA Food Code 2022, Section ,d+[DATE].11, Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A) Equipment, food contact surfaces, and utensils shall be clean to sight and touch, (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 9. During an observation on [DATE] at 2:52 p.m., in the nutrition room, Certified Nurse Assistant (CNA) H removed a half gallon of milk from the resident refrigerator, dated and labeled the milk and handed to a family member of Resident 12. Milk was observed to be poured into a glass for resident and left on the bedside table with resident's other personal belongings. During an observation on [DATE] at 3:00 p.m., the opened half gallon of milk remains on bedside table of Resident 12. During an observation on [DATE] at 4:00 p.m., the opened half gallon of milk was placed back in resident refrigerator. Facility did not have policy regarding food removed and returned to the resident refrigerator.

Based on interview and record review the failed to ensure a Quality Assurance Performance Improvement (QAPI) plan that resolved consistent complaints from residents about environmental temperatures, food temperatures, food palatability, and food preferences. This failure resulted in the lack of a systematic approach to determine underlying causes of problems impacting temperature of the environment, food palatability, medication errors; and no guidance on how the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Findings: (Reference F837, F804, F806) During an interview on 1/21/25 at 9:56 a.m., Resident 29 stated the meals were not like home cooking. During an interview with Resident 35 on 1/21/25 at 12:10 p.m., she stated her meals were not like home cooking. She stated the food was bland and not taste as good as it could. She stated cold food was Not very appetizing. During an interview with Resident 4, on 1/21/25 at 12:22 p.m., She stated she was the president of the Facility Resident Council, and consistent issues brought up by residents was dissatisfaction with meal menus and the temperature of food. She stated her meals are never served hot and were warm at best. During an interview with Resident 154, on 1/21/25 at 3:54 p.m. , Resident 154 stated the food at the facility was not very good. She stated substitutions were limited to cheese based options that did not taste good and was served cold. She stated too much cheese created a constipation problem. Cold food is not appetizing and not like home cooking. She stated it made her feel like the food was from an institutional cafeteria. During an observation and interview on 1/22/25 at 8:21 a.m., Resident 154 and Resident 36 both stated the room felt cold. Resident 154 stated breakfast was French Toast, and it was cold and tough. She stated she did not finish her breakfast, and her plate was observed to have 25% of her French Toast not eaten. She stated she lost her desire to eat when food is cold and tough. Resident 36 stated her French Toast was cold and tough. She stated she did not have teeth, and it was difficult to chew. She pointed to her breakfast plate that indicated she had eaten 25% and stated she missed hot food, and the meals were not like being at home. She was observed to be tearful when she stated she was not able to enjoy her breakfast but all the meals in general. During an observation and interview on 1/22/25 at 8:24 a.m., Certified Nurses Aid (CNA) N was observed to exit Resident 1's room with a breakfast tray that indicated the resident had not eaten anything. He stated Resident 1 had told him the breakfast was cold and tough. He stated he did not ask her if she wanted a substitute breakfast tray or if she wanted him to heat it up for her. During an interview on 1/22/25 at 8:28 a.m., Resident 29 stated her breakfast was French Toast that she never ordered. She stated I have no teeth, and the French Toast was cold and tough. During an interview on 1/22/25 at 2:41 in the back hallway nursing station, License Nurse I stated she did not know much about QAPI except that they meet on Mondays. She stated she was not aware of any performance improvement projects or what QAPI does. During an interview on 1/23/25 at 9:10 a.m., Resident 29 stated she was very upset about her breakfast. She stated she had requested oatmeal, and they served her cold cream of wheat. She had refused another tray because they told her there was no oatmeal and they would have to cook it for her. She stated she needed her breakfast in the morning because she needed it to take with her morning medications because she cannot take them on an empty stomach. She stated when dietary does not serve her food that she requested that was hot made her feel unimportant. She stated this is my home and it is not right. During an interview and record review on 1/23/25 at 10:40 a.m., Operations Manager stated the Quality Assurance Performance Improvement (QAPI) Committee met in January and had had discussed resident dissatisfaction with meals. He stated QAPI had a plan to test meal trays and audit resident meals. He stated QAPI had not started the process yet and there were no performance improvement projects that included resident food palatability, temperature of food or temperature of the ambient temperature of facility areas. Operations Manager was asked to provide the policy and procedures for the QAPI Committee. He stated everything for QAPI was in the 2024 Quality Assurance and Performance Improvement (QAPI) Plan. During a review of the document he stated there were no policy and procedures for QAPI. He stated he did not know what Appendix PP (Appendix PP to a section within the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), which provided detailed guidance that outlined the standards and expectations for nursing homes facilities. Nursing homes needed to be familiar with the guidelines in Appendix PP to ensure they are operating in compliance with CMS standards.) was or how to access the regulations. He stated QAPI was going to start a process to improve resident satisfaction with meal preferences. He stated there was no documentation that a performance improvement plan (PIP) had started yet. He stated there were no PIP's for resident complaints for consistent resident complaints about the cold temperatures in the facility or cold food. He stated he was unsure if QAPI had monitored any pharmacy or resident medication issues. During a phone interview on 1/23/25 at 1:07 pm Administrator stated Operations Manager was not a licensed Skilled Nursing Home Administrator. Administrator stated There is no governing body. He stated he lived in Southern California. During an interview on 1/24/25 at 10:00 a.m., Operations Manager stated there was no documentation of any audits or monitoring. He stated he was unsure if the QAPI had monitored any pharmacy or resident medication issues. He stated QAPI tracks adverse events by when the Director of Nursing presented them to the QAPI and then she would investigate and present her findings at the meeting. He stated there was no QAPI policy and procedures for root cause analysis or investigation of adverse events. When asked how those processes occurred he stated the Director of Nursing was responsible. Operations Manager stated there were only two PIPs; one for resident falls and one for wound care documentation. He stated the PIPs collection of data was from informal observations and not on a documentation form. He stated the Director of Nursing was responsible for collecting and calculating everything. He stated the 2024 QAPI plan was not approved by the Governing Body. A request at the survey entrance for the QAPI minutes and membership was made 1/21/25. No QAPI policy and procedures, QAPI minutes, QAPI Agendas were provided by the end of survey. A review of the Resident Council meeting minutes from 10/24 indicated resident grievances included the resident rooms temperatures were cold for rooms 1, 2, 3, 9, 11, 15, 19, 24, 27, 28, 30. Grievances from resident included complaints that food temperatures were cold. The Resident Council meeting minutes from 11/24 did not indicate follow up from the facility administration for the grievances that included cold resident rooms and cold meals. Review of the minutes for the past year indicated resident complaints about their rooms being cold were discussed at Resident Council on 1/24, 2/24, 4/24, 6/24, 10/24, 11/24 and 12/24. A review of a facility document titled 2024 Quality Assurance and Performance Improvement (QAPI) Plan, indicated The Administrator has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. QAPI Governance: The governing body is ultimately responsible for overseeing the QAPI Committee. At a minimum, the QAPI Committee will report the progress on the established QAPI goals and current data trends to the following: Governing Body . The QAPI Committee, which includes the Medical Director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. A review of a facility document titled 2024 Quality Assurance and Performance Improvement (QAPI) Plan, indicated QAPI PLAN REVIEWED & APPROVED BY: Governing Body-Member _____ Sginature__________ Date______. The two Governing Body-Member signature lines indicated no signature. A review of a facility document titled 2024 Quality Assurance and Performance Improvement (QAPI) Plan, indicated REFERENCES: CMS QAPI Website: quality Assurance & Performance Improvement. Effective QAPI programs are critical to improving the quality of life, and quality of care and services delivered in nursing homes. https://www.cms.gov/medicare/provider-enrollment-and-certifications/qapi/downloads/qapifiveelements.pdf. Element 5: Systematic Analysis and Systemic Action The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/ structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement.

Based on observation, interview and record review the facility failed to ensure sufficient and competent staff were scheduled to carry out the functions of the food and nutrition service safely when: 1. Two staff members worked tray line affecting timeliness of meal delivery. 2. One dietary aide (DA B) could not verbalize or demonstrate proper method to check sanitizing solution. 3. Presentation of pureed food was not appetizing. Findings: 1. During an observation on 1/21/25 at 10:00 a.m., a posted sign at the nursing station 2 read: breakfast served at 7:30 a.m., lunch at 11:30 a.m. and dinner at 5:30 p.m. daily. During an observation on 1/21/25 at 11:49 a.m., a food cart arrived in the dining room. Five residents seated at different tables were served and started eating. The second cart arrived at 12:07 p.m. During an observation on 1/22/25 at 12:11 p.m., the lunch food cart was delivered to nursing station 2. During an observation on 1/22/25 at 7:15 a.m., breakfast trayline was in progress. [NAME] (CK) C plated entrees and sides while Dietary Aide (DA) B placed drinks, condiments, extra items and silverware on tray. During an observation on 1/23/25,dietary leadership assisting with the following tasks: At 10:28 a.m., Dietary Services Supervisor (DSS) held strainer for CK 3 allowing meat juice to be strained. At 10:32 a.m., Registered Dietitian (RD) retrieved an ivory scoop for CK 3. At 10:57 a.m., RD washed Robo Coupe bowl for CK 3. At 11:03 a.m., DSS placed rice and beans in oven. At 11:10 a.m., RD washed blender. At 11:23 a.m., DSS made gravy on stovetop from strained meat juices. RD washed teal scoop. At 11:46 a.m., DSS plated Caeser Salad during trayline. RD replaced sanitizer bucket. During an interview on 1/23/25 at 2:58 p.m., CK B stated there are normally only 2 dietary personnel to plate all meals with no additional help from dietary leadership. During an interview on 1/23/25 at 3:01 p.m., RD confirmed there are normally only 2 people on trayline for all meals. She stated she is not normally the runner or helper during trayline. During a record review of a document titled Trayline Setup Procedure: Breakfast, Lunch, Dinner dated 2023, a diagram depicts 4 dietary staff for trayline. 2. During a record review of document titled Verification of Job Competency dated August 2024, DA B was granted competency of Sanitizing Solution; test concentration and record results; when to replace solution by demonstration and verbalization. During a concurrent observation and interview on 1/22/25 at 8:50 a.m., Dietary Aide (DA) B stated the cleaning procedure in the kitchen consisted of washing, rinsing and sanitizing. DA B then demonstrated testing of sanitizer solution. DA B held the strip for four seconds, when RD corrected DA B by stating to hold the strip for 10 seconds. DA B repeated the demonstration a second time with a new testing strip, holding it in the sanitizer solution for 7 seconds. DA B was unable to verbalize proper test result range of strip or demonstrate proper testing method of sanitizer solution despite showing competency on his job competency checklist. During a record review of document titled Job Description: Dietary Aide dated 2023, a duty and responsibility of the DA is cleaning as assigned on cleaning schedule. During a record review of document titled AM Dietary Aide, undated, a posted sign in the kitchen indicates at 5:30 a.m., the dietary aide is assigned to prepare the quat bucket, use the quat strip to test the ppm. During a record review of the Food and Nutrition Department Cleaning Schedule (undated), sanitizing the tray carts had been assigned to dietary aide. During a document review from Ecolab titled Oasis 146 Multi-Quat Sanitizer dated 2016 indicated the testing strip is to be held in the sanitizer solution for 10 seconds. Result range for testing solution should be between 150-400 ppm. 3. During an observation on 1/23/25 at 9:47 a.m., in the kitchen, CK C pureed Caeser salad. Excess dressing added to the mixture resulted in a runny texture. CK C added croutons and stated he would check before serving the salad to ensure proper consistency. Pureed Caeser salad was not rechecked prior to trayline start. The texture was observed to be not fully formed. During an observation on 1/23/25 at 10:50 a.m., CK C pureed carrots with parsley by adding 3/4 cup warmed milk. The texture was observed to be not fully formed. During an observation on 1/23/25 at 11:05 a.m., CK C pureed rice and beans, then added 1/2 cup warm milk. The texture was observed to be not fully formed. CK C stated that Rice is tricky. It looks right but then it seizes up when it sits. During an observation on 1/23/25 at 12:15 p.m., the pureed test tray was inspected. Pureed rice & beans and pureed carrots spread across plate due to thin consistency. During a record review of a document titled Regular Pureed Diet/IDDSI Level #4, dated 2024 indicated the texture of pureed food items should .hold their shape .and should not weep.

Based on observations, interviews and record reviews, the facility failed to ensure: 1. Staff were following the Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) when administering medications via feeding tube (tube inserted into the stomach to provide a patient with enteral nutrition, used when someone is unable to eat or drink safely by mouth). This failure could lead to spread of infection, increased complications and adverse events. 2. Staff were performing hand hygiene (HH, cleansing of your hands with soap and water, antiseptic hand washes, antiseptic hand rubs such as alcohol-based hand sanitizers) prior to donning gloves. These failures could lead to spread of infection, increased complications and other adverse events. Findings: A review of Resident face sheet (demographics) indicated an admitted [DATE] with a diagnoses of Dysphagia (difficulty swallowing) and Esophagitis (an inflammation of the esophagus, the tube that carries food from the mouth to the stomach). Resident 45 had a feeding tube and was on EBP. During an observation on 1/22/25 at 8:09 a.m., Licensed Nurse (LN) J provided Resident 45s medications via feeding tube without wearing a gown. During an interview on 1/22/25 at 11:21 a.m., Registered Nurse (RN) I stated EBP must be followed when giving medications to the residents via feeding tube to protect the staff and the resident. RN I stated it was also to prevent spread of infection at the facility. During an interview on 1/22/25 at 12:05 p.m., the Infection Preventionist stated nurses had to follow the EBP when administering medications to residents via feeding tube. The IP stated this was for infection control and residents' safety to prevent spread of infection. During an interview on 1/22/25 at 12:07 p.m., the Director of Nursing (DON) stated nurses had to follow EBP whenever giving medications to a resident via feeding tube. The DON stated this was an infection control measure and was used to prevent spread of infection. During an interview on 1/23/25 at 10:18 a.m., LN J verified she did not follow the EBP when she administered Resident 45s medications via feeding tube. LN J verified nurses should follow the EBP when administering Resident 45s medications. LN J stated not following EBP when administering medications via feeding tube was an infection control issue. A review of the facility's policy and procedure (P&P) titled Policy on Enhanced Barrier Precaution, effective date 8/2024, it stated EBPs must be implemented for residents who have wounds or indwelling medical devices such as urinary catheters (a tube placed in the body to drain and collect urine from the bladder), feeding tubes .EBPs apply during device care or handling .gowns and gloves must be worn during all high contact care activities . 2. During a concurrent observation and interview on 1/22/25 at 7:56 a.m., Licensed Nurse (LN) J removed her gloves and wore new gloves with no HH. LN J stated she should have performed HH prior to donning new gloves. LN J stated this was important for infection control and to prevent spread of infection. During an interview on 1/23/25 2:10 p.m., Licensed Nurse (LN) K stated staff were required to perform HH prior to donning gloves and after removing gloves. LN K stated if this was not done, then it was an infection control issue which could lead to spread of infection. During an interview on 1/23/25 at 4:15 p.m., the Director of Nursing (DON) stated staff should be performing HH prior to donning gloves. The DON stated if HH was not done prior to donning gloves, then it was an infection control issue. The DON stated performing HH prior to gloving decreases the risk of spread of infection. The Centers for Disease Control and Prevention (CDC) recommends that healthcare workers (HCWs) wash their hands before and after putting on gloves, and after removing gloves.

Based on observation, interview and record review the facility failed to accommodate resident food preferences or offer snacks to seven of 46 residents (Resident 154, Resident 36, Resident 1, Resident 3, Resident 27, Resident 11, Resident 29), when alternate menu items were continuously repeated, and snacks were not offered to all residents in the facility. This failure had the potential for residents in the facility to experience weight loss and become malnourished. Findings: During an interview with Resident 154, on 1/21/25 at 3:54 p.m., Resident 154 stated the food at the facility was not very good. She stated substitutions were limited to cheese based options that did not taste good and was served cold. She stated too much cheese created a constipation problem. She stated she was not offered snacks ever. During an interview on 1/22/25 at 8:21 a.m., Resident 154 and Resident 36 stated they were not offered snacks last night. Resident 36 stated the facility had never offered bedtime snacks. During an observation and interview on 1/22/25 at 8:24 a.m., Certified Nurses Aid (CNA) N was observed to exit Resident 1's room with a breakfast tray that indicated the resident had not eaten anything. He stated Resident 1 had told him the breakfast was cold and tough. He stated he did not ask her if she wanted a substitute breakfast tray or if she wanted him to heat it up for her. During an interview on 1/22/25 at 8:39 a.m., Resident 3 stated he was not offered snacks last night. He stated the staff do not provide bedtime snacks. He stated staff have never asked him if he wanted a meal substitution if he did not like something. During an interview on 1/22/25 at 9:09 a.m., Certified Nurse Assistant N stated Resident 27 had refused her breakfast and did not eat anything. He stated he did not offer her another breakfast substitution. During an interview on 1/22/25 at 11:50 a.m., in resident's room, Resident 11 stated that she wants snacks but does not like what they send her, because it is normally a half sandwich. She stated she dislikes sandwiches. She would like to have raw vegetables with hummus for a snack. She stated she often does not like the meat served for meals because it is often dry and tough. The alternate menu for meals is never different, always sandwiches. She stated that she is hungry all the time, and that the facility does not give them very much to eat. During an interview on 1/23/25 at 9:10 a.m.,Resident 29 stated last night the nurse promised her a bag of chips but she never got it. She stated she was mad because they never offer snacks before bed. She stated she was really excited about the snack of chips and then mad because she never got them. During an interview on 1/22/25 at 2:33 p.m., Registered Nurse (RN) I stated that resident snacks come out in between meals. Snacks consists of half sandwiches, juices, cheese and crackers. All snacks come out from the kitchen with a name label. She stated that nursing staff do not go around and offer snacks to resident and that they can request to be placed on a snack list through the kitchen. During an interview on 1/22/25 at 2:35 p.m., the Registered Dietitian (RD) stated that upon admission the resident can request to have snacks ,choose what they want to eat, and they can update as needed. Residents who wish to change their snack or wish to begin receiving a snack would tell their CNA, Nurse or contact the RD. During a record review of the Meal Service Alternatives choices for Spring 2024, Summer 2024 and Fall 2024, a grilled cheese sandwich (or ungrilled) is offered on each menu. Fall 2024 has 2 sandwich options: grilled cheese or turkey. Winter 2024-2025 has 2 sandwich options: grilled ham and cheese or tuna salad. During a record review of responses to facility document Resident Council, an email, dated 6/24/24, was sent to RD stating that residents are requesting more drinks and snacks to the day room. Record review of Resident Council meeting minutes dated 9/20/24 , indicated they would like to switch alternating meals. Minutes from 10/15/24 indicate that residents would like to add resident choice meal to the calendar, and to replace the set menu. A review of a facility minutes document titled Resident Council, dated 12/7/24, indicated Department: Dietary Issues: More fresh fruit, too much pork, protein substitution/not grilled cheese, alternative always out . Record review of a document titled Food Preferences, dated 2023, indicated resident's food preferences will be adhered to within reason. Record review of document titled Food Substitutes for Residents who Refuse the Meal, dated 2023, indicated residents will be provided a suitable nourishing alternate meal after the served planned meal has been refused. According to this document, nursing staff would ask those residents who refused the meal why they are not eating, and offer a food substitution in accordance with the resident's diet order. 38088

Based on observation, interview, and record review the facility failed to promote resident respect and dignity when three out of eight residents (Resident 36, 10 and 154) were served their lunch trays late when others in the dining room were already eating. This failure had the potential to impact the three residents' self-esteem and self-worth. Findings: During an observation on 1/21/25 at 10:00 a.m., a posted sign at the nursing station 2 read the lunch meal would be served at 11:30 a.m. daily. The sign indicated dining room was first served. During an observation on 1/21/25 at 11:30 a.m., eight residents were seated at three different tables in the dining room. During an observation on 1/21/25 at 11:49 a.m., a food cart arrived in the dining room. Five residents seated at different tables were served and started eating. During an observation on 1/21/25 at 12:07 p.m., a second food cart arrived in the dining room. The remaining three residents were served. During an interview on 1/21/25 at 12:09 p.m., Resident 36 indicated she frequently had to wait because meals were not served at the same time in the dining room. Resident 36 stated it bothered her and made her sad to wait and watch others eat. During a record review of policy Meal Service dated 2023 indicated All residents at the same table should be served at the same time. During a record review of Resident Council Meeting Minutes dated 7/17/24, three residents voicing concern over trays being delivered at very different times.

Based on interviews and record reviews, the facility failed to ensure medications were administered timely for three out of three sampled residents (Residents 11, 32 and 45). This failure put Residents 11, 32 and 45 at significantly increased risk of worsened health condition, untreated symptom, and complications from untreated symptoms. Findings: A review of Resident 11s face sheet indicated an admitted [DATE] with a diagnoses of Weakness, Hypertension (HTN, high blood pressure) and Hyperlipidemia (HLP, high levels of fat particles (lipids) in the blood. Resident 11s BIMS dated 11/19/24 score was 15 indicating intact cognition. A review of Resident 11s MAAR indicated 2 medications were administered late on 1/19/25: Insulin injection scheduled time was 6:30 a.m. and was not administered until 8:15 a.m. and Insulin injection scheduled time was 4:30 p.m. and was not administered until 5:41 p.m., A review of Resident 11s MAAR indicated at least 2 medications were administered late on 1/21/24: Vasoconstrictor scheduled time was 6:30 a.m. and was not administered until 08:25 a.m., and Insulin injection scheduled time was 6:30 a.m. and was not administered until 8:19 a.m. A review of Resident 32s face sheet indicated an admitted [DATE] with a diagnoses of Weakness, HTN, and HLP. Resident 32s BIMS dated 11/7/24 score was 15 indicating intact cognition. A review of Resident 32s MAAR indicated 2 medications were administered late on 12/6/24: 2 antidiabetic medications were scheduled at 7:00 a.m. but was not administered until 8:07 a.m. A review of Resident 45s face sheet indicated an admitted [DATE] with a diagnoses of Dysphagia (difficulty swallowing), Insomnia (a sleep disorder where a person have trouble falling asleep, staying asleep, or both). Resident 45s BIMS dated 12/30/24 score was 12 indicating moderately impaired cognition. A review of Resident 45s MAAR indicated at least 8 medications were administered late on 1/19/25: Insulin injection scheduled time was 8:00 a.m. and was not administered until 12:10 p.m., 2 Antihypertensive medication scheduled time was 8:00 a.m. 1 was not administered until 12:16 p.m. and the other was not administered until 12:17 p.m., Antiarrhythmic medications (used to treat abnormal heart beats) medication scheduled time was 8:00 a.m. and was not administered until 12:16 p.m., Blood thinner medication scheduled time was 8:00 a.m. and was not administered until 12:16 p.m., water pill medication scheduled time was 8:00 a.m. and was not administered until 12:16 p.m., The afternoon medications potassium supplement scheduled time was 4:00 p.m. and was not administered until 6:41 p.m., Antihypertensive medication scheduled time was 4:00 p.m. and was not administered until 6:41 p.m., A review of Resident 45s MAAR indicated at least 6 medications were administered late on 1/20/25: 2 Antihypertensive medication scheduled time was 8:00 p.m. and was not administered until 9:48 a.m. and 9:49 a.m., water pill medication scheduled time was 8:00 a.m. and was not administered until 9:49 a.m., Potassium supplement scheduled time was 8:00 a.m. and was not administered until 9:46 a.m., blood thinner scheduled time was 8:00 p.m. and was not administered until 9:49 a.m., Antiarrhythmic medication scheduled time was 8:00 a.m. and was not administered until 9:49 a.m., During an interview on 11/23/25 at 10:15 a.m., Resident 45 stated staff were usually late in administering her medications. Resident 45 stated she wished staff were more cognizant of giving her medications timely. During an interview on 1/22/25 10:36 a.m., Resident 11 stated staff would give her medications late most of the time. Resident 11 stated it was important for her to receive her medications timely. During a concurrent interview and Residents 11, 32 and 45s MAAR record review on 1/23/25 at 2:14 p.m., the Director of Nursing (DON) verified there were medications that were administered late for Resident 11 on 1/19/25 and 1/21/25, Resident 32 on 12/6/24 and Resident 45 on 1/19/25 and 1/20/25. The DON stated it was important to follow the physician's orders and to administer medications on time to prevent medication errors and for residents' safety. The DON stated to consider a medication was administered timely, a medication should be given within 1 hour before and 1 hour after the scheduled time. During an interview on 1/23/25 at 2:10 p.m., Licensed Nurse (LN) K stated, in order for a medication to be administered timely, the medications should be administered 1 hour before up to 1 after the scheduled time. LN K stated it was important to follow this time frame because it was a physician's order and for residents' safety. LN K also stated giving the medications timely reduced the risk of error in drug administration. A review of the facility's policy and procedure (P&P) titled Medication Administration-Oral, revised 11/2019, the P&P indicated . the purpose was to ensure safe, accurate, and effective administration of medication while maintaining compliance with state, federal including California Department of Health guidelines .no medication is to be administered without a physician's written order .Accurate and timely administration according to MD (physician) order is essential. California Advocates for Nursing Home Reform (CANHR), published on 10/24/22 indicating the time frame for medication administration. It stated A drug, whether prescribed on a routine, emergency, or as needed basis, must be provided in a timely manner. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. https://canhr.org/nursing-home-care-standards/#

Based on observation, interviews and record reviews, the facility failed to ensure: 1. the opthalmic (eye) suspension medication of one out of two sampled residents (Resident 4) was labeled properly when the physician's order had changed. 2. the discontinued level II-V medications (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) were stored in a permanently affixed compartment prior to destruction. These failures had the potential to cause medication errors and/or lead to drug diversion. 1. Findings: A review of Resident 4s face sheet (demographics) indicated an admitted [DATE] with a diagnoses of Low Back Pain and Weakness. A review of Resident 4s Physician Order Summary (POS, a written physician order/instruction for staff to follow) indicated an order of ophthalmic (eye) suspension 1 percent (%, one part in every hundred) instill 1 drop (gtt) in left eye two times a day dated 1/20/25 for herpes viral keratitis (infection of the eye caused by the herpes simplex virus (HSV). During a concurrent observation and interview on 1/22/25 at 9:38 a.m., Registered Nurse (RN) I confirmed the label on the ophthalmic suspension 1% indicated to instill 1 gtt on left eye three times daily. RN I stated this label was inaccurate since the order was changed to instill 1 gtt in left eye two times daily with a start date on 1/21/25. RN I confirmed the label for the ophthalmic suspension 1% was incorrect. During an interview on 1/22/25 at 11:21 a.m., RN I stated the medication orders in the POS, electronic medication administration record (EMAR, digital version of the traditional paper medication administration records) and the medication label should all match to prevent confusion and medication error. During an interview on 1/22/25 at 12:00 p.m., the Infection Preventionist (IP) stated labels on medications including instructions should match what was on EMAR and POS to ensure safe medication administration, to ensure right dose was being administered to the resident and to prevent medication error. During an interview on 1/22/25 at 12:06 p.m., the Director of Nursing (DON) stated medication labels should match the POS and EMAR to prevent medication error and to ensure residents were receiving the correct medication and dose. A review of the facility's policy and procedure (P&P) titled Medication Ordering and Receiving From Pharmacy updated 9/2019, the P&P indicated .only the dispensing pharmacy /registered pharmacist can modify, change or attach prescription labels .if the physician's directions for use have changed, the nurse may place change of order- check chart label on the container indicating there is a change in directions for use. 2. During a concurrent observation and interview on 1/23/25 at 8:34 p.m. it was noted the discontinued controlled drugs/narcotics were stored in a safe not permanently affixed to a compartment. The Director of Nursing (DON) verified the discontinued controlled drugs were kept in this safe. The DON confirmed the safe was not in a permanently affixed compartment. A review of the Comprehensive Drug Abuse Prevention and Control Act of 1976 indicated the facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II and other drugs subject to abuse.

Based on observation, interviews and record reviews, the facility allowed one out of two sampled residents (Resident 11) to self-administer medications without the Interdisciplinary Team (IDT, a collaborative approach that combines data, techniques, and perspectives from multiple disciplines) determining if self-administration was clinically appropriate for Resident 11. This failure was a safety issue which could lead to dosing errors and ineffective symptom management. Findings: A review of Resident 11s face sheet (demographics) indicated an admitted [DATE] with a diagnoses of Weakness, Hypertension (HTN, high blood pressure) and Hyperlipidemia (HLP, high levels of fat particles (lipids) in the blood. During a concurrent observation and interview on 1/22/25 at 10:36 a.m., there was a medicine cup with 4 1/2 tablets noted on top of Resident 11's overbed table. Resident 11 stated the morning nurse left it there. Resident 11 could not recall the name of the pills but knew one of them was tramadol (opioid analgesic and had high potential for misuse and abuse). Resident 11 stated nurses occasionally would leave medications at her bedside and allowed her to self-administer her medications. Resident 11 stated staff did not perform any assessments to determine whether it was safe and appropriate for her to self-administer her medications. During an interview on 1/22/25 at 11:21 a.m., when shown a photograph of the medication cup containing 4 1/2 tablets on top of Resident 11s overbed table, Registered Nurse (RN) I verified these medications were Resident 11s medications and the 1/2 pill was tramadol. RN I stated she could not recall why the medications were left at Resident 11s overbed table. RN I stated leaving medications at bedside should not happen and was a safety issue as other residents may accidentally take the medications, residents may not take the medications and could end up having pain. RN I could not recall whether an assessment was done to check if Resident 11 was safe to self-administer her medications. During an interview on 1/22/25 at 12:07 p.m., the Director of Nursing (DON) stated medications should not be left at bedside if they did not have an order and if they did not have an assessment indicating they were safe to self-administer their medications. The DON stated leaving medications at bedside was a safety issue and could lead to other residents accidentally ingesting medications not meant for them. During an interview on 1/24/25 at 9:10 a.m., the DON verified there were no assessment done to determine if Resident 11 was safe to self-administer her medications. The DON verified there were no IDT assessment or progress note that would indicate Resident 11 was assessed for safety and appropriateness to self-administer her medications. A review of the facility's policy and procedure (P&P) titled Self-Administration of Medication, revised 8/2024, the P&P indicated .if a resident desires to participate in self administration, the IDT will assess and periodically re-evaluate the resident based on change in resident status .

Based on interviews and record reviews, the facility failed to ensure: 1.there were adequate staff to care for the residents at the facility when three out of three sampled residents (Residents 1, 2 and Anonymous 1) complained the facility was short staffed and staff would take a long time to answer their call lights. 2.the Abuse Policy and Procedure (P&P) were updated to reflect correct reporting guidelines and staff were aware on which agencies to report abuse allegations and the reporting time frame for abuse allegations. These failures: 1a. resulted in residents feeling frustrated, upset and worried nobody will answer their call light on time in case of emergency. This also had the potential for neglect, late provision of care or care not being provided at all. 2a. had the potential for abuse to not be reported to the appropriate agency timely and could result in ongoing abuse and safety risk for the resident. Findings: A review of Resident 1's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. His diagnoses included Essential Hypertension (high blood pressure), Type 2 Diabetes Mellitus (DM, a chronic (long-lasting) health condition that affects how your body turns food into energy) and Primary Osteoarthritis (OA, a type of arthritis that only affects the joints, usually in the hands, knees, hips, neck). His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 3/22/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 12 indicating moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 2's face sheet (demographics) indicated she was initially admitted to the facility on [DATE]. Her diagnoses included Type 2 DM, Chronic Pain Syndrome (CPS, pain lasting for more than 3 months, symptoms include pain, itching, numbness, and loss of sensation) and Gout ( a painful form of arthritis- joint inflammation caused by uric acid crystals a chemical created when the body breaks down substances called purines) that form in and around the joints. Her MDS, dated [DATE], BIMS score was 15 indicating intact cognition. During an interview on 4/11/24 at 1:09 p.m. Unlicensed Staff A stated the facility was short staff especially on the weekends and she usually had between 8 up to 12 residents to care for in the morning shift. Unlicensed Staff A stated it was hard to finish her task on time. Unlicensed Staff A stated short staffing could lead to residents' neglect, late provisions of care and increased fall incidents and injury. Unlicensed Staff A stated short staffing was a safety risk. During an interview on 4/11/24 at 1:46 p.m., Resident 1 stated he felt the facility could improve their staffing as sometimes staff takes a while to answer calls for help. Resident 1 stated it could be frustrating to wait for a long time when you needed help. Resident 1 stated he was worried nobody would see him and answer his call light on time in case of an emergency. During an interview on 4/11/24 1:58 p.m., Licensed Staff B stated the facility was short staffed when there were call off. Licensed Staff B stated short staffing meant little more time allotted per each resident. Licensed Staff B stated short staffing could lead to late provision of care and wait time for staff to answer residents call light could be longer. Licensed Staff B also stated short staffing was a safety risk for the residents. During an interview on 4/11/24 at 3:20 p.m., Licensed Staff C stated the facility was short staffed. Licensed Staff C stated it would be beneficial for the residents if the facility was adequately staffed. Licensed Staff C stated short staffing made it difficult for her to complete her task safely and timely. Licensed Staff C stated short staffing could lead to late provision of care, care not being rendered at all, residents' change of condition (COC, a change in the residents' health or functioning) could be missed which could be a safety issue for the resident. During an interview on 4/11/24 at 3:23 p.m., Resident 2 stated the facility was short staffed. Resident 2 stated there were not enough staff to care for the residents at the facility. Resident 2 stated during resident council (an independent group of long-term care facility residents who typically meet at a minimum of once a month to discuss concerns and suggestions in the facility and to plan activities that are important to them) meeting, she had also heard residents complained of short staffing and staff taking a long time to answer call lights. Resident 2 stated she felt frustrated and concerned about short staffing. Resident 2 stated despite being discussed in resident council, short staffing was still happening in the facility. During an interview on 4/11/24 at 3:40 p.m., Anonymous 3 stated the facility was short staffed. Anonymous 3 stated she had to wait for 1 up to 2 hours before staff answers her call light. Anonymous 3 stated staffing was bad at nighttime. Anonymous 3 stated about a month ago, she was left soiled on her brief, and it took about an hour for staff to change her brief. Anonymous 3 stated it was embarrassing and frustrating. Anonymous 3 stated she hoped the facility would have adequate staff to care for the residents. During an interview on 4/11/24 at 3:57 p.m., Unlicensed Staff D stated the facility was short staffed. Unlicensed Staff D stated taking care of 12 to 13 residents on morning shift was a lot. Unlicensed Staff D stated short staffing was a safety risk for the residents. Unlicensed Staff D stated short staffing could lead to late provision of care and staff rushing residents to complete their task. During a telephone interview on 4/11/24 at 4:14 p.m., the Interim Director of Nursing (DON) stated that at this time the facility was struggling with short staffing. The Interim DON stated some staff had left due to issues with short staffing. The Interim DON stated short staffing could result to decreased quality of care. Based on the staffing documentation provided by the facility, it indicated that on these dates, the CNAs had a higher number of residents to care for on these dates: 3/1/24 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/2/24, the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/3/24 the facility had a census of 49, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/6/24 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/10/24 the facility had a census of 49, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/15/16 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/16/24 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/24/24 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. A review of the facility's policy and procedure (P&P) titled Staffing, Adequate , revised 1/2024, the P&P indicated it was the policy of the facility to provide adequate staffing to meet the needs of the resident population. B. During an interview on 4/11/24 at 1:14 p.m., Licensed Staff A stated abuse allegation should be reported as soon as possible within 4 hours. Licensed Staff A stated if an abuse allegation was not reported timely, it could lead to continued abuse, further abuse and worst case scenario, injury or death to the resident. During an interview on 4/11/24 at 1:30 p.m., the Occupational Therapist (OT) stated abuse allegations were only reported to the Ombudsman (an independent official who has been appointed to investigate complaints) and should be reported within 24 hours. The OT stated if an abuse allegation was not reported timely, it could result to further abuse, psychological harm and neglect. During an interview on 4/11/24 at 1:44 p.m., Unlicensed Staff A stated abuse allegations should be reported to the Ombudsman (an official who investigates complaints) and State (CDPH, the state department responsible for public health in California) within 24 hours. Unlicensed Staff A stated, if an abuse allegation was not reported timely, it could result to ongoing abuse. Unlicensed Staff A stated it was a safety issue to the resident if an abuse allegation was not reported timely. During an interview on 4/11/24 at 2:08 p.m. Licensed Staff B stated abuse allegation should be reported to the Ombudsman, the State and the local police as soon as possible within 24 hours. Licensed Staff B stated if an abuse allegation was not reported to the appropriate agencies and was not reported timely, residents could be at risk for neglect, ongoing abuse. Licensed Staff B stated not reporting an abuse timely was a safety risk, residents would not feel safe in the facility and residents would not feel staff were protecting them. During an interview on 4/11/24 at 2:33 p.m., the Interim DON stated abuse allegations with injury should be reported to the Ombudsman and the CDPH within 24 hours. The Interim DON stated if there was no injury, there would be no need to report the abuse allegation to the local police. The Interim DON stated if an abuse allegation resulted in injury, it should be reported to the Ombudsman, CDPH and the local police within 2 hours. During an interview on 4/11/24 at 3:57 p.m., Unlicensed Staff D stated abuse allegations should be reported to the Ombudsman within 24 hours. Unlicensed Staff D stated if an abuse allegation was not reported timely, it could lead to continued abuse and resident could get hurt. A review of the facility's policy and procedure (P&P) titled Abuse Prevention Program , revised 11/2022, the P&P indicated when an incident or allegation of resident abuse was reported, the allegation will be reported within 24 hours to the appropriate agency.

Based on dietetic services observations, dietetic staff and Registered Dietitian interview and departmental document review the facility failed to ensure meals were prepared in a sanitary manner, in accordance with standards of practice and departmental procedures as evidenced by 1) holding of foods for extended periods of time at a temperature which may promote bacterial growth; 2) vegetable preparation without prior washing; 3) use of wiping cloths that were not immersed in a chemical sanitizer; 4) undated, thawed nutrition supplements; 5) multiple kitchen areas and equipment that were not clean and 5) storage of scoops in shelf stable foods. Failure to follow standardized sanitation practice may result in bacterial growth associated with foodborne illness, cross contamination of foods, retention of expired items and create an environment that supports a vermin infestation. Findings: 1. Foods which require time/temperature control for food safety include protein-based products such as meat as well as starch-based products such as cooked rice. These foods are often called potentially hazardous foods (PHFs) and have the capability of supporting bacterial growth associated with foodborne illness. The temperature range of 41 F (degrees Fahrenheit) to 135 F is the range when PHFs are most susceptible to bacterial growth. Food kept without temperature control allows products to warm or cool as it equilibrates with the environment. Each food incurs different risks regarding the type of foodborne pathogens able to grow and the rate of growth likely to occur. For both cooling and warming conditions, growth depends on the amount of time the food spends in an optimum growth temperature range. Several factors influence the rate of temperature change in a food, such as the type of food, thickness of the food, and temperature differential between the food and its surroundings. When evaluating the safety of a 4-hour limit for food with no temperature control, products and environmental parameters must be selected to create a worst-case scenario for pathogens growth and possible toxin production (USDA Food Code Annex, 2022). During initial tour on [DATE] beginning at 12:30 p.m., there was a one-half sized deep steam pan as well as a one-quarter sized deep pan on the steam table containing fried rice. In a concurrent interview Dietary Staff (DS) 2 stated the item was just prepared. The smaller pan was for residents with fruit allergies and the larger one was for the remaining diets. DS 2 stated the items were for dinner meal distribution which would start at 5:15 p.m. In a follow up observation on [DATE] at 3:05 p.m., the internal temperature of the rice was 102 F. An additional observation on [DATE] at 5:20 p.m., revealed the temperature of the rice was 168 F. In a concurrent interview DS 2 stated she turned down the temperature of the steam table then turned it back up around 4:30 p.m. DS 2 also indicated she has been working at the facility for approximately 2 months. She stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any training and was never instructed on what time to begin preparing meals. Departmental policy titled Food Preparation dated 2023 instructed staff to .5. Prepare food as close as possible to serving time .7. Hold foods prior to service for as short a time as practical. A maximum 1-hour holding time is recommended . 2. During cold food production observation on [DATE] beginning at 4 p.m., DS 2 was observed preparing a salad for the evening meal. DS 2 obtained cucumbers and tomatoes from the walk-in refrigerator, placed them on the food production counter, placed pre-washed lettuce in small bowls and proceeded to peel the cucumbers and cut the tomatoes without prior washing. Facility policy titled Food Preparation dated 2023 listed the process for preparation of vegetables as washing fresh vegetables thoroughly under running water before cutting or peeling. 3. It is the standard of practice to ensure cloths used for wiping counters and other equipment surfaces, shall be held between uses, in a chemical sanitizer solution (USDA Food Code, 2023). During intermittent food production and meal distribution observations on [DATE] from 2:35 p.m., through 6:15 p.m., there were two dry [NAME] towels on the food production counter. It was noted that both DS1 and DS2 would intermittently use these towels to wipe food particles from food production surfaces. 4. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated. Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. Studies regarding the rigor required to remove biofilms from smooth surfaces highlight the need for materials of optimal quality in multiuse equipment. The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. The requirement for easy disassembly recognizes the reluctance of food employees to disassemble and clean equipment if the task is difficult or requires the use of special, complicated tools. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (USDA Food Code Annex, 2022). During initial tour on [DATE] beginning at 12:30 p.m., in the kitchen, the following was observed: a. The shelving in the walk-in refrigerator was not clean. The shelves had a black fuzzy material resembling mold, which was wipeable with a paper towel, on all the shelves. Similarly, the floor was soiled with unidentified food particles and dried on liquids. There were also multiple areas that had a brown material resembling rust on the walls of the unit. The crevices and wall projections had a buildup of brown, sticky unidentified material. b. In the walk-in refrigerator there were 2 nutritional supplements in a steam pan, with ice that were undated. It was also noted there was an opened case, containing greater than 10 supplements, which were thawed and undated. There was also an undated salad plate, where the edges of the lettuce turned brown; an undated cardboard box of approximately 4 cups of sliced mushrooms that were dark brown, rather than tan colored; a to-go container dated [DATE] with no label; and an employee ' s commercially prepared coffee drink dated [DATE]. In an interview on [DATE] at 11:45 a.m., Regional Dietary Staff (RDS) acknowledged stored items needed to be labeled with a use by date. Facility policy titled Procedure for Refrigerated Storage dated 2023 indicated .14. Supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. Follow the manufacturer ' s recommendations (specifications) for shelf life. c. There were multiple areas of the kitchen that were not clean. The plate warmer unit had a build-up of black grease-like material on the crevices around the plate holding chamber as well as around the rubber stoppers and indicator lights. There were greater than 5 clear food storage containers that had a build-up of labeling stickers on the outside. It was also noted the storage containers had dried, unidentified food particles. There was a buildup of grey material, resembling dust, on all protruding surfaces such as light and electrical switches, plumbing and electrical cords on equipment. The floor sinks in the kitchen were not clean. They contained unidentified food particles as well as brown and black discolorations. Floors throughout the kitchen had scattered food particles. The wall underneath the window had peeling paint exposing the drywall underneath. There were also towels on the floor underneath the wire rack adjacent to the dry storage area. The steam table was not clean, the knobs had a buildup of a tan/black stick substance resembling grease. The surfaces of the shelving beneath the steam table were also compromised as it had multiple areas of a brown material, resembling rust. Similarly, the drying mats underneath the steam table were not clean. There was a build-up of brown liquid resembling dried coffee on, behind and beneath the coffee maker. The integrity of the trays holding cleaned/sanitized serving items were not clean and were compromised in multiple areas with cuts, like a knife cut. There were multiple portable ventilation units all of which were covered with unidentified food particles and a grey fuzzy material resembling dust. The ceiling around the main vent in the kitchen was covered with grey fuzzy material, resembling dust. The light fixtures (ballast) adjacent to the window were not covered and appeared to have a retrofitted LED light strip, rather than the manufacturers specifications of fluorescent tubing with cover. The surface of greater than five baking sheets were black and brown resembling burned on oils and the byproduct of an aluminum oxidation process. On the food production surface adjacent to the steam wells there was a hole measuring approximately 1 inch in diameter in the countertop. There was a buildup of dried on food particles inside the hole. In an interview on [DATE] beginning at 4:45 p.m., DS 2 stated each employee is responsible for cleaning their own area, however, was unfamiliar whether there was a cleaning checklist. In an interview on [DATE] at 10:45 a.m., the Administrator stated to his knowledge there was no outside vendor contract for deep cleaning dietetic services. In an interview on [DATE] at 11:45 a.m., RDS stated she was unable to locate any current cleaning logs but was able to offer two untitled documents dated February/March and February 2023. While the department had two basic cleaning checklists, one for the cook and a second for the diet aide that included equipment surfaces such as cleaning the stove top, spice shelf, cleaning ovens and under the steam table, cleaning drains and wiping down multiple surfaces the checklist did not fully reflect the equipment present or the necessary cleaning tasks for the department. As an example, there was no mechanism to clean the shelving or floors in the walk in or other pieces of equipment. It was also noted for the cleaning list intended for the cook cleaning tasks were limited to 2 of 7 days. Departmental document titled Sanitation and Food Safety Checklist dated [DATE], which was not completed by the RD, rather by the RDS, noted there were multiple areas in the kitchen that were not clean, including but not limited to baseboards, dry storage area and food production related equipment. While the RDS identified the lapses in sanitation there was no indication the facility addressed the issues. Facility Policy titled Storage of Food and Supplies dated 2023 noted 4. All shelves and storage racks .and promote easy and regular cleaning .5. Routine cleaning and pest control procedures should be developed and followed . Facility document titled Work History Report dated [DATE] and beginning [DATE] revealed the only outside work orders for the department were listed as services related to the fire suppression system. Facility policy titled Sanitation dated 2023 indicated it was the Director of Food Services (DFS) who was responsible for comprehensive training for sanitation. The policy also indicated the Maintenance Department will assist in janitorial duties the dietary employees cannot do. The policy indicated ceilings and vents were to be cleaned by maintenance staff. Additionally, the policy indicated all areas of the kitchen, and equipment will remain clean, in good repair and free from breaks, corrosions and open seams. d. In the food production area, staff were storing serving scoops inside an unlabeled/undated container, identified by DS 1 as thickener. There was also an undated/unlabeled container containing a small tan pearl sized product, identified by DS 1 as mashed potatoes. Similarly, dietary staff were storing scoops in dry cereal, and flour. There was also a bag of flour in a rolling bin that was stored in the original shipping bag. Additionally, there was a box of lasagna noodles that was opened, and not resealed leaving it susceptible to contamination. Facility policy titled Storage of Food and Supplies dated 2023 guided staff to .7. Remove foods from packing boxes upon delivery .9. Dry food items which have been opened ., noodles, etc. will be tightly closed labeled and dated . Facility policy titled Ingredient Bins dated 2023 guided staff 6.If using a bag inside the bin it is to be of food grade quality. 7. Scoops used in bins must NOT be left in the bin .

Based on dietetic services observations, dietary and administrative staff interview and departmental document review the facility failed to ensure staff competency as evidenced by lack of training and orientation of 2 of 2 dietary staff (Dietary Staff 1 and 2) members present during the abbreviated survey. Findings: 1. During meal distribution observation on 9/11/23 beginning at 5:15 p.m., the evening meal consisted of soy glazed pork, pineapple fried rice, spinach salad and fresh fruit. It was noted except for the texture altered diets all residents received the same meal tray. In a concurrent interview the surveyor asked DS 2 the meaning of fortified on the tray tickets. DS 2 stated the terminology indicated residents were losing weight and needed to gain fat. In an interview on 9/11/23 at 4:30 p.m., DS 2 indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any additional training, was not given guidance for food preparation, however, was interested in acquiring the skills necessary to do her job well. Departmental job description titled Cook dated 12/27/21 indicated it was the responsibility of this position to prepare food for therapeutic diets. 2a. During initial tour on 9/11/23 beginning at 12:30 p.m., there was a one-half deep steam pan as well as a one-quarter deep pan on the steam table containing fried rice. In a concurrent interview Dietary Staff (DS) 2 stated the item was just prepared. The smaller pan was for residents with fruit allergies and the larger one was for the remaining diets. DS 2 stated the items were for dinner meal distribution which would start at 5:15 p.m. In a follow up observation on 9/11/23 at 3:05 p.m., the internal temperature of the rice was 102 F. An additional observation on 9/11/23 at 5:20 p.m., revealed the temperature of the rice was 168 F. In a concurrent interview DS 2 stated she turned down the temperature of the steam table then turned it back up around 4:30 p.m. DS 2 also indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any training and was never instructed on what time to begin preparing meals. Departmental job description titled Cook dated 12/27/21 indicated it was the responsibility of this position to prepare food in accordance with sanitary regulations. b. During cold food production observation on 9/11/23 beginning at 4 p.m., DS 2 was observed preparing a salad for the evening meal. DS 2 obtained cucumbers and tomatoes from the walk-in refrigerator, placed them on the food production counter and proceeded to peel the cucumbers and cut the tomatoes without prior washing. Departmental job description titled Cook dated 12/27/21 indicated it was the responsibility of this position to prepare food in accordance with sanitary regulations. c. It is the standard of practice to ensure cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution (USDA Food Code, 2023). During intermittent food production and meal distribution observations on 9/11/23 from 2:35 p.m., through 6:15 p.m., there were two dry [NAME] towels on the food production counter. It was noted that both DS1 and DS2 would intermittently use these towels to wipe food particles from food production surfaces. Departmental job description titled Cook dated 12/27/21 indicated it was the responsibility of this position to prepare food in accordance with sanitary regulations. 3. During initial tour on 9/11/23 beginning at 12:30 p.m., in the dry storage area it was noted there was a plastic thermometer hanging on the wall, however the glass tube containing the red dye colored alcohol liquid, which depicts the room temperature, was missing. In a follow up observation on 9/11/23 at 1:30 p.m., it was there was a document titled Dry Food Storage Temperature Log dated September 2023 hanging on the wall next to the door. There were 2 entries for each day (morning and evening). The entries were consistently 61 F (degrees Fahrenheit). Above the log there was an electronic remote digital device that was labeled kitchen. The device indicated a reading of 61 F. The surveyor placed a thermometer on the electrical outlet underneath the document, registering a temperature of 73 F. In an interview on 9/11/23 at 4 p.m., Dietary Staff (DS) 1 indicated the log was filled out twice daily by the diet aides. The surveyor indicated this device was a remote-control unit for the air conditioner, rather than a room temperature monitoring device. DS 1 stated the log was put up recently and he was told to just record the temperature on the device. DS 1 stated this was his first employment position and he was not provided any additional guidance or training. Facility policy titled Storage of Food and Supplies dated 2023 noted 1 .Thermometers should be placed in all storage areas and checked frequently . Review of facility training transcript for DS 1 revealed general standardized training modules, eight of which had a foodservice component. It was also noted the cumulative time spent in the eight modules was recorded as less than 2 hours. The facility was unable to provide any additional training documentation. The facility also presented a document titled Verification of Job Competency Demonstration-Diet Aides dated 2023 listed DS 1 as verbally competent, however there was no evidence to support any formal training. There was no indication on what the verbal confirmation consisted of, the specific date, time and duration of the competency determination. The competency documents for DS 1 also included a Competency Test for Cools and FNS [food and nutrition staff] dated 7/14/23. It was noted 3 of 12 questions had an incorrect answer, however the supervisor marked that 12 out of 12 questions were correct. An identical test was given to DS 2 who did not answer one question, yet the test was marked as 12 out of 12 correct. Review of the training record for DS 2 indicated the training was limited to administrative topics such as caring for those with cognitive impairment, drug diversion in healthcare, abuse and sexual harassment training. There was no documentation of any training related to dietetic services. The facility presented a Verification of Job Competency Demonstration-Cooks dated 2023, listing competency was primarily determined through verbal confirmation, however there is no indication on what the verbal confirmation consisted of or the specific date, time and duration of the competency determination. Review of positions description titled Cook indicated one year of dietary experience in a licensed facility was desired, but not necessary. The position description titled Dietary Aide indicated there was no required education or experience required and On the job training provided. While the facility provided check off lists for competency assessment there was no indication of comprehensive training for Dietary staffs 1 or 2.

Based on dietetic services observations and administrative and dietetic staff interview the facility failed to ensure frequent and comprehensive consultative departmental oversight by a Registered Dietitian and to employ a qualified Director of Food Services for day-to-day management duties. Failure to provide an organizational structure led by qualified staff, in a consistent manner, resulted in lapses related to staff competency, safe food handling practices, ineffective meal distribution and poor sanitation practices in dietetic services. Failure to develop staff and systems in accordance with regulatory requirements and professional standards may result in practices that put residents at risk for foodborne illness, decreased meal intake further compromising the medical status of 44 residents receiving meals from the facility dietetic services. Findings: During the abbreviated survey on 9/11/23 between the hours of 12:30 p.m. and 6:30 p.m., and on 9/12/23 between the hours of 9:30 a.m., and 12:30 p.m., there were multiple lapses in dietetic services oversight by qualified individuals (Cross Reference F 812, F802, and 808). During entrance on 9/11/23 at 12:30 p.m., the Administrator indicated the Director of Food Services (DFS) was not in the facility, however, would return on 9/12/23. As of 9/12/23 at 12:30 p.m., the DFS was unavailable. Cross Reference 812 1. Foods which require time/temperature control for food safety include protein-based products such as meat as well as starch-based products such as cooked rice. These foods are often called potentially hazardous foods (PHFs) and have the capability of supporting bacterial growth associated with foodborne illness. The temperature range of 41 F (degrees Fahrenheit) to 135 F is the range when PHFs are most susceptible to bacterial growth. When evaluating the safety of a 4-hour limit for food with no temperature control, products and environmental parameters must be selected to create a worst-case scenario for pathogens growth and possible toxin production (USDA Food Code Annex, 2022). During initial tour on 9/11/23 beginning at 12:30 p.m., there was a one-half deep steam pan as well as a one-quarter deep pan on the steam table containing fried rice. In a concurrent interview Dietary Staff (DS) 2 stated the item was just prepared. The smaller pan was for residents with fruit allergies and the larger one was for the remaining diets. DS 2 stated the items were for dinner meal distribution which would start at 5:15 p.m. In a follow up observation on 9/11/23 at 3:05 p.m., the internal temperature of the rice was 102 F. An additional observation on 9/11/23 at 5:20 p.m., revealed the temperature of the rice was 168 F. In a concurrent interview DS 2 indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any training and was never instructed on what time to begin preparing meals. 2. During cold food production observation on 9/11/23 beginning at 4 p.m., DS 2 was observed preparing a salad for the evening meal. DS 2 obtained cucumbers and tomatoes from the walk-in refrigerator, placed them on the food production counter, placed pre-washed lettuce in small bowls and proceeded to peel the cucumbers and cut the tomatoes without prior washing. 3. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period. Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. During initial tour on 9/11/23 beginning at 12:30 p.m., in the kitchen, the following was observed: a. The shelving in the walk-in refrigerator was not clean. The shelves had a black fuzzy material resembling mold, on all the shelves, which was wipeable with a paper towel. Similarly, the floor was soiled with unidentified food particles and dried on liquids. There were also multiple areas that had a brown material resembling rust on the walls of the unit. The crevices and wall projections had a buildup of brown, sticky unidentified material. b. In the walk-in refrigerator there were 2 nutritional supplements in a steam pan, with ice that were undated. It was also noted there was an opened case, containing greater than 10 supplements, which were thawed and undated. In an interview on 9/12/23 at 11:45 a.m., Regional Dietary Administrative Staff acknowledged stored items needed to be labeled with a use by date. c. There were multiple pieces of equipment and areas of the kitchen that were not clean. Examples include but are not limited to the plate warmer, steam table, clear food storage containers, grey material, resembling dust, on all protruding surfaces such as light and electrical switches, plumbing and electrical cords on equipment, the floor sinks in the kitchen were not clean, food production equipment and surfaces, walls and ceilings were not clean, multiple portable ventilation units all of which were covered with unidentified food particles or a grey fuzzy material resembling dust. In an interview on 9/11/23 beginning at 4:45 p.m., DS 2 stated each employee is responsible for cleaning their own area, however, was unfamiliar whether there was a cleaning checklist. In an interview on 9/12/23 at 10:45 a.m., the Administrator stated to his knowledge there was no outside vendor contract for deep cleaning dietetic services. In an interview on 9/12/23 at 11:45 a.m., Regional Dietary Administrative Staff stated she was unable to locate any current cleaning logs but was able to offer two untitled documents dated February/March and February 2023. Cross Reference 802 4a. During initial tour on 9/11/23 beginning at 12:30 p.m., there was a one-half deep steam pan as well as a one-quarter deep pan on the steam table containing fried rice. In a concurrent interview Dietary Staff (DS) 2 stated the item was just prepared. The smaller pan was for residents with fruit allergies and the larger one was for the remaining diets. DS 2 stated the items were for dinner meal distribution which would start at 5:15 p.m. In a interview n 9/11/23 at 5:20 p.m., DS 2 stated she turned down the temperature of the steam table then turned it back up around 4:30 p.m. DS 2 also indicated she has been working at the facility for approximately 2 months. She stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any training and was never instructed on what time to begin preparing meals. b. It is the standard of practice to utilize and follow standardized recipes. A standardized recipe is a set of written instructions used to consistently prepare a known quantity and quality of food for a specific location. A standardized recipe will produce a product that is close to identical in taste and yield every time it is made, no matter who follows the directions (University of Pennsylvania, Introduction to Food Production and Preparation, 2023). During food production observations on 9/11/23 beginning at 2:25 p.m., DS 2 was preparing the evening meal which consisted of soy glazed pork as an entree. DS 2 was observed placing 10 pounds of pre-cooked, diced pork, in a stock pot that contained sauteed onions. In a concurrent interview DS 2 indicated she was instructed to use a pre-cooked product. Concurrent review of departmental document titled Soy Glazed PorK guided staff to use raw pork cubes and browning them with the onions. Review of food invoices dated 9/4, 9/9 and 9/11/23 failed to indicate raw pork cubes were ordered in accordance with the standardized recipe. c. During cold food production observation on 9/11/23 beginning at 4 p.m., DS 2 was observed preparing a salad for the evening meal. DS 2 obtained cucumbers and tomatoes from the walk-in refrigerator, placed them on the food production counter and proceeded to peel the cucumbers and cut the tomatoes without prior washing. d. It is the standard of practice to ensure cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution (USDA Food Code, 2023). During intermittent food production and meal distribution observations on 9/11/23 from 2:35 p.m., through 6:15 p.m., there were two dry [NAME] towels on the food production counter. It was noted that both DS1 and DS2 would intermittently use these towels to wipe food particles from food production surfaces. 5. During initial tour on 9/11/23 beginning at 12:30 p.m., in the dry storage area, there was a plastic thermometer hanging on the wall, however the glass tube containing the red dye colored alcohol liquid, which depicts the room temperature, was missing. In a follow up observation on 9/11/23 at 1:30 p.m., it was there was a document titled Dry Food Storage Temperature Log dated September 2023 hanging on the wall next to the door. There were 2 entries for each day (morning and evening). The entries were consistently 61 F (degrees Fahrenheit). It was also noted above the log there was an electronic remote digital device that was labeled kitchen. The device indicated a reading of 61 F. In an interview on 9/11/23 at 4 p.m., Dietary Staff (DS) 1 indicated the log was filled out twice daily by the diet aides. DS 1 stated the log was put up recently and he was told to just record the temperature on the device. DS 1 stated he was not provided any additional guidance or training. Cross Reference F808 6. During meal distribution observation on 9/11/23 beginning at 5:15 p.m., the evening meal consisted of soy glazed pork, pineapple fried rice, spinach salad and fresh fruit. It was noted except for the texture altered diets all residents received the same meal tray. In a concurrent interview the surveyor asked DS 2 the meaning of fortified on the tray tickets. DS 2 stated the terminology indicated residents were losing weight and needed to gain fat. In an interview on 9/11/23 at 4:30 p.m., DS 2 indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any additional training, was not given guidance for food preparation, however, was interested in acquiring the skills necessary to do her job well. Review of posted document titled Fortified Foods-Week 2 guided staff to add an extra tablespoon of whipped topping to the fresh fruit dessert. Review of the facility diet list revealed there were 5 residents with physician ordered fortified diets. In an interview on 9/12/23 beginning at 9:45 a.m., the surveyor asked the Registered Dietitian (RD)to describe her typical tasks within the facility. The RD indicated she has been with the facility approximately 2 months, spending 10-12 hours per week. The RD described her duties as clinical, completing individual nutrition assessments as well as attending weight and skin committee meetings. The RD also indicated she attempted to connect with the DFS and was told by the DFS her guidance was not necessary as she was responsible for the kitchen. The RD also stated the kitchen door had a lock that required a code, she was not given and did not have access to the kitchen, therefore has not done an evaluation of the service, any staff training or provided guidance to the DFS. On 9/12/23 at 10:20 a.m., the qualifications of the DFS were reviewed in the presence of the Administrator and the RD. The Administrator presented copies of a State University diploma indicating the DFS had a Master of Science (M.S.) in Health Sciences awarded on 12/1/91; a private school of medicine certificate indicating she was a physician, a certificate with a diploma in holistic nutrition as well as a copy of an official transcript titled fitness and nutrition. None of these degrees/certificates would meet State regulatory qualifications for the DFS. In a concurrent interview the Administrator acknowledged the facility had not completed source verification of the presented educational degrees/certificates and thought a M.S. in health sciences would meet educational qualifications. He also stated human resources (HR) would have completed official verification of any educational materials presented. In an interview on 9/13/23at 2:13 p.m., the Activities Director whose position also incorporated HR duties indicated she does not do any verification for supervisory staff and provided a corporate contact. In an interview on 9/19/23 at 2:39 p.m., Administrative Staff 2 stated it is the responsibility of individual facilities to ensure staff are qualified for the positions hired. In a written communication from the State University Campus dated 9/13/23 at 11:56 a.m., ' .without any specific information about the person, we cannot specifically verify their degree but at this time we can verify from 1987 to current there was no Masters in Health Sciences offered . Review of departmental document titled Sanitation and Food Safety Checklist dated 7/27, 6/23 and 6/1/23 revealed during the previous 3 months the Registered Dietitian (RD) identified issues with cleanliness of the kitchen floors and equipment, labeling and dating of products, storage of scoops, the janitorial area was listed as a mess on the 6/23/23 report. The 6/1/23 report also indicated there were issues with dating, however there was no indication the identified issues were addressed or resolved by the facility.

Based on observations, interviews and records review, the facility failed to assess two of twelve sampled residents (Resident 23 and 38) who were identified at risk for pressure ulcer when: 1. The facility did not assess Resident 23's skin integrity under the left lower extremity (part of the body that includes the leg, ankle, and foot) immobilizer (removable devices that maintain stability of the knee) for a period of two weeks when nursing and therapy staff were providing care and treatment. This failure resulted to the development of a Suspected Deep Tissue Injury (SDTI - Intact or non-intact skin with localized area of persistent non-blanchable [when the skin is pushed and the area stays red, that means that there is little or no blood flow going to that area] deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister [(a painful skin condition where fluid fills a space between layers of skin]) to Resident 23's left heel. 2. The facility did not assess Resident 38's skin integrity to her left heel after an old pressure ulcer resolved. This failure resulted to the development of a stage two (Partial-thickness loss of skin with exposed dermis [middle layer of skin]) pressure ulcer in a form of a ruptured blister to Resident 38's left heel to which Resident 38 experienced pain and inability to relax when she repeatedly called out for help and moaned (to make a long, low sound of pain, suffering). Findings: Resident 23 During a record review for Resident 23, the Face sheet indicated Resident 23 was admitted on [DATE] with diagnoses including but not limited to Fracture of Shaft of Left Fibula (a break in the small bone that runs along the outside of the lower leg); Diabetes Mellitus (disease that result in too much sugar in the blood); Protein Calorie Malnutrition (when a person is not consuming enough protein and calories) and COVID (Corona Virus Disease - an infectious respiratory disease). During a record review for Resident 23, the document titled LN (Licensed Nurse) - Braden Scale for Predicting Pressure Sore Risk dated 2/07/23 indicated Resident 23 scored 13 indicating she was moderate risk for pressure ulcer. During a record review for Resident 23, the document titled LN - Initial Admission Record dated 2/07/23 indicated Resident 23 had an immobilizer to her left lower extremity. During a record review for Resident 23, the Care Plan initiated on 02/08/23 indicated, [Resident 23 had the potential for pressure ulcer development related to immobility, incontinence, and use of brace (a device used to immobilize a joint or body segment) to LLE (Left Lower Extremity). Care Plan interventions indicated, Monitor/document/report to MD (Medical Doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage; and Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 23, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 2/14/23 indicated Resident 23 had a BIMS score of 01 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 23 required extensive (resident involved in activity; staff provide weightbearing support) two-person physical assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). The MDS indicated Resident 23 was at risk for developing pressure ulcers. The MDS indicated Resident 23 did not have unhealed pressure ulcers during the assessment period. During a record review for Resident 23, the document titled SBAR (Situation, Background, Assessment and Recommendation - a tool used by health care professionals to communicate with each other about critical changes in patient's status) communication form dated 2/25/23 indicated Resident 23 was noted to have discoloration to her left heel that measured 7.5 cm (centimeter - a metric unit of length, equal to one hundredth of a meter) in length and 2.5 cm. in width. The document indicated Resident 23 was wearing immobilizer to her left foot. During a record review for Resident 23, the document titled Progress Note dated 2/28/23 at 11:17 a.m. indicated Resident 23 had a non-blanchable purple tissue with some dry well adherent eschar to her left heel. During a review of the Certified Nursing Assistant (CNA) job description dated 12/17/21 indicated essential duties and responsibilities for CNAs include but not limited to observe and report the presence of pressure areas and skin breakdowns to prevent pressure ulcers. During an interview with Licensed Staff G on 3/14/23 at 11:28 a.m., Licensed Staff G stated Resident 23's left leg was on immobilizer which caused a pressure ulcer to Resident 23's left heel. When Licensed Staff G was asked how often did nursing staff check the skin integrity under Resident 23's LLE immobilizer, she stated dressing to Resident 23's left knee was left untouched until the doctor said it was okay to remove the dressing. When Licensed Staff G was asked if there was an order to not remove the immobilizer, she stated there was no order. Licensed Staff G concurred Resident 23' LLE under the immobilizer should be checked daily for skin changes. During an interview and concurrent record review with Licensed Staff F on 3/15/23 at 10:13 a.m., when Licensed Staff F was asked how often did nursing staff check Resident 23's skin integrity under the LLE immobilizer, Licensed Staff F stated Resident 23's entire left leg was checked daily for skin changes and would document findings in Resident 23's record. Review of the document titled Nursing Weekly skin assessment for Resident 23 dated 3/14/23 with Licensed Staff F indicated the check box for current pressure ulcer was not checked. Licensed Staff F verified Resident 23 was receiving treatment to her left heel pressure ulcer. During an interview and concurrent record review with the Director of Rehabilitation (DOR) on 3/15/23 at 2:42 p.m. when asked whose responsibility to ensure, skin integrity under the immobilizer of Resident 23's left leg was not compromised, the DOR stated Physical Therapist (PT - A health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities) had to make sure Resident 23's skin under the left lower immobilizer did not have any skin problem every time PT provided treatment. The DOR stated PT would document their skin observation to Resident 23's record. During an interview and concurrent records review with the DON (Director of Nursing) on 3/15/23 at 2:51 p.m. when asked about her expectation from the nurses for resident who came with an immobilizer, the DON stated if the doctor gave an order to leave the immobilizer in place, then nurses were not allowed to remove the immobilizer; however, nurses could check for circulation like pulse and skin temperature. Review of the physician's order for February 2023 with the DON and verified there was no doctor's order to not remove Resident 23's LLE immobilizer. The DON stated if there was no order to leave the immobilizer in place, nurses should definitely check the skin integrity for changes under the immobilizer at least once a day and document. Review of Resident 23's Progress notes with the DON did not show any documentation from nursing staff indicating Resident 23's left heel was checked at least once a day for skin changes prior to the identification of the SDTI. During a review of the bathing record for Resident 23 with the Infection Preventionist (IP) on 3/16/23 at 2:29 p.m., the IP verified the bathing record from 2/15/23 to 3/16/23 indicated Resident 23 received bed bath once on 3/14/23 and no record of shower given. The IP stated CNAs would document skin changes to the shower sheet and give to the nurse for follow-up. IP was asked to provide shower sheets for Resident 23 from February 2023 to present; however, this writer did not receive shower sheets for Resident 23 at time of exit from the facility. Resident 38 During an observation and concurrent interview with Resident 38 in her room on 3/13/23 at 3:21 p.m., Resident 38 was sitting on her wheelchair, awake wearing a Prevalon heel protection boot (help reduce the risk of pressure ulcer by keeping the heel floated) to her left foot. Resident 38's top of left foot appeared swollen. When Resident 38 was asked if she had any concern with her skin, Resident 38 stated she believed she had an open area to her left foot and stated, it hurts. During a record review for Resident 38, the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the document titled LN - Braden Scale for Predicting Pressure Sore Risk (a tool to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer) dated 12/22/22 indicated Resident 38 had a total score of 14 (Total Score of 9 or less was Very High Risk; 10 to12 was High Risk; 13 to 14 was Moderate Risk; 15 to 18 was Mild Risk and 19 to 23 was No Risk). During a record review for Resident 38, the document titled Initial Care Plan dated 12/22/22 indicated Resident 38 had left heel pressure ulcer and potential for pressure ulcer. Care Plan intervention include but not limited to: daily body skin checks; Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 38, the MDS dated [DATE] indicated Resident 38 was at risk for developing pressure ulcers. The MDS indicated Resident 38 had an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead tissue that separates from living tissue in a wound) or eschar (dead tissue that sheds or falls off from the skin) that was present upon admission. During a record review for Resident 38, the document titled LN - Skin Pressure Ulcer Weekly dated 1/11/23 at 6:20 a.m. indicated Resident 38 had an unstageable pressure ulcer to left heel. During a record review for Resident 38, the document titled Skin Wound Note dated 1/17/23 at 1:22 p.m. indicated Resident 38's pressure ulcer to left heel was resolved. During a record review for Resident 38, the Care plan initiated on 1/18/23 indicated Resident 38 had the potential for pressure ulcer development related to Resident 38's history of pressure ulcer. Care Plan interventions include: Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 38, the document titled Progress Notes dated 3/9/23 at 3:54 p.m. indicated Resident 38 had a change of condition. The Progress Notes indicated Resident 38 had left hand and left leg swelling. During a record review for Resident 38, the document titled Progress Note dated 3/10/23 at 5:37 p.m. indicated doctor assessed Resident 38's swollen leg and ordered ultrasound (the standard imaging test for patients suspected of having acute DVT [Deep Vein Thrombosis - a blood clot forms in one or more of the deep veins in the body, usually in the legs]) to rule out DVT. The Progress Note also indicated Resident 38 was on monitoring for left heel blister. During a record review for Resident 38, the ultrasound report dated 3/14/23 indicated the ultrasound was performed on 3/14/23 at 4:23 p.m. The report indicated, There is extensive DVT involving left common femoral vein (a large blood vessel in your thigh), superficial femoral vein and popliteal vein (vein located behind your kneecap). During an observation in Resident 38's room on 3/14/23 at 8:57 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello. During an observation in Resident 38's room on 3/15/23 at 8:52 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello, and help. During an interview and concurrent record review with the DON on 3/15/23 at 3:12 p.m. when asked about facility process with skin assessment for residents who had previous pressure ulcers, the DON stated nurses were to do a weekly skin assessment and CNAs providing daily care like shower to residents would be able to identify any skin issues and would be reported to the nurse for further assessment. The DON verified there was no documentation from nursing staff indicating Resident 38's left heel was checked at least once a day for skin changes since Resident 38's old pressure ulcer resolved. During an observation in Resident 38's room on 3/16/23 at 8:29 a.m., Resident 38 was sitting on her wheelchair with a diabetic shoe on her left foot. Resident had facial grimacing, moaning, and repeatedly saying hello and help me. During an interview with Unlicensed Staff E on 3/16/23 at 9:11 a.m. when asked about resident's shower schedule, Unlicensed Staff E stated they give shower twice a week for all residents. Unlicensed Staff E stated they would do head to toe skin check when giving shower to residents; any skin changes would be documented to the shower sheet and would be given to the nurse. When Unlicensed Staff E was asked if he checked Resident 38's left heel when providing care, Unlicensed Staff E stated, no because her left leg was always wrapped. During an interview with Licensed Staff F on 3/16/23 11:24 a.m. Licensed Staff F stated she was not sure if Resident 38 was in pain, she stated it was normal for Resident 38 to call out and count loudly. When Licensed Staff F was asked how she would determine actual pain from behavior, Licensed Staff F stated she would observe for nonverbal indications of pain like facial grimacing, fidgeting, and restless; Licensed Staff F stated she would try to console Resident 38 and if it did not work, then it could be an indication that Resident 38 was in pain. Licensed Staff F stated Resident 38 received Tylenol (pain reliever) for two consecutive days and had asked Resident 38's doctor for a routine pain medication to manage potential pain from the pressure ulcer. During an interview with Licensed Staff B on 3/16/23 at 1:45 p.m., Licensed Staff B stated Resident 38's left heel blister would be a stage 2 pressure ulcer (Partial-thickness loss of skin with exposed dermis [middle layer of skin]) because it was a ruptured blister, and the location of wound was on a bony prominence. Licensed Staff B stated Resident 38 was super restless and moved her feet all the time. When Licensed Staff B was asked if Resident 38 having pressure ulcer on her left heel would experience pain, Licensed Staff B stated, she could. During a review of the bathing record for Resident 38 with the IP on 3/16/23 at 2:29 p.m., the IP verified the bathing record from 2/15/23 to 3/16/23 indicated Resident 38 received shower once on 3/11/23. The IP stated CNAs would document skin changes to the shower sheet and give to the nurse for follow-up. IP was asked to provide shower sheets for Resident 38 from February 2023 to present however, there were only two shower sheets received for 2/15/23 and 3/15/23. During an observation in Resident 38's room on 03/17/23 at 9:29 a.m., Resident 38 was on her bed with eyes closed, moaning. During a telephone interview with the Medical Director on 3/21/23 at 12:09 p.m. when asked about his expectation for resident skin assessment, the Medical Director stated daily skin assessment was very important for pressure ulcer prevention especially for residents who were at risk for pressure ulcer. Review of the Facility policy titled Skin and Wound Monitoring and Management revised on 1/2022 indicated, A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed injury was unavoidable; and A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Procedure indicated: - It is understood that a resident may experience pain associated with the presence of skin injury and/or any form of compromise. Therefore, the nursing staff shall be responsible to assess the resident for complaints of pain on assessment, prior to treatment, and as appropriate. - Monitoring indicated Skin inspection on showering: On shower days, CNAs to observe resident skin; identify any areas of skin breakdown, discoloration, tears, or redness. Review of the Facility policy titled Pressure Ulcer dated 2/2023 indicated The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable and that the facility provides care and services to: Promote the prevention of pressure ulcer development . Procedures indicated monitoring daily.

Based on observations, interviews, and records review, the facility failed to provide adequate supervision for two of twelve sampled residents (Resident 249 and 38) when: 1. The facility did not follow their Fall Care plan to provide staff supervision to Resident 249 when sitting on his wheelchair. This failure resulted to Resident 249's repeated falls requiring two hospitalization s due to nasal laceration (a deep cut or tear in skin) and bilateral nasal bone fractures (a break in the bone or cartilage over the bridge, or in the sidewall or septum [structure that divides the nostrils] of the nose) to which Resident 249 experienced pain. 2. The facility failed to follow the doctor's order for nectar thick liquid for Resident 38 who had difficulty swallowing and did not provide staff supervision when drinking liquid. This failure had the potential for Resident 38 to aspirate (to breathe a substance into your lungs by accident) which could lead to choking, respiratory complications, serious infections or even death. Findings: Resident 249 During a record review for Resident 249, the Face sheet (A one-page summary of important information about a resident) indicated Resident 249 was admitted on [DATE] with diagnoses including but not limited to Difficulty Walking; Muscle Weakness; and Hemiplegia and Hemiparesis (paralysis of one side of the body). During a record review for Resident 249, the document titled LN (Licensed Nurse) - Fall Risk Evaluation dated 6/09/22 indicated Resident 249 was high risk for fall. During a record review for Resident 249, the Fall Care Plan initiated on 6/11/22 indicated Resident 249 was at risk for falls related to generalized weakness. Care Plan interventions indicated: - Be sure the call light is within reach and encourage to use it to call for assistance as needed - Bed in lowest position with fall mat at bedside - Educate resident/family/caregivers about safety reminders and what to do if a fall occurs - Keep needed items, water, etc., in reach - Occupational, Physical Therapy evaluation and treatment per physician orders - Educate resident/ family/caregivers about safety reminders and what to do if a fall occurs - Monitor placement of wedge cushion and dycem (non-slip products) in reclining wheelchair During a record review for Resident 249, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 6/16/22 indicated Resident 249 had a BIMS score of 4 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive (involving conscious intellectual activity [such as thinking, reasoning, or remembering)]) screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 249 required extensive (resident involved in activity; staff provide weightbearing support) one-person physical assist from staff with transfers and walking. First Fall 6/25/22 During a record review for Resident 249, the document titled Progress Notes dated 6/25/22 at 10:10 a.m. indicated Resident 249 was found on the floor yelling for help. The Progress Note indicated Resident 249 claimed he had fallen from the wheelchair trying to get to restroom. The Progress Note indicated Resident 249 sustained small laceration outside right eye, inner area alongside nose and larger laceration to outer, lower area under right eye. During a record review for Resident 249, the document titled Progress Notes dated 6/25/22 at 12:34 p.m. indicated Resident 249 was sent to the emergency room for evaluation. During a record review for Resident 249, the document titled Progress Notes dated 6/25/22 at 6:13 p.m. indicated Resident 249 returned to the facility. During a record review for Resident 249, the document titled Progress Notes dated 6/27/22 at 10:59 a.m. indicated the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) met to discuss Resident 249's fall incident. The Progress Note indicated, [Resident 249] must be within view of staff/family members when sitting up in wheelchair. During a record review for Resident 249, the Fall Care Plan indicated interventions initiated on 6/25/22 indicated, Staff will not place the resident on wheelchair without family/staff supervision. Second Fall 7/7/22 During a record review for Resident 249, the document titled Progress Notes dated 7/7/22 at 6:30 a.m. indicated, at 0612 [Resident 249] was heard hollering from room. Found on floor on left side curled around transfer pole. Bed was in lowest position and call light was within reach. Resident assisted back on the bed. Crescent shaped skin tear back of left hand ; bruising left elbow. Said hit head (pink mark to back of head to left side, but no swelling or broken skin), but that it only hurt a little. During a review of the Fall Care Plan for Resident 249 and concurrent interview with the DON on 03/17/23 at 3:01 p.m., the DON verified Resident 249's Fall Care Plan did not have new intervention to prevent Resident 249 from further fall. Third Fall 7/13/22 During a record review for Resident 249, the document titled Progress Notes dated 7/13/22 at 7:09 a.m. indicated Resident 249's roommate notified the nurse that Resident 249 was on the floor. The Progress Note indicated the nurse and the CNA (Certified Nursing Assistant) found Resident 249 next to the bed on floor laying on a pillow on his right side. The Progress Note indicated Resident 249 had redness to his right elbow and right shoulder. During a record review for Resident 249, the document titled Progress Notes dated 7/14/22 at 2:42 p.m., indicated, IDT met to discuss resident recent fall. Resident was found on floor at bedside Will do room change closer to nurses' station, to monitor resident closer. Will provide floor mat at bed side. During an interview and concurrent record review with the DON on 03/17/23 at 3:07 p.m. when asked what interventions were put in place after the 7/13/22 fall incident to prevent Resident 249 from falling, the DON stated Resident 249 was moved to 18B which is closer to the nurse's station. The DON stated they also used regular mattress on the floor at bedside to prevent Resident 249 from sustaining fall related injury. The DON verified the fall care plan did not indicate floor mattress was used. Fourth Fall 9/11/22 During a record review for Resident 249, the document titled Progress Notes dated 9/11/22 at 4:32 p.m. indicated, 0800 at the Hallway [Resident 249] was in his wheelchair eating breakfast. The Progress Note indicated the housekeeper observed Resident 249 from afar leaning on his right side all the way to the floor and saw Resident 249 fell down. The Progress Note indicated staff immediately responded to the incident and found Resident 249 with blood coming from his nose and some blood coming from his mouth. The Progress Notes indicated Resident 249 possibly bit his right cheek with 2 small openings, right eyebrow laceration, right side of nose has laceration. The Progress Note indicated staff was assisting the resident across the room when the incident occurred. The Progress Note indicated Resident 249 was transferred to the hospital at 8:21 a.m. During a record review for Resident 249, the document titled ED (Emergency Department) Physician Notes dated 9/11/22 at 8:47 a.m. indicated, [Resident 249] was apparently complaining of neck pain after the fall. The Physician Note indicated a rhino rocket (designed for the treatment of nosebleed) was placed which was initially avoided due to Resident 249 nasal bone fractures, discomfort, and deviated septum, however Resident 249 had ongoing profuse bleeding. The Physician Note indicated Resident 249 received a dose of Fentanyl (a powerful pain medication). During a record review for Resident 249, the document titled Computerized Tomography (diagnostic imaging that shows detailed images of any part of the body, including the bones) dated 9/11/22 indicated, New on old bilateral nasal bone fractures with a new fracture of the bony nasal septum (the cartilage and bone in your nose) since 06/25/2022. During a record review for Resident 249, the document titled Progress Notes dated 9/11/22 at 4:33 p.m. indicated Resident 249 returned to the facility with rhino rocket clamp in right nose in place. During a record review for Resident 249, the document titled Progress Notes dated 9/11/22 at 5:35 p.m. indicated Resident 249 had some grimacing. During a record review for Resident 249, the Medication Administration Record (MAR) indicated Resident 249 received two tablets of Tylenol 325 mg (milligram) for pain level of 7 out of 10 on 9/11/22 at 5:31 p.m. The MAR indicated a score of 0 was no pain; 1 to 3 was mild pain; 4 to 6 was moderate pain; and 7 to 10 was severe pain During a record review for Resident 249, the MAR indicated Resident 249 received two tablets of Tylenol 325 mg (milligram) for pain level of 5 out of 10 on 9/12/22 at 1:56 p.m. During an interview with Unlicensed Staff J on 3/17/23 at 09:29 a.m., Unlicensed Staff J stated Resident 249 required extensive assist with transfers and toilet use, Resident 249 was non-ambulatory. During an interview with Unlicensed Staff E on 3/17/23 at 2:03 p.m., Unlicensed Staff E stated Resident 249 required two-person total assist with transfer and non-ambulatory. Unlicensed Staff E stated Resident 249 had at least 2 to 3 fall incidents since he was admitted to the facility. When Unlicensed Staff E was asked about interventions put in place to prevent Resident 249 from further fall, Unlicensed Staff E stated Resident 249 was put on frequent check, lowered his bed, and placed fall mat at bedside right after the first fall incident. Unlicensed Staff E was asked if Resident 249 had complained of pain after he sustained a nasal fracture from the 9/11/22 fall incident, Unlicensed Staff E stated Resident 249 spoke Spanish; however, he stated he knew Resident 249 was in pain because his body language indicated he was in pain like grimacing and guarding. During an interview with Licensed Staff A on 3/17/23 at 2:08 p.m., Licensed Staff A stated Resident 249 had complained of pain a few times after he sustained the nasal fracture and was medicated with Tylenol. Licensed Staff A was asked what interventions were put in place to prevent Resident 249 from further fall, Licensed Staff A stated Resident 249 could not be left alone in wheelchair without supervision because he moved a lot. During an interview and concurrent record review with the DON on 03/17/23 at 3:19 p.m. when asked about Resident 249's 9/11/22 fall, the DON stated the incident happened in the morning when Resident 249 was sitting on his wheelchair outside of his room. The DON stated staff were providing oversight supervision to Resident 249 while passing breakfast tray; however, fall incident happened. The DON verified the fall care plan for Resident 249 initiated on 6/25/22 indicated, Staff will not place the resident on wheelchair without family/staff supervision. The DON concurred they did not follow the care plan to provide supervision when Resident 249 was up on his wheelchair. Review of the Facility policy titled Fall Management System revised on 2/2023 indicated This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. Resident 38 During a record review for Resident 38, the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the MDS dated [DATE] indicated Resident 38 required supervision (oversight, encouragement, or cueing) with eating. During a record review for Resident 38, the document titled Order Summary Report indicated an order for Resident 38 with a start date on 2/24/23 for CCHO diet (consistent, constant, or controlled carbohydrate [food consisting of or containing a lot of sugars, starch]) mechanical soft texture, nectar thick consistency. During a record review for Resident 38, the document titled SLP (Speech Language Pathologist - also known as a Speech Therapist, is a health professional who diagnoses and treats communication and swallowing problems) Evaluation and Plan of Treatment with certification period from 1/17/23 to 2/12/23 indicated, Resident 38 was referred to Speech Therapy for Dysphagia (difficulty swallowing) services due to decline, risk for aspiration and oral/pharyngeal function. Resident 38referred to Speech Therapy due to decline in safety awareness, ability to use compensatory strategies and ability to effectively communicate needs/preferences. During an observation in Resident 38's room on 3/13/23 at 3:16 p.m., an unidentified CNA (Certified Nursing Assistant) offered a diet ginger ale to Resident 38. The CNA was observed opening the soda can, poured in a cup and assisted Resident 38 to drink. During an observation in Resident 38's room on 3/15/23 at 8:52 a.m., Resident 38 was up on her wheelchair. Kept on saying hello, cherry and help. Resident 38 had half full cup of thick clear liquid in front of her on top of the bedside table and a quarter full cup of thin consistency coffee. During an observation and concurrent interview with Director of Staff Development (DSD) on in Resident 38's room on 3/15/23 at 8:58 a.m., the DSD verified the cup of water in front of Resident 38 was thicker than the coffee. The DSD stated the coffee should be thick and took coffee away. During an observation and concurrent interview with the Director of Nursing (DON) in Resident 38's room on 3/16/23 at 3:11 p.m. DON verified Resident 38 had an almost empty container and an approximately 40 ml (milliliter - one thousandth of a liter) of Boost (nutritional supplement) in a cup on top of Resident 38's bedside table. The DON verified Resident 38 had an order for nectar thick liquid. The DON stated Resident 38 would be at risk for aspiration pneumonia when drinking thin liquid. During an interview with the Dietary Manager on 3/16/23 at 3:18 p.m. when asked about their process of preparing liquid consistency for residents prior to sending food trays out to the unit, the Dietary Manager stated they would put one pump of thickener for thin liquid, 2 pumps for honey thick and 3 pumps for nectar thick. The Dietary Manager stated they would send the nutritional supplements like boost with the resident's meal tray unopened and it was the nurse's responsibility to mix the drink according to the doctor's order before serving it to the residents. During an interview and concurrent observation with on 3/16/23 at 3:27 p.m., the Speech Therapist (ST) stated Resident 38 received speech therapy services due to difficulty swallowing and risk for aspiration. The ST verified Resident 38 should have nectar thick liquid. When ST was asked to check the boost on top Resident 38's bedside table, the ST stated the boost consistency was thin and it should have been thickened before it was served to Resident 38. The ST stated Resident 38 required supervision during meals and drinking due to Resident 38's fluctuating mentation (process of reasoning and thinking). During an interview with Licensed Staff F on 3/16/23 at 3:31 p.m. when asked how she prepared the boost for Resident 38, Licensed Staff F stated there was no need to thicken the boost because it was already thick.

Based on observations, interviews and records review, the facility failed to assess and provide necessary services to one of twelve sampled residents (Resident 38) when the facility did not ensure Resident 38 was free from pain due to left foot pressure ulcer and Deep Vein Thrombosis (DVT - a blood clot forms in one or more of the deep veins in the body, usually in the legs) to left leg. This failure resulted to Resident 38's inability to relax when she repeatedly called out for help and moaned (to make a long, low sound of pain, suffering). (Reference F686) Findings: During a record review for Resident 38, the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the document titled Progress Notes dated 3/9/23 at 3:54 p.m. indicated Resident 38 had a change of condition. The Progress Notes indicated Resident 38 had left hand and left leg swelling. During a record review for Resident 38, the document titled Progress Note dated 3/10/23 at 5:37 p.m. indicated doctor assessed Resident 38's swollen leg and ordered ultrasound (an imaging test that uses sound waves to create a picture of organs, tissues, and other structures inside the body) to rule out DVT. The Progress Note also indicated Resident 38 was on monitoring for left heel blister (a painful skin condition where fluid fills a space between layers of skin). During an observation and concurrent interview with Resident 38 in her room on 3/13/23 at 3:21 p.m., Resident 38 was sitting on her wheelchair, awake wearing a Prevalon heel protection boot (help reduce the risk of pressure ulcer (also known as bedsore - damage to an area of the skin caused by constant pressure on the area for a long time)by keeping the heel floated) to her left leg. Resident 38's top of left foot appeared swollen. When Resident 38 was asked if she had any concern with her skin, Resident 38 stated she believed she had an open area to her left foot and stated, it hurts. During an observation in Resident 38's room on 3/14/23 at 8:57 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello. During a record review for Resident 38, the ultrasound report dated 3/14/23 indicated the ultrasound was performed on 3/14/23 at 4:23 p.m. The report indicated, There is extensive DVT involving left common femoral vein (a large blood vessel in your thigh), superficial femoral vein and popliteal vein (vein located behind your kneecap). During an observation in Resident 38's room on 3/15/23 at 8:52 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello, and help. During an interview with Licensed Staff F on 3/15/23 2:28 p.m. when asked about reason for delay of the left leg ultrasound for Resident 38, Licensed Staff F stated the Social Service Director (SSD) was responsible for scheduling all appointments for the residents. Licensed Staff F stated they sometimes had a hard time to schedule an appointment with the hospital. During an interview with the SSD on 3/15/23 at 4:10 p.m. when asked about the reason for the delay of the ultrasound for Resident 38's left leg, the SSD stated the hospital would not schedule Resident 38 for the ultrasound until they get an order that had the doctor's signature, so she had to return the request form to the nurses to obtain the doctor's signature. The SSD stated when she was able to arrange the appointment for Resident 38, there was no transportation available to take Resident 38 to the appointment. During an observation in Resident 38's room on 3/16/23 at 8:29 a.m., Resident 38 was sitting on her wheelchair with a diabetic shoe on her left foot. Resident had facial grimacing, moaning, and repeatedly saying hello and help me. During an interview with Licensed Staff F on 3/16/23 11:24 a.m. Licensed Staff F stated she was not sure if Resident 38 was in pain, she stated it was normal for Resident 38 to call out and count loudly. When Licensed Staff F was asked how she would determine actual pain from behavior, Licensed Staff F stated she would observe for nonverbal indications of pain like facial grimacing, fidgeting, and restless; Licensed Staff F stated she would try to console Resident 38 and if it did not work, then it could be an indication that Resident 38 was in pain. Licensed Staff F stated Resident 38 received Tylenol (pain reliever) for two consecutive days and had asked Resident 38's doctor for a routine pain medication to manage potential pain from the pressure ulcer and DVT. During an interview with Licensed Staff B on 3/16/23 at 1:45 p.m., Licensed Staff B stated Resident 38 was super restless and moved her feet all the time. When Licensed Staff B was asked if Resident 38 having the DVT and pressure ulcer on her left heel would experience pain, Licensed Staff B stated, she could. Licensed Staff B was asked how pain was assessed when resident had behavior, Licensed Staff B stated she would observe for physical signs of pain like facial grimacing, tensed muscle, moaning, and restlessness. Licensed Staff B stated although these signs of pain were observed from Resident 38, Licensed Staff B stated she could not tell if Resident 38 was in pain due to Resident 38's history of calling out in the past. During an observation in Resident 38's room on 03/17/23 at 9:29 a.m., Resident 38 was on her bed with eyes closed, moaning. During a record review for Resident 38, the Medication Administration Record (MAR) for March 2023 indicated Resident 38 was monitored for pain every shift. The MAR indicated from 3/01/23 to 3/16/23, Resident 38 had 4 out of 10 level of pain (score of 0 no pain; 1 to 3 mild pain; 4 to 6 moderate pain and 7 to 10 severe pain) on 3/05/23. The MAR indicated Resident 38 received Tylenol on the following days: 3/3/23 for 6 out of 10 level of pain; 3/5/23 for 4 out of 10 level of pain; and 3/15/23 for 4 out of 10 level of pain. Review of the Facility policy titled Skin and Wound Monitoring and Management revised on 1/2022 indicated, A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed injury was unavoidable; and A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Procedure indicated, It is understood that a resident may experience pain associated with the presence of skin injury and/or any form of compromise. Therefore, the nursing staff shall be responsible to assess the resident for complaints of pain on assessment, prior to treatment, and as appropriate. Review of the Facility policy titled Recognition and Management of Pain dated 2/2023 indicated, It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Based on observation, interview and record review, the facility failed to protect Resident 1 with [DIAGNOSES REDACTED]. asking to go home. These failures resulted in an Immediate Jeopardy being called on 7/27/17 at 4 p.m. The Operations' Manager and Director of Nursing were present. Findings: On 7/3/17 at 9:26 a.m., the Department received an Entity Reported Incident (ERI) for a resident elopement that occurred 6/30/17 at 10:40 p.m. The report indicated Resident 1 had a history of [REDACTED]. Police were called at 10:50 p.m., and the Sheriff returned Resident 1 without injury at 11 p.m The Facility Demographic indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS), a resident assessment tool, dated 4/25/16, reflected a Brief Inventory of Mental Status (BIMS) score of 13 and indicated moderate cognitive impairment. Resident 1's care plan, dated 8/4/14, and revised 11/10/15, indicated Resident 1 was an, Elopement risk/wanderer related to impaired safety awareness. History of attempts to leave facility unattended. History of removal of Wanderguard when applied to ankle. Interventions included: 1) Apply Wanderguard (resolved 8/14/14), 2) Monitor placement of Wanderguard. Apply to right wrist only (revised 11/10/15), 3) Identify pattern of wandering ( .) Intervene as appropriate (8/4/14), 4) Report any wandering behavior and attempted diversion interventions to charge nurse (revised 12/18/14). A fax to Resident 1's Physician, dated 4/18/17, indicated Resident has been more agitated than usual, had an episode of elopement outside building and was very difficult to redirect. Nursing Progress Notes for Resident 1, dated 6/27/17 at 11:09 p.m., indicated Resident 1 was agitated related to an incident with her roommate and walked out the front door and was immediately attended by a staff member who was able to persuade her to re-enter the facility and go to bed. During an interview on 7/27/17 at 11:35 a.m., the DON said Resident 1 was on every 15 minute visual checks after the intended elopement on 6/27/17 through 7/1/17. The DON was unable to provide documentation of every 15 minute visual checks for 6/29/17 - 7/1/17. During an interview on 7/27/17 at 10:20 a.m., the Director of Staff Development (DSD), stated she was the facility manager on call for the weekend beginning Friday 6/30/17 through Monday 7/3/17. On Friday 6/30/17 at 10:40 p.m., she was notified by Nurse A that Resident 1 had eloped. Nurse A indicated Resident 1 was last seen walking in the hallway at 10:15 p.m., and during the last round of the shift was not seen in her bed at 10:40 p.m The DSD immediately drove to the facility, arrived at a little after 11 p.m. and was informed Resident 1 had been returned to the facility by the police before she arrived. The DSD confirmed with Nurse A the Wanderguard was checked for placement and was found to be functional. Resident 1's Wanderguard was exchanged for a new Wanderguard even though the old one was working. All residents wearing Wanderguards were then placed on every 15 minutes checks. The DSD stated the every 15 minute visual checks continued on Sunday 7/2/17 and Monday 7/3/17. She was unsure when the 15 minute checks stopped. She was uncertain how Resident 1 was able to leave the facility and confirmed Resident 1 had a history of [REDACTED]. The only care plan revisions for Resident 1 after the elopement on 7/1/17, were; 1) Every 15 minute visual checks initiated 7/2/17, which was discontinued / resolved 7/14/17. 2) A medical alert bracelet was placed on Resident 1 on 7/17/17. On 7/27/17, at 12:05 p.m., an interview with the Operations' Manager indicated he did not know how Resident 1 was able to get out of the facility and stated she may have memorized the code to the front door. When he returned to the facility on [DATE], he had all the facility alarms tested by the Facility's Manager. He confirmed all door alarms were functioning correctly. A new Wanderguard sensor unit was purchased and installed on the front door, and the security code was changed in case Resident 1 had memorized the code. When asked if anything had changed in the facility process for prevention of elopement after Resident 1 eloped, the Business Manager stated, other than the new code on the front door, that nothing was changed for the facility's prevention of elopement. A fax received from the Operations Manager on 7/7/17 at 10:35 a.m., revealed Nurse A checked the alarm system and found it to be working intermittently at the front door. An interview with Nurse D on 7/27/17 at 12:45, indicated, when he arrived for his day shift on 7/1/17, he was informed of Resident 1's elopement during the previous night shift. He stated the DSD and Nurse A tested Resident 1's Wanderguard she was wearing at the time of elopement, and discovered it was not activating the front door alarm sensor. A new Wanderguard for Resident 1 was immediately applied by Nurse 1 and the DSD. Nurse D stated it apparently just stopped working, and the battery was probably dead. He indicated Wanderguard devices are have a life span of 90 days to one year depending on the model and can be checked to see if they are working by using a testing device. He was able to locate a testing device in Nursing Station #1 Medicine room, and stated there was only one device for the entire facility. He was unable to describe the expectation for how often they were to be checked. During a concurrent Record Review and Interview, on 7/27/17 at 1 p.m., Nurse B stated Residents with Dementia who are at risk of elopement have Wanderguard devices ordered and applied. They are monitored for placement every shift by the nurse and documented on the Medication Administration Record/Treatment Administration Record (MAR/TAR). She reviewed the MAR/TAR, dated 12/18/13, for another resident (Resident 2) and showed where she documented placement check. The TAR indicated check for placement every shift. Nurse B was unable to find any order to test for functionality. When asked how to test if it was working, Nurse B stated you could walk the resident by an alarm to see if it was activated. She was unaware of a device to check for functionality. An interview with Staff E on 7/27/17 at 1: p.m. indicated she heard that morning nurses are supposed to check functionality of Wanderguards by using a device. She had not seen the testing device before and did not know its location. A phone interview with Nurse A on 8/3/17 at 12 p.m., indicated the placement of Wanderguard devices were checked and documented every shift. Nurse A stated the facility had recently obtained a hand-held device to check if the Wanderguard was still operating and before this event staff did not check. There was no device to check Residents' Wanderguards Resident 3's MAR /TAR indicated he was admitted [DATE], and not assessed for elopement risk until 7/27/17, when a Wanderguard was applied. Resident 3's Progress Notes, dated 7/27/17, at 2:28 p.m., indicate, after daughter took him to a doctors appointment, he became confused and attempted to leave facility unattended. Resident 3 was not previously evaluated for elopement risk. A record review of the MAR/TAR of all sampled Residents indicated 2 of 10 Sampled Residents did not have written instructions to check functionality of Wanderguards, until 7/27/17. An Immediate Jeopardy was called, and the Administrator and DON were present on 7/27/17 at 4 p.m., due to Resident 1's history of two previous attempted elopements and, the facility's inability to prevent Resident 1 from leaving the facility on 6/30/17 around 10:40 p.m. Resident 1 left the facility, wandered two blocks in the dark on a major street, knocked on a stranger's house and asked to go home. The occupant called 911, and the police returned Resident 1 to the facility. The facility failed to develop, modify, and implement a wandering/elopement prevention plan to protect Resident 1 or other residents from further elopement risk. There were inconsistent orders in the MAR/TAR for directions to check placement and/or functionality of residents wearing Wanderguard bracelets. There was no facility oversight of staff to determine if they were competent and compliant with checking Wanderguards every shift, and there was no facility-wide in service or education about using the Wanderguard device. An immediate Plan of Action was requested. The facility DON, Administrator and Operations' Manager provided a Plan of Action on 8/1/17 at 8:30 a.m The plan included additional staff assigned to have line-of-site visual supervision on Resident 1 from 6 a.m. to 11 p.m., and, during hours of sleep an additional care partner will be assigned to do walking rounds every 30 minutes on all residents identified at risk of elopement. Care partners (Nurses aid or Certified Nursing Assistants) will be assigned to all residents at risk every 24 hours. Rounds and supervision will continue until the facility is able to complete necessary assessments and patient-centered plans of care that specifically address each resident's risk behavior and level of required supervision. Daily assignment sheets will reflect all residents who are at risk for elopement and have care partners assigned. An elopement risk assessment was performed on all facility residents. MAR's / TAR's were revised and updated for testing functionality and placement every shift. Blue tape identifiers were added to room name plates, wrist bands, wheelchairs and walkers.All staff will receive education on the Elopement Risk Policy and Procedure and proper use and testing of Wanderguard devices. During an on-site visit on 8/1/17 at 11:15 a.m., the Immediate Jeopardy was removed. The DON, Administrator, Business Manager and Health Facilities Evaluator Nurse, , were present at the time the Immediate Jeopardy was removed.

Based on observation, interview, and record review, the facility failed to ensure that Resident 1, who was at high risk for falls and known attempts to get out of bed and the wheelchair unassisted, was provided adequate supervision by direct care staff and had effective revisions and development of an individualized care plan for Resident 1 to prevent further falls to keep Resident 1 safe. Resident 1 had eight falls during a six month period from 12/11/13 to 6/9/14. These failures caused Resident 1 to sustain a right hip fracture after falling while attempting to ambulate unassisted and required Resident 1 to undergo right hip surgery. Findings: Resident 1's admission record indicated that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The fall risk evaluation dated 11/9/13 and 12/2/13 revealed that Resident 1 was at high risk for falls due to multiple problems including mental status problem, history of falls, and gait/balance problems. The Admission Minimum Data Set (MDS, an assessment tool), dated 11/15/13 and the most recent quarterly MDS, dated [DATE], indicated Resident 1 had short-term and long-term memory problems, moderately impaired cognition, unsteady gait/balance, required extensive assistance with transfers, walking, dressing, and risk for falls. The Care Area Assessment (CAA, a tool used to identify resident concerns and develop an individualized care plan), dated 11/21/13, indicated Resident 1 had history of falls, impaired safety awareness, impulsiveness, cognition and balance problem, and Alzheimer's type dementia. A care plan for At Risk for Falls indicated: "1) Alarm devices (a device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or bed) as indicated and educated resident as to reasons. Remind resident to call for and wait for staff assistance before getting up OOB (Out of Bed) or chair; 2) Anticipate and meet needs; 3) Bed in lowest position; 4) Be sure the call light is within reach and encourage to use it to call for assistance as needed; 5) Floor mat." The goals included that Resident 1 would have no falls or injuries. First Fall: The nurse's note, dated 12/11/13, indicated on 12/11/13 at 9:30 a.m., Resident 1 had an unwitnessed fall. The nurse' note indicated that Resident 1 was found sitting on the floor mat at the right side of the bed. The care plan regarding at risk for falls for Resident 1 indicated that, on 12/11/13, Resident 1 required one to one staffing assignment due to increased confusion, combative behavior, and wandering. The care plan indicated that the intervention of one to one staffing assignment was added on 11/9/13 and discontinued on 12/13/13. During an interview on 7/28/14, at 12:10 p.m., Administrative Staff B stated that she could not find any documentation showing one to one staffing assignment for Resident 1 except on the care plan. She also stated that she did not know why the intervention, one to one staffing assignment, was initiated and discontinued. When asked if the resident required "one to one staffing assignment due to increased confusion, combative behavior, and wandering," (per the care plan,) Administrative Staff B stated that a staff member should be with the resident at all times. Second Fall: The nursing post fall assessment, dated 12/12/13, indicated on 12/12/13 at 9:10 p.m., Resident 1 was found on the floor next to the bathroom door. Resident 1 sustained a skin tear on her right arm from this fall. The Fall Committee IDT (interdisciplinary team) note, dated 12/30/13 (18 days after two falls on 12/11/13 and 12/12/13), indicated "New interventions" were: 1) Place resident in common areas when out of bed; and 2) RNA (Restorative Nursing Assistance) program for ambulation and lower extremity strengthening. The IDT note and the care plan lacked specificity and did not indicate providing supervision to Resident 1 to prevent further falls. The care plan reflected that the continuous intervention included, "Be sure the call light is within reach and encourage to use it to call for assistance as needed." The MDS dated [DATE] indicated that Resident 1 made poor decisions and required cues and supervision. The care plan lacked specificity of how Resident 1 was going to call for help when she required cueing and supervision. The care plan did not specify providing supervision to Resident 1 to prevent further falls. During an interview on 6/17/14, at 11:35 a.m., Unlicensed Staff E stated that Resident 1 was confused and was not able to use the call light and wait for assistance. Unlicensed Staff E stated that she just put the call light within reach of the resident. She also stated that she would not remind the resident to wait for assistance because the resident was confused. Unlicensed Staff E further stated that staff would go in the resident's room and check on the resident if the alarm sounded. During an interview on 6/19/14 at 3:15 p.m., Management Staff A was asked the reasons for taking 18 days to have a Fall Committee IDT meeting and develop new interventions. She stated that, "I cannot answer that...I was not here that time." When she was asked how would the intervention, "keep in common areas when out of bed" prevent Resident 1 from falling, she stated that the common areas included hallways and the day room. She stated that the staff left the resident in common areas so that staff could keep an eye on the resident when they performed other tasks or when they were near the resident. When asked what happened if no staff was near the resident, she stated that nobody watched the resident. During an interview on 7/28/14 at 2:25 p.m., Licensed Staff G stated that on 12/12/13, prior to Resident 1's fall, no staff supervised the resident. Licensed Staff G stated that Resident 1 went to the bathroom by herself and fell . She further stated that the staff went into the resident's room when the resident's alarm sounded and found the resident was on the floor near the bathroom. Licensed Staff G stated that if a resident was on one to one staffing assignment, a staff member should be with the resident at all times. Third Fall: The nursing post fall assessment, dated 1/8/14, indicated on 1/8/14 at 2:15 p.m., Resident 1 was found sitting on the floor mat. The Fall Committee IDT note, dated 1/10/14, indicated "New intervention of wedge cushion (a type of cushion used in bed) for positioning as fall intervention." The IDT note and care plan lacked specificity and did not indicate providing supervision to Resident 1 to prevent further falls. During an interview on 6/19/14, at 3:15 p.m., when Management Staff A was asked how the wedge cushion prevented the resident from falling out of the bed, she stated that the wedge cushion was for positioning but could not keep the resident from falling out of the bed. Fourth Fall: The nursing post fall assessment, dated 2/13/14, indicated on 2/13/14 at 7 p.m., Resident 1 tried to pick something up on the floor and slid out of the chair. The Fall Committee IDT note, dated 2/14/14, indicated the plan was to continue current interventions for fall prevention; request physical therapy (PT) screening; and recommend Dysem (non-slip material) for the wheelchair to prevent sliding. The care plan lacked specificity of providing supervision to Resident 1 to prevent further falls. During an interview on 6/19/14, at 3:15 p.m., when Management Staff A was asked how the Dysem prevented Resident 1 from getting up from the wheelchair unassisted, she stated that the Dysem helped prevent Resident 1 from sliding out the wheelchair. She further stated that the resident could still stand up and walk. The PT evaluation dated 3/11/14, indicated that Resident 1 "...Has difficulty following simple motor commands and has little to no safety awareness..." Fifth Fall: The nursing post fall assessment, dated 3/22/14, indicated on 3/22/14 at 6:45 a.m., Resident 1 was found sitting on the floor next to her bed in front of the wheelchair and the resident was unable to describe the fall. The Fall Committee IDT note, dated 3/24/14, indicated on 3/22/14, Resident 1 fell out of bed at 6:30 a.m. New interventions were: 1) Request physician to review medications for insomnia; and 2) Assist resident out of bed at 6:30 a.m. The IDT note and the care plan lacked specificity of providing supervision or monitoring to Resident 1 to prevent further falls. The fall risk assessments, dated 3/18/14 and 3/24/14, indicated Resident 1 was a high risk for falls due to multiple problems including mental status problem, history of falls, gait and balance problems. Sixth Fall: The Fall Committee IDT note, dated 4/9/14, indicated Resident 1 fell from her wheelchair on 4/4/14 (no time provided). The Fall Committee IDT note indicated interventions included 1) Therapy to screen for occupational therapy services; 2) Activities to review the care plan; and 3) Continue with current fall interventions/alarms. The care plan interventions included a body alarm for the wheelchair (a device attached to the resident and the wheelchair that triggers a noise when the resident attempts to get up); and a pressure pad alarm for the bed (a pad placed on the bed that alarms when the patient attempts to get up). The care plan lacked specificity of how staff provided supervision and monitoring of the resident to prevent further falls. The fall risk assessment, dated 4/8/14, indicated Resident 1 was at high risk for falls due to multiple problems including mental status problem, history of falls, gait and balance problems. Seventh Fall: The nursing post fall assessment, dated 4/13/14, indicated on 4/13/14 at 4:55 a.m., Resident 1 fell from her wheelchair in the hallway. The nursing post fall assessment indicated the immediate interventions included visual check every 10 minutes and supervision "constantly". However, the Fall Committee IDT note and the care plan did not indicate the intervention for visual check every 10 minutes and supervision "constantly." The Fall Committee IDT note, dated 4/14/14, indicated Resident 1 continued "to be at risk for falls due to impaired cognition, balance and poor safety awareness." The Fall Committee IDT note indicated that, "New intervention" was to request occupational therapy. The IDT note and care plan lacked specificity of how staff provided supervision to prevent further falls. During an interview on 6/17/14, at 3:15 p.m., Management Staff B was asked to define "constant monitoring or supervision." She stated that staff would watch the resident every one to two hours. She stated there was no set time frame or assigned staff to monitor and supervise the resident. She stated staff would watch the resident during rounding or passing by the resident. During an interview on 6/17/14 at 3:25 p.m., Licensed Staff G stated that "constant monitoring or supervision" meant to watch the resident every 20 minutes. During an interview on 6/19/14, at 3:15 p.m., Management Staff A stated that "constant" meant all the time. When queried that the care plan and other documents did not indicate "supervise constantly," Management Staff A stated that she reviewed the care plan and the IDT notes and stated "I do not see that too." When asked about care planning and implementing supervision to Resident 1, Management Staff A stated, "It is not specified." When Management Staff A was notified that staff gave different answers for the definition of "constant monitoring or supervision" (every 20 minutes, every one or two hours), she stated, "Then we need in-services." The fall risk assessment, dated 4/14/14 and 5/26/14, indicated Resident 1 continued to be a high risk for falls due to multiple problems including mental status problem, history of falls, balance problem. During an interview on 6/17/14, at 12:02 p.m., Licensed Staff C stated that Resident 1 was at high risk for falls. He stated that Resident 1 was not able to use call light because she was confused, forgetful, and had memory problems. Licensed Staff C stated that staff put the call light for every resident. He also stated that the care plan for Resident 1 needed to be updated. During an interview on 6/17/14, at 2:25 p.m., regarding the intervention, "Continue interventions on the at-risk plan" in the care plan initiated on 12/13/13, Management Staff A stated that she assumed that the at-risk plan was the care plan and the severity of the resident's risk. She further stated that the care plan for Resident 1 was not individualized. Eighth Fall: The Fall Committee IDT note, dated 6/10/14, indicated on 6/9/14 at 1:50 p.m., Resident 1 fell to the floor when she attempted to ambulate without assistance. The nursing note dated 6/9/14 indicated that the occupational therapist (OT) witnessed the fall and the body alarm did not sound. Resident 1 was sent to an acute care hospital. During an interview on 6/13/14, at 12 p.m., the OT stated that on 6/9/14 at 1:50 p.m., Resident 1 fell in the hallway near the nurse station. The OT stated that she was working on another resident's paperwork in the hallway and did not know Resident 1 was behind her. She felt that a person was falling on her back so she turned around and noted that Resident 1 stood up near her wheelchair and was falling. She stated that she tried to hold Resident 1 to break the fall; however, Resident 1 fell and both the OT and Resident 1 were on the floor. She stated that Resident 1 was alert and complained of hip pain. The OT stated that she did not hear Resident 1's body alarm sound. The OT also stated that Resident 1 was in the hallway alone. No other staff was around. She had to yell out for help. During a concurrent observation and interview on 6/17/14, at 10:45 a.m., Resident 1 was in bed and was awake. When asked how she would call the staff for help when staff staff were not in her room, Resident 1 stated, "I do not know." When asked about the call light, Resident 1 pointed at her blanket and stated, "I do not know. That is all I have." During an interview on 6/19/14, at 3:15 p.m., when Management Staff A was asked how the facility had provided adequate supervision for Resident 1, she stated that she could not answer the question for the first fall to the seventh fall. Management Staff A stated that the facility provided adequate supervision for the eighth fall because on 6/9/14, prior to the fall, the staff assisted Resident 1 for eating, toileting, and positioning. She further stated that the OT was not intended to supervise Resident 1, but the OT reacted appropriately to assist the resident when she fell . The acute care hospital emergency department notes and x-ray result, dated 6/9/14, indicated that Resident 1 sustained a right hip fracture from the fall. Resident 1 was admitted to the acute hospital on [DATE] and had a surgical repair of the right hip. The fall risk evaluation for Resident 1 on admission (Resident 1 was readmitted to the facility), dated 6/13/14, indicated that Resident 1 was at high risk for falls. The care plan for at risk for falls was not initiated until 6/23/14. During an interview on 8/4/14, at 1:50 p.m., Management Staff A stated that the facility had a previous care plan for at risk for falls and the care plan was discontinued on 6/18/14. Management Staff A also stated that the facility initiated a new care plan on 6/23/14. Management Staff A further stated that the facility had 21 days to complete the care plan. When asked how would staff know what interventions should be provided to the resident between 6/18/14 and 6/23/14 (without a care plan), Management Staff A stated that the staff knew Resident 1 because the resident was a re-admission, and staff knew some of the interventions from the treatment sheet. The facility policy and procedure titled, "Fall Risk Assessment," dated 5/2012, indicated "Any resident identified as high risk will have a prevention protocol initiated and documented on the care plan. Prevention protocol examples...Provide supervision..." The facility policy and procedure titled, "Fall Management System," dated 6/2013, indicated "Residents with a Falls Risk Assessment score of 10 or above are considered high risk and will have an individualized care plan developed that includes measurable objectives and timeframes."

Based on observation, interviews, and record review, the facility failed to keep Resident 1 safe from injury when it did not follow its nursing care plan by providing supervision to Resident 1, in the bathroom, resulting in a fall with a fractured left rib. Findings: Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During an interview on 6/14/12 at 10:05 a.m., Certified Nursing Assistant (CNA) A stated that on 6/9/2012 she assisted Resident 1 to the bathroom and left Resident 1 on the toilet to go and get a brief for the resident. CNA A stated that before she left Resident 1 unattended in the bathroom, she attached a tab alarm (an alarm that is attached to the resident that sounds when the resident moves or rises from a sitting position) to the resident. CNA A stated that while she was gone to find a brief, Resident 1 stood up and fell on the floor hitting her head. CNA A stated that she should have used her "walkie-Talkie" to ask another staff member to bring her a brief. CNA A stated that she was aware that Resident 1 was at risk for fall, but not aware that Resident 1 was not to be left unattended in the bathroom. During an interview on 6/14/12 at 2:50 p.m., Licensed Staff B stated that at approximately 9:45 a.m. on 6/9/2012, upon entering Resident 1 room she found Resident 1 on the bathroom floor with her back to the door. Licensed Staff B further stated that when she asked Resident 1 if she had hit her head Resident 1 stated that she had, and that Resident 1 was grabbing her chest and when asked if Resident 1 was having chest pain she had stated, yes, and when asked if the pain was sharp and radiating Resident 1 responded, yes. Licensed Nurse B also stated that she noted a large reddened area on Resident's 1 left upper back and that Resident 1 complained of discomfort upon palpitation of the area. Licensed Nurse B further stated that Resident 1's physician was notified and Resident 1 was transferred to the acute care hospital emergency room at about 10:00 a.m., and returned to the facility at 2:30 p.m.. Licensed Nurse B also stated that upon contacting the ER physician who had treated the resident, the physician had stated that he suspected Resident 1 had sustained a rib fracture. Licensed Nurse B also stated that since her return to the facility Resident 1 has been grimacing and appears to be in pain at times and that Resident 1 has been medicated with pain medication. Review of Resident 1's medical record on 6/14/2012 at 3:50 p.m., reflected that the "Fall Risk Assessment" dated 3/12/12., indicated a total score of 12 with "TOTAL SCORE above 10 Represents High Risk." The record also indicated that Resident 1 had 4 falls, (1/3/12, 1/8/12, 2/25/12, 4/24/12) prior to her recent fall on 6/9/12. During a review of Resident 1's care plan entitled "Fall" ,undated, the "Plan/Approach" was listed as "Do not leave alone in the bathroom". During a review of Resident 1's clinical record on 6/14/12 at 3:20 p.m., the emergency department report from the acute care hospital for the admission date of [DATE] indicated that "... sitting on the toilet and did not realize that she was unable to walk without assistance, got up and walked, falling, hitting her left posterior ribs on the sink." The report also indicated that "Chest x-ray reveals some atelectasis (abnormal condition characterized by the collapse of lung tissue) in the left base and a hint of a left lower rib fracture." The report indicated that one of the discharge [DIAGNOSES REDACTED].". During an interview on 6/14/12 at 11:50 a.m., the DON stated that "The CNAs are required not to leave the resident unattended in the bathroom, and that CNA caring for Resident 1 should have not left the resident in the bathroom unattended"