Every finding on record at Veterans Home Of California - Chula Vista

Based on interview and record review, the facility failed to ensure a medication was administered as prescribed for one of three sampled residents (Resident 1), when the physician orders for that medication was not transcribed (copying a doctor's medication order into a residents medication administration record or electronic health record), by the licensed nurse. This failure resulted in Resident 1 missing a cycle of her breast cancer medication for approximately 25 days.Findings: During a review of Resident 1's Face Sheet (demographics), dated 6/30/2026, the face sheet indicated, Resident 1 had a diagnosis of malignant neoplasm (abnormal growth of tissue) of the nipple and areola of the right female breast (breast cancer). During a review of Resident 1's Medication Administration Record (MAR), for the months of May 2026 and June 2026, the MAR indicated Resident 1 was receiving letrozole (a breast cancer medication), 2.5 mg (milligrams), tablet daily. Review of the MAR indicated Resident 1 was receiving Kisqali (also known as ribociclib, a breast cancer medication), 400 mg, tablets daily for malignant neoplasm of the nipple and areola of the right female breast. Further review of the MAR indicated Resident 1 did not receive the medication Kisqali for 25 days from 5/15/2026 to 6/4/2026 and from 6/12/2026 to 6/15/2026. During a review of Resident 1's Clinical Note, dated 5/5/2026 at 2:27 p.m., by the Registered Nurse (RN 1), the note indicated Resident 1 returned from the oncology appointment with a treatment prescribed for the medication Kisqali 400 mg, by mouth daily for 21days (starting on 5/15/2026 to 6/4/2026) and off 7 days (from 6/5/2026 to 6/11/2026), and repeat the cycle (repeating pattern). During a review of Resident 1's Clinical Note, dated 6/16/2026 at 4:11 p.m., by the Supervising Registered Nurse (SRN 1), the note indicated Resident 1 returned from the oncology appointment with a treatment prescribed for the medication Kisqali 400 mg, by mouth daily as previously ordered. The note further indicated that last month's appointment on 5/5/2026, the medication order for Kisqali was not re-entered and there was no record that it was given to Resident 1. During a concurrent interview and record review on 6/30/2026 at 12:01 p.m., with SRN 1, Resident 1's Physician's Orders, for the months of March 2026, April 2026, May 2026 and June 2026 and the Specialty Services Consultation and Tracking Form, dated 3/3/2026, 5/5/2026, and 6/16/2026 were reviewed. Review of the specialty services consultation and tracking form dated 5/5/2026, indicated, Treatment Prescribed: To continue Kisqali, 400 mg, PO (by mouth), daily x 21 days (5/15/2026 to 6/4/2026), then 7 days off (6/5/2026 to 6/11/2026) and to repeat the cycle. Review of the physician orders for the month of May 2026, indicated there was no physician order for the medication Kisqali prescribed on 5/5/2026. SRN 1 stated this was a medication error and Resident 1 missed a cycle (from 5/15/2026 to 6/4/2026) of the medication Kisqali for the month of May 2026. During a concurrent interview and record review on 6/30/2026 at 2:17 p.m., with the Director of Nursing (DON) and SRN 1, the following medical records for Resident 1 were reviewed:-The MARs for the months of March 2026, April 2026, and May 2026.-The Specialty Services Consultation and Tracking Form dated 3/3/2026, 5/5/2026, and 6/16/2026.-The physician's orders for letrozole and Kisqali dated 3/3/2026, 4/16/2026 and 6/16/2026. The DON stated on 4/16/2026, Resident 1 had a physician's order for a cycle of Kisqali 400 mg daily for 21 days (until 5/7/2026) and then off for 7 days (from 5/8/2026 to 5/14/2026). The DON stated on 5/5/2026, Resident 1 had a follow up oncology (the study of cancer) appointment and Resident 1 was prescribed to continue Kisqali 400 mg daily for 21 days (starting on 5/15/2026 to 6/4/2026), then 7 days off (from 6/5/2026 to 6/11/2026) and to repeat the cycle. The DON further stated on 6/16/2026, Resident 1 had another follow up oncology appointment and Resident 1 was prescribed to continue Kisqali 400 mg daily for another 21 days. The DON stated per RN 1, they acknowledged Resident 1's prescription on 5/5/2026 to continue the Kisqali 400 mg, daily for 21 days (starting on 5/15/2026 to 6/4/2026), then 7 days off (from 6/5/2026 to 6/11/2026), however, RN 1 did not transcribe the physician's order for Resident 1's medication. The DON stated RN 1 should have written an order for Resident 1's Kisqali medication on 5/5/2026 to have it restarted on 5/15/2026, but since the physician order was not transcribed, Resident 1 did not receive the medication from 5/15/2026 through 6/4/2026 (for 21 days). During an interview on 6/30/2026 at 2:17 p.m., with SRN 1, SRN 1 stated on 6/16/2026, after reviewing Resident 1's MAR, it was discovered that there was no physician's order transcribed on 5/5/2026 for the medication Kisqali 400 mg daily. During an interview on 6/30/2026 at 3:12 p.m., with Resident 1, Resident 1 stated she recalled the facility staff informing her that she had missed taking her cancer drug. Resident 1 stated she was not happy about not taking her cancer drug, stating the facility was careless about it. During an interview on 7/1/2026 at 8:59 a.m., with RN 1, RN 1 stated she signed the Specialty Services Consultation and Tracking Form and acknowledged Resident 1's prescribed medication treatment of Kisqali 400 mg on 5/5/2026. RN 1 stated she thought the order would automatically continue. RN 1 stated she should have written the new order on 5/5/2026 for the medication Kisqali. During an interview on 7/1/2026 at 9:50 a.m., with the physician (Physician 1), Physician 1 stated he expressed his frustration to the facility's supervisor when he was notified that Resident 1 missed doses of the Kisqali medication. Physician 1 stated it was a mistake, and it was not okay for Resident 1 to have missed a cycle of Kisqali. Physician 1 stated missing cycles of Kisqali could impact the trajectory of care for Resident 1 and may have changed the progression of Resident 1's metastatic cancer. During a review of the facility's policy and procedures (P&P) titled, Skilled Nursing Facility Outside Medical Referrals, dated 6/15/2026, the P&P indicated, 1. Consultations. E. Nurse receiving paperwork on return of Resident will: 1. Review consultation. 2. Inform physician of consultation report and/or recommendation 3. G. Nurse will note and carry out orders. During a review of the facility's policy and procedures (P&P) titled, Transcribing Physician Orders, dated 12/26/2025, the P&P indicated, The facility will ensure that all orders .shall be noted and carried out promptly. Nursing staff will: Note orders in the Electronic Health Record.

Based on observation, interview, and record review, the facility failed to ensure nursing staff did not leave medication unattended on the bedside for one of two sampled residents (Resident 1). This failure had the potential to compromise the health and safety of Resident 1.Findings: During a review of Resident 1's Face Sheet (demographics), dated 3/25/2026, the face sheet indicated Resident 1 has a diagnosis of nicotine dependence (an addiction to tobacco products caused by the drug nicotine). During a review of Resident 1's Physician Orders, dated 3/18/2026, the physician order indicated Resident 1 had a medication order for nicotine 2 milligrams (mg), lozenge (small tablet that dissolves in the mouth and helps you quit smoking), give one (1) as needed every 2 hours. During a concurrent observation and interview on 3/20/2026 at 11:31 a.m., in Resident 1's room with Resident 1, Resident 1 was lying in bed. On top of a bedside drawer next to Resident 1's bed was a clear plastic medication cup with one white circular tablet in it. There was no nursing staff in Resident 1's room. Resident 1 stated the white circular tablet inside the clear medication cup was his nicotine wafer and the nurse left it there. Resident 1 took the white circular tablet and stated he hoped it was the nicotine lozenge. During an interview on 3/20/2026 at 11:40 a.m., with the Registered Nurse (RN 1), RN 1 stated Resident 1 had an order for nicotine lozenges every 4 hours as needed. RN 1 stated she gave Resident 1 two nicotine lozenges earlier. RN 1 stated she only saw Resident 1 take one of the two nicotine lozenges. RN 1 further stated since the nicotine lozenges were ordered as needed, she did not have to see Resident 1 take the nicotine lozenges. During a review of Resident 1's Medication Administration Record (MAR), dated for the month of March 2026, the MAR indicated, documentation by the Registered Nurse (RN 1), that Resident 1 was given nicotine 2 mg, (1) lozenge on 3/20/2026 at 10:34 a.m. During an interview on 3/20/2026 at 11:53 a.m., with the Supervising Registered Nurse (SRN 1), SRN 1 stated the nursing staff should not have left the medication unattended at Resident 1's bedside. During a concurrent interview and record review on 3/20/2026 at 4:31 p.m., with SRN 1, Resident 1's nursing assessments, were reviewed. SRN 1 stated Resident 1 did not have an evaluation to self-administer medication. During an interview on 3/25/2026 at 3:07 p.m., with RN 2, RN 2 stated Resident 1 did not have a physician order to self-administer medication. During a review of the facility's policy and procedure (P&P) titled Medication and Treatment Administration, dated 6/23/2025, the P&P indicated, Medications and treatments will be administered as prescribed, in accordance with good nursing principles and practices. The complete act of administration involves removing an individual dose from a previously dispensed, properly labeled container, verifying the dose with the transcriber's orders and promptly giving the individual dose to the proper Resident.

Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and sanitary environment when: 1.One of the shower rooms, Room A729, was found with broken tiles and an exposed wall cavity. This failure had the potential to result in exposing residents to pests and contaminants, compromising the hygiene and safety of a medically vulnerable population of 107 residents.2. The shared bathroom for one of 24 sampled resident's (Resident 39) and one unsampled resident (Resident 34), had a large, unsealed hole located directly above the toilet. This failure resulted in Resident 39 and Resident 34 feeling stress and discomfort with the disrepair (poor condition of a building) and had the potential to result in injuries or infections from dust, insulation, or debris falling from an unsealed ceiling. Findings: 1.During a concurrent observation and interview on 1/15/2026 at 11:20 a.m. with the Charge Nurse (CN), in shower room A729, there were broken tiles and an exposed wall cavity. The CN stated shower room A729 was one of two in the whole facility used by residents. The CN stated the broken tiles should have been reported for repair to plant operations. During a concurrent interview and record review on 1/15/2026 at 11:57 a.m. with the Staff Service Manager (SS), the documents' titled, Environmental Rounds, dated February 2025 to January 2026 were reviewed. The Environmental Rounds indicated broken tiles were noted and recommended for repair and replacement on the following dates: 2/12/2025, 4/23/2025, 7/3/2025, 10/22/2025, and 1/9/2026. The SS stated the broken tiles were unsafe and should have been repaired. During a review of a Work Order, #24_094880, dated 10/23/2024, the work order indicated tile repair was needed in the shower room A729 for broken tiles. Further review of the work order indicated the work order was created back on 10/23/2024 and was left opened with no repair date and no completion date.During an interview on 1/15/2026 at 12:30 p.m. with the Building Maintenance Worker (BMW), the BMW stated it was not safe for the shower disrepair to be left like that. During a follow up interview on 1/15/2026 at 4:38 p.m. with the SS, the SS stated the broken tiles and an exposed wall cavity measured at 5.5 inches by 16 inches (unit of measurement). During a review of the facility's policy and procedure (P&P) titled, Environment of Care Rounds, dated 10/9/2025, the P&P indicated, Any safety issues will .require that immediate action be taken to prevent harm to resident, staff, or visitors. During a review of the facility's policy and procedure (P&P) titled, General Maintenance, dated 5/1/2025, the P&P indicated, All building, fixtures, equipment, and spaces will be maintained in operable conditions. Maintenance of [the facility], including the grounds, in a clean and sanitary condition and in good repair at all times was to ensure the safety and well-being of residents, staff, and visitors. 2. During a concurrent observation and interview on 1/15/2026 at 11:46 a.m. with Resident 39, in the resident's room, there was a large, unsealed hole observed in the bathroom ceiling located directly above the toilet. Resident 39 stated, I don't like the hole; it feels like the devil would come out. During an interview on 1/15/2026 at 12:30 p.m. with the Building Maintenance Worker (BMW), the BMW stated it was not safe for the unsealed hole to be left like that and it should have been covered up. During a follow up interview on 1/15/2026 at 3:00 p.m. with the BMW, the BMW stated a maintenance worker was supposed to do the dry wall and cover the hole but did not. During an interview on 1/15/2026 at 4:38 p.m. with the Staff Service Manager (SS), the SS stated the unsealed hole in the ceiling was measured at 33 inches by 19 inches (unit of measurement). During an interview on 1/16/2026 at 8:15 a.m. with Resident 34, Resident 34 stated, the hole on the bathroom ceiling bothers me. During a review of the facility's policy and procedure (P&P) titled, General Maintenance, dated 5/1/2025, the P&P indicated, All building, fixtures, equipment, and spaces will be maintained in operable conditions. Maintenance of [the facility], including the grounds, in a clean and sanitary condition and in good repair at all times was to ensure the safety and well-being of residents, staff, and visitors.

Based on interview and record review, the facility identified building damage that remained consistent during the public safety committee meeting reports from 4/23/2024 to 10/23/2025, and the facility's Quality Assurance and Performance Improvement failed to address a plan of repair to correct the issue. This failure had the potential to adversely affect the health of residents.Cross-reference F584Findings:During a review of the facility's Health and Safety Committee Meetings Records, from 4/23/2024 to 10/23/2025, the meeting records indicated that the walls have holes, scrapes, and paint damage, and this remains consistent.During an interview on 1/15/2025 at 4:16 p.m. with the Staff Services Manager (SS), SS stated he keeps track of all damage found during Environment of Care (EOC-area in building where residents are cared for) rounds. SS confirmed, there is building damage that remained unaddressed for over a year.During an interview on 1/16/2025 at 8:27 a.m. with the Skilled Nursing Facility Administrator (SA), the Standards and Compliance Coordinator (SCC) and the Quality Assurance Registered Nurse (QA), the SA stated they attend the Health and Safety Meetings, and were aware of the building damage reported.During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 4/30/2025, the P&P indicated, Reports will be evaluated to determine further quality issues, plan solutions, implement actions, and ensure follow-up as well as consistent monitoring or results over a specified time frame.

Based on observation, interview and record review, the facility failed to ensure the garbage was disposed properly, when one of the garbage compactor's (a machine that reduces the volume of trash by compacting it) had no top cover and was not closed when not in use.This failure had the potential to attract pests and rodents.Findings:During a concurrent observation and interview on 1/14/2026 at 2:04 p.m. with the Food Service Manager (FSM), in the garbage disposal area, the blue garbage compactor door was opened, no staff around and missing a lid cover. The FSM stated the garbage compactor should had been covered from all sides when not in use to prevent odor and to prevent attracting pests.During a follow up concurrent observation and interview on 1/15/2026 at 10 a.m. with the FSM, in the garbage disposal area, the blue garbage compactor door was opened, no staff around and missing a lid cover. The FSM stated she didn't know why it was like this yesterday and today. The FSM further stated this was not okay and will attract pest and rodents.During an interview on 1/15/2026 at 2:36 p.m. with the Plant Operations Supervisor (POS), the POS stated the garbage compactor had to be a closed container to prevent odor and harborage of pests.During an interview on 1/15/2026 at 3:10 p.m. with the Infection Preventionist (IP), the IP stated the garbage compactor should had been covered in all directions so it reduces the risk of bringing infection to our residents.During a review of the facility's policy and procedure (P&P) titled, Waste Management Program, dated 5/1/2025, the P&P indicated, All containers.will have tight fitting covers in good repair, external handles, and be leak proof and rodent proof.and will meet the following requirements: 1. Have a tight fitting covers, closed when not being loaded.4. Be rodent proof unless stored in a room.

Based on interview and record review, the facility failed to provide the necessary treatment for one of three sampled residents (Resident 1), when the facility accepted Resident 1 for readmission with an order of intravenous (IV, into a vein) antibiotic and the facility was unable to provide this treatment after admission. This failure resulted in delayed medication treatment and Resident 1 being transferred to a different facility that could provide the necessary treatment. Findings:During a phone interview on 11/13/2025 at 8:55 a.m., with the hospital Social Worker (SW), the SW stated a hospital discharge referral was provided to the facility for Resident 1 to be transferred to them on 11/8/2025 with Resident 1 requiring IV Zosyn (also known as piperacillin-tazobactam, an antibiotic). The SW stated when Resident 1 arrived at the facility on 11/8/2025, the facility stated their pharmacy was closed and they could not get the IV Zosyn that Resident 1 required. The SW further stated, Resident 1 had to be transferred to another facility that had the IV Zosyn available for Resident 1. During a review of the email correspondence from the Registered Nurse Case Manager (RNCM), dated 11/7/2025 at 5:13 p.m. and at 5:17 p.m., addressed to the staff, the email correspondence indicated Resident 1 was admitted to the hospital on [DATE] and the plan was for Resident 1 to return to the facility on [DATE] with IV Zosyn.During a review of the hospital's After Visit Summary, dated 11/8/2025, the after visit summary indicated, start taking Zosyn to infuse 3.375-gram (unit of measurement) into a venous catheter (a thin, flexible tube inserted into a large vein), every 8 (eight) hours for infection within the abdomen. Further review of the after visit summary indicated, Zosyn was last given to Resident 1 in the hospital on [DATE] at 8:37 a.m.During a review of Resident 1's Physician Orders, dated 11/8/2025, the physician orders indicated an order for Zosyn, infuse 3.375 grams into a venous catheter, every 8 hours for infection within the abdomen. Further review of the physician orders indicated at 5:50 p.m., Resident 1 was transfer from the hospital and readmitted to the facility with diagnosis of acute appendicitis with appendiceal abscess (a ruptured appendix causes an infection to form a pocket of pus in the abdomen). A 11:05 p.m., Resident 1 was transfer to another facility.During a review of Resident 1's Nursing Notes, dated 11/9/2025 at 12:52 a.m., by Supervising Registered Nurse (SRN 1), the nursing notes indicated, IV Zosyn was not available at the facility, and the in-house pharmacy was closed on the weekends and after hours. Further review of the nursing notes indicated, the after-hours IV pharmacy was called and the operator stated it was the weekend hours, and no one was in the pharmacy. During an interview on 11/19/2025 at 11:06 a.m., with RNCM and SRN 2, RNCM stated she spoke with the hospital's case manager on 11/7/2025, the plan was for Resident 1 to return to the facility on [DATE] and that Resident 1 will be on IV Zosyn. RNCM stated she communicated via email with the staff including the director of nursing and the supervising registered nurses, that Resident 1 will possibly be returning to the facility on [DATE] with IV Zosyn. RNCM further stated she replied yes to the hospital on accepting Resident 1 back at the facility because they can administer the IV Zosyn. SRN 2 stated when the facility gets referrals for a new admission or readmission, the process was to review the referral to determine whether the facility could take that resident. During an interview on 11/19/2025 at 11:55 a.m., with the Director of Nursing (DON), the DON stated the facility was notified on 11/7/2025 that Resident 1 will be on IV Zosyn upon admission. The DON further stated SRN 1 called their contracted after-hours IV pharmacy and was informed that no one could process the IV antibiotic request.During a concurrent interview and record review on 11/19/2025 at 1:25 p.m., with the Pharmacy Manager (PM), the facility's after-hours IV Pharmacy Contract, dated 12/30/2022 was reviewed. The PM stated the after-hours IV pharmacy was not frequently used and did not seem like they were open 24/7. During a follow up interview on 11/19/2025 at 2:47 p.m., with the DON, the DON stated Resident 1 previously lived at the facility and so Resident 1 was accepted to be readmitted to the facility on [DATE]. The DON stated the facility did not ensure that they had the antibiotic available to administer and the after-hours IV pharmacy was called, but the nurse was told no one was there to process the order. The DON stated the assumption was that the hospital would provide the antibiotic when Resident 1 was transferred to the facility. The DON further stated the facility thought the after-hours IV pharmacy was open 24/7.During a follow up interview on 11/19/2025 at 3:33 p.m., with RNCM, RNCM stated on 11/7/2025, she did not check if the facility had IV Zosyn available because their in-house pharmacy was closed already.During a follow up interview on 11/19/2025 at 3:48 p.m., with PM, the PM stated she was not made aware that Resident 1 would be on IV Zosyn.During a phone interview on 11/21/2025 at 6:10 p.m., with SRN 1, SRN 1 stated the last administration of IV Zosyn that Resident 1 received was on 11/8/2025 at around 8:30 a.m. SRN 1 stated the E-kit (also known as emergency kit, a supply of prescription medications), did not have the IV Zosyn.During a review of the facility's after-hours IV Pharmacy Contract, dated 12/30/2022, the contract indicated, Contractor will provide anti-infectives and drugs used to treat symptoms that are determined severe by the treating medical personnel, available (e.g. delivered) the same day of receipt of order if order is received before 12 pm and delivery is within one hundred (100) miles of contractor. Same-day delivery may be available beyond 100 miles upon mutual agreement between dispensing pharmacy and ordering Participating Entity. Emergency/expedited orders: upon mutual agreement of the participating entity and dispensing pharmacy, contractor will make weekend and holiday deliveries at no additional fees beyond the cost of the courier or other delivery services outside of normal delivery methods within the agreement.During a review of the facility's 2025 Skilled Nursing Facility Assessment, dated April 2025, the facility assessment indicated, Part 2: Services and Care We Offer Based on our Resident's Needs. Medications. Emergency medication orders are obtained from Talyst e-kit or manual e-kit. If medication is not available from the e-kit, it is obtained thru the Home's off-hours contracted pharmacy.During a review of the facility's policy and procedure (P&P) titled, Nursing Admission, dated June 2025, the P&P indicated, The facility will accept and retain only those residents for whom it can provide care .I. Pre-admission of New or Returning Residents: Information shall be obtained regarding a new or returning resident relative to their .status prior to transfer. Information can be obtained from the hospital or discharge coordinator or case manager.

Based on observation, interview, and record review, the facility failed to ensure surgical masks (a loose-fitting mask worn over the nose and mouth to help reduce the spread of infection) were worn on Unit 300 where Covid-19 (a contagious respiratory disease) positive residents resided. This failure had the potential to spread respiratory disease to the residents, staff, and visitors.Findings:During an observation on 9/3/2025 at 10:14 a.m., on Unit 300, Certified Nursing Assistant (CNA 1) and CNA 2, were observed in the hallway at a cart containing food items. CNA 1 and CNA 2 were observed wearing a surgical mask around their necks not covering their nose and mouth. In addition, a Licensed Vocational Nurse (LVN 1) was observed at the nurse's station not wearing a mask.During an interview on 9/3/2025 at 10:20 a.m., with CNA 1, CNA 1 stated she and CNA 2 were passing nourishments to the residents. CNA 1 stated she was supposed to wear the surgical mask over her nose and mouth.During an interview on 9/3/2025 at 10 a.m., with the Infection Preventionist (IP), IP stated four residents on Unit 300, one resident on Unit 700, and four staff had tested positive for Covid-19. IP stated, a surgical mask was required to be worn on the residents' units, and an N-95 mask (a tight-fitting mask that filtered out small and large infectious airborne particles) for direct care of Covid-19 positive residents.During an interview on 9/3/2025 at 10:22 a.m., with the Director of Nursing (DON), the DON stated staff should not pull their surgical masks down around their necks.During an interview on 9/3/2025 at 10:35 a.m., with LVN 1, LVN 1 stated she was the visiting hospice nurse for a resident. LVN 1 stated she was supposed to follow the facility's masking procedures. LVN 1 stated she should have been wearing a surgical mask.During an interview on 9/3/2025 at 12:22 p.m., with Standard Compliance Coordinator (SCC) and the DON, SCC stated the facility's Covid-19 policy and procedure was being developed. SCC stated, We have a mitigation plan we are following. The DON stated staff, visitors, and visiting hospice nurses were to follow the mitigation's plan for source control and masking.During a review of the facility's mitigation plan titled, Viral Respiratory Illness Mitigation Plan, dated August 2025, the mitigation plan indicated, 15. Source Control Masking, Source control masking reduces the risk of spreading VRI (Viral Respiratory Illness) to others and is recommended for Residents and Staff especially in gatherings and during periods of increased VRI activity. There are times when source control masking is required. 15.1 General Indications for Source Control Masking Specific masks types or universal source control masking may be required at times when: The facility is experiencing a VRI Outbreak and/or a surge in cases.

50674 Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation measures were maintained in the kitchen according to standards of practice and facility policy when: 1. One plastic bin containing white colored powder was observed underneath food preparation counter and was unlabeled and undated. 2. One bag of opened frozen peanut butter cookies was observed in the walk-in freezer and three sandwiches observed in the refrigerator were unlabeled and undated. 3. One bag of food labeled, meat substitute was observed expired in the walk-in freezer. 4. Five broken tiles were observed at the base of the wall in the kitchen next to the dish drying racks. These failures had the potential to place residents at risk for developing foodborne illnesses by exposing residents to contaminated food and unsanitary practices. Findings: 1. During a concurrent observation and interview on [DATE] at 1:10 p.m. with the Food Service Manager 1 (FSM 1) in the kitchen, there was a plastic bin underneath the preparation counter which was filled with a white powdered substance. No label or date was found on the plastic bin. The FSM 1 stated the white powdered substance was a thickening agent used for pureed foods. The FSM 1 stated the bin should have been labeled and dated. During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section ,d+[DATE].11 titled, Food Labels, the FDA Food Code indicated, (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement. 2. During a concurrent observation and interview on [DATE] at 11:00 a.m. with the Food Service Manager 1 (FSM 1) in the kitchen, a bag of frozen peanut butter cookies was found in the walk-in freezer, two peanut butter and jelly sandwiches, and one egg sandwich in the refrigerator were found unlabeled and undated. The FSM 1 stated the sandwiches did not have labels. During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section ,d+[DATE].18 titled, Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, the FDA Food Code indicated, A food shall be discarded if it is in a container or PACKAGE that does not bear a date or day. 3. During a concurrent observation and interview on [DATE] at 11:05 a.m. with the Food Service Manager 1 (FSM 1) in the kitchen, a clear medium sized plastic bag of ground crumbled brown food labeled as, meat substitute was found in the freezer. The date on the bag indicated, 7 [DATE]- 7 [DATE]. The FSM 1 stated it should not be in the freezer because it is past the date on the label. During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section ,d+[DATE].17 titled, Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, the FDA Food Code indicated, Refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Food Storage Procedure Guidelines, dated [DATE], the P&P indicated, A 'Use-By' date is the last date recommended for the use of the product. 4. During a concurrent observation and interview on [DATE] at 10:40 a.m. with the Food Service Manager 2 (FSM 2) in the kitchen, multiple broken tiles were found near the base of the wall next to the dish drying racks. There were 9 total damaged tiles, 5 of the tiles had large cracks and/or were broken from the wall which resulted in holes the size of an orange. The FSM 2 stated she was unsure of how long the tiles had been broken. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Sanitation, dated [DATE], the P&P indicated, Kitchen and serving area(s): Will be kept clean, free from litter and rubbish. Ceilings, walls, windows, floors, and doors will be kept clean and maintained in good repair [i.e. free from breaks, corrosion, holes, cracks, chips, dirt, and/or grime].

Based on interview and record review, the facility failed to ensure a copy of a notice of transfer/discharge was sent to the Ombudsman (an advocate for residents of nursing homes) for three of 44 sampled residents (Residents 19, 47, and 99) when: 1. Resident 19 was transferred to the hospital on 1/22/2025. 2. Resident 47 was transferred to the hospital on 8/27/2024. 3. Resident 99 was transferred to the hospital on 1/8/2025. This failure had the potential for residents to be inappropriately transferred or discharged which could result in violating their rights. Findings: 1. During a review of Resident 19's Physician's Progress Note, dated 12/4/2024, the Physician's Progress Note indicated Resident 19 had diagnoses of diabetes mellitus (a disorder that results in too much sugar in the blood) and sacral (buttocks) moisture associated skin damage (MASD, skin irritation caused by prolonged exposure to moisture usually from incontinence). During a review of Resident 19's Physician's Orders, dated 1/22/2025, the Physician's Orders indicated, for Resident 19 to be Send to [hospital's name] for further evaluation and treatment related to left and right buttocks wound. Further review of Resident 19's medical record indicated there was no documented evidence that the ombudsman was notified of Resident 19's transfer to the hospital on 1/22/2025. During an interview on 1/29/2025 at 4:05 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility does not notify an ombudsman when a resident is transferred to the hospital or discharged from the facility. During an interview on 1/30/2025 at 11:56 a.m. with the ADON, the ADON stated he was not aware the ombudsman had to be notified of resident transfers or discharges. During a review of the facility's policy and procedure (P&P) titled, Transfer/Discharge, dated 9/27/2022, the P&P did not address notifying the ombudsman of resident transfers/discharges. 2. During a review of Resident 47's Physician's Progress Note, dated 12/9/2024, the Physician's Progress Note indicated Resident 47 was readmitted to the facility from the hospital on 12/7/2024 with a diagnosis of status post right above knee amputation. The Physician's Progress Note further indicated Resident 47 was hospitalized from 8/27/2024 - 12/6/2024. During a review of Resident 47's Nursing Notes, dated 8/27/2024 at 10:46 p.m., the Nursing Notes indicated the facility placed a call to [hospital's name] and was informed that Resident 47 will be admitted . Further review of Resident 47's medical record indicated there was no documented evidence that the ombudsman was notified of Resident 47's transfer to the hospital on 8/27/2024. During an interview on 1/29/2025 at 4:05 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility does not notify an ombudsman when a resident is transferred to the hospital or discharged from the facility. During an interview on 1/30/2025 at 11:56 a.m. with the ADON, the ADON stated he was not aware the ombudsman had to be notified of resident transfers or discharges. During a review of the facility's policy and procedure (P&P) titled, Transfer/Discharge, dated 9/27/2022, the P&P did not address notifying the ombudsman of transfers/discharges. 50148 3. During a review of Resident 99's Admission Face Sheet Record (demographics), [undated], the Face Sheet indicated Resident 99 had a diagnosis of osteomyelitis (a chronic bone infection). During a review of Resident 99's Physician Order, the Physician Order indicated, send Resident 99 to [hospital's name] on 1/8/2025 for further evaluation and treatment related to the bone infection. Further review of Resident 99's medical record indicated there was no documented evidence that the ombudsman was notified of Resident 99's transfer to the hospital on 1/8/2025. During an interview on 1/29/2025 at 4:05 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility does not notify the ombudsman when a resident is transferred to the hospital or discharged from the facility. The ADON confirmed that the ombudmsman was not notified when Resident 99 was transferred out. During a review of the facility's policy and procedure (P&P) titled, Transfer/Discharge, dated 9/27/2022, the P&P did not address notifying the ombudsman of transfers/discharges.

Based on observation, interview, and record review, the facility failed to ensure safe infection control practices were followed when: 1. Enhanced Barrier Precautions (EBP - infection control practice that uses PPE-personal protective equipment to reduce the spread of bacteria) was not followed for Resident 84 during perineal hygiene care (cleaning of genital area), medication administration, and tube feeding (liquid nutrition delivered through a tube that is inserted through the skin into stomach) administration. 2. Enhanced Barrier Precautions (EBP-infection control practice that uses PPE-personal protective equipment to reduce the spread of bacteria) was not followed for Resident 25 during medication administration via tube feeding (liquid nutrition delivered through a tube that is inserted through the skin into stomach). 3. An opened single-use syringe labeled sterile was observed attached with a rubber band to a gabapentin (drug to manage chronic pain condition) medication bottle for Resident 51. 4. One unsealed bottle of saline spray was observed stored missing the printed neckband. These failures had the potential to result in the spread of communicable diseases (illnesses that spread from one person to another) to residents, staff, and visitors. In addition this had the potential for transfer of microorganisms (germs) to the residents and/or for the residents to be treated with ineffective or deteriorated (reduced quality) supplies, which could negatively impact the resident's clinical conditions. Findings: 1. During a review of Resident 84's Face Sheet (demographics), dated 1/30/2025, the Face Sheet indicated Resident 84 was admitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing foods and liquids) and gastrostomy tube (G-tube, a tube inserted through the skin directly into the stomach to provide medications and liquid nutrition). During an observation on 1/29/2025 at 4:04 p.m., in Resident 84's room, a sign was observed outside of the room alerting staff Resident 84 required EBP. The EBP sign indicated, Providers and staff must also: wear gloves and a gown for the following High-Contact resident care activites . Device care or use: feeding tube . Resident 84 was observed lying in bed. Certified Nursing Assistant 1 (CNA 1) was at the resident's bedside holding soiled linen and a bag containing soiled cleansing wipes and a soiled brief. CNA 1 was not wearing a gown. Licensed Vocational Nurse 5 (LVN 5) was observed entering Resident 84's room. LVN 5 administered medications through Resident 84's G-tube and administered tube feeding formula (liquid nutrition) through Resident 84's G-tube. LVN 5 was not wearing a gown. During an interview on 1/29/2025 at 4:19 p.m. with CNA 1, CNA 1 stated she did not wear gown during perineal hygiene care for Resident 84. CNA 1 stated a gown was required for perineal hygiene care for the protection of residents and staff. CNA 1 confirmed, she should have worn a gown while attending to Resident 84. During a concurrent observation and interview on 1/29/2025 at 4:22 p.m., with LVN 5, LVN 5 confirmed EBP signage was posted outside of Resident 84's room but was unaware why Resident 84 was on EBP. LVN 5 confirmed she did not wear a gown during medication and G-tube feeding administration, and should have worn a gown. During an interview on 1/30/2025 at 12:03 p.m. with Infection Control Nurse (ICN), ICN stated EBP was required for perineal hygiene care, G-tube medication administration, and G-tube feeding. ICN stated CNA 1 and LVN 5 should have worn a gown while performing these tasks for Resident 84. ICN stated EBP was important to prevent and reduce the spread of Multiple Drug Resistant Organisms (MDRO - bacteria that are resistant to multiple antibiotics and can cause serious infections). During a review of Resident 84's Care Plan, dated 1/30/2025, the Care Plan indicated, Enhanced Barrier Precautions due to G-tube use. The facility did not provide an Enhanced Barrier Precautions policy and procedure during the survey, as requested. During a review of the CDC (Centers for Disease Control) Guidance, dated 4/2/2024, the guidance indicated, Use EBP for residents with indwelling medical devices, wounds, or those who are colonized by or infected with a multidrug-resistant organism. Use EBP when: Dressing or bathing, transferring, changing linens, assisting with toileting, accessing indwelling medical devices, providing wound care, other high-contact resident care activities .before entering a resident's room with an EBP sign, correctly put on a gown and gloves. 35030 2. During a review of Resident 25's Face Sheet (demographics), [undated], the face sheet indicated, Resident 25 was admitted to the facility on [DATE], with diagnoses of multiple sclerosis (a condition that affects the brain), dysphagia (difficulty swallowing) and status post gastrostomy (G-tube, a tube inserted into the stomach to provide medication and liquid nutrition). During an observation on 1/28/2025 at 9:14 a.m. outside Resident 25's room, an EBP sign was posted. The EBP sign indicated, Providers and Staff must also: Wear gloves and a gown for the following High-Contact resident Care activities . Device care or use: feeding tube. During a concurrent observation and interview on 1/29/2025 at 4 p.m. with Licensed Vocational Nurse 4 (LVN 4) in Resident 25's room, LVN 4 was observed administering medications to Resident 25 via a G-tube. LVN 4 did not have on a gown. LVN 4 stated, I only wear a gown when the resident has an active infection. During an interview on 1/29/2025 at 4:34 p.m. with Registered Nurse 4 (RN 4), RN 4 stated Resident 25 was on Enhanced Barrier Precautions and staff should have worn a gown and gloves for Resident 25's G-tube care. During an interview on 1/30/2025 at 11:50 a.m. with the Infection Control Nurse (ICN), the ICN stated staff should have worn a gown and gloves when performing G-tube care to include medication administration. The ICN stated staff should have worn a gown and gloves to prevent/limit the spread of MDRO (Multidrug-Resistant Organisms- bacteria that has become resistant to multiple antibiotics) transmission. The facility did not provide an Enhanced Barrier Precautions policy and procedure during the survey, as requested. During a review of the CDC (Centers for Disease Control) Guidance, dated 4/2/2024, the guidance indicated, Use EBP for residents with indwelling medical devices, wounds, or those who are colonized by or infected with a multidrug-resistant organism. Use EBP when: Dressing or bathing, transferring, changing linens, assisting with toileting, accessing indwelling medical devices, providing wound care, other high-contact resident care activities .before entering a resident's room with an EBP sign, correctly put on a gown and gloves. 35335 3. During a concurrent observation and interview on 1/27/2025 at 2:48 p.m., an inspection of the Unit 700 Medication Room was conducted with Pharmacist 1 (RPH 1) and Registered Nurse 1 (RN 1). During a concurrent observation and interview on 1/27/2025 at 2:48 p.m., in the medication room, an opened single-use syringe labeled sterile was observed attached with a rubber band to a gabapentin (drug to manage chronic pain condition) medication bottle for Resident 51. The syringe was stored in Unit 700 Medication Room refrigerator inside an opened manufacturer's packaging. The syringe manufacturer's product labeling indicated Sterile. Do Not Reuse. RPH 1 acknowledged the syringe in the open manufacturer's packaging was stored and rubber banded to the gabapentin medication bottle. RPH 1 and RN 1 acknowledged the syringe manufacturer's product labeling indicated Sterile. Do Not Reuse. RPH 1 and RN 1 stated the opened syringe had risk for contamination. During an interview on 1/30/2025 at 11:53 a.m., the Infection Control Nurse (ICN) stated there is potential for contamination if the single-use syringes are reused on the resident. During a review of the facility's policy and procedure (P&P) titled, Drug Storage, dated 8/15/2022, the P&P indicated, Drugs will not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs will be available for use. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 3/26/2024, the P&P indicated, The [name of the facility] each maintain a comprehensive Infection Prevention and Control Program (ICP) and is an essential component of quality care. The ICP is a facility-wide system designed to prevent the occurrence or limit the spread of infections through the prevention, identification, and control of infectious organisms. The ICP is based on the facility assessment, best practices and maintains compliance with all county, state, and federal regulations. 4. During a concurrent observation and interview on 1/27/2025 at 2:48 p.m., an inspection of the Unit 700 Medication Room was conducted with Pharmacist 1 (RPH 1). During a concurrent observation and interview on 1/27/2025 at 2:48 p.m., in the Unit 700 medication room, one unsealed bottle of saline spray was stored with other sealed bottles, and was observed missing the red printed neckband. The manufacturer's product labeling indicated on the bottle DO NOT USE IF PRINTED NECKBAND IS BROKEN OR MISSING. RPH 1 acknowledged the saline spray was missing the printed neckband and the manufacturer's product labeling. During an interview on 1/30/2025 at 11:53 a.m., the Infection Control Nurse (ICN) stated there is potential for contamination if an unsealed saline spray is used on the resident. During a review of the facility's policy and procedure (P&P) titled, Drug Storage, dated 8/15/2022, the P&P indicated, Drugs will not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs will be available for use. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 3/26/2024, the P&P indicated, The [name of the facility] each maintain a comprehensive Infection Prevention and Control Program (ICP) and is an essential component of quality care. The ICP is a facility-wide system designed to prevent the occurrence or limit the spread of infections through the prevention, identification, and control of infectious organisms. The ICP is based on the facility assessment, best practices and maintains compliance with all county, state, and federal regulations.

50674 Based on observation, interview, and record review, the facility failed to ensure food was served at an acceptable temperature to be appetizing for residents according to the facility's resident council and the facility policy. This failure had the potential to affect meal and food intake which could impair the nutrition status of the residents. Findings: During a review of the facility's menu titled, January 26, 2025-February 01, 2025, the menu for Tuesday 1/28/2025 indicated, the lunch meal for a Regular diet included, Carrot Raisin Pineapple Salad, Carne [NAME]/Soft Tortilla, Pinto Beans/Corn Muffin, Tomato/Onion/Cilantro, Sour Cream/Salsa and Chocolate Cake with Icing for dessert. During a concurrent test tray observation and interview on 1/28/2025 at 12:50 p.m. in the 1000 Unit pod common dining area, the meal cart left the kitchen and arrived at the Unit at 12:18 p.m. The entree of carne [NAME] with tortilla was 128 degrees Fahrenheit (F- measurement of temperature) and the 8-ounce carton of 2% milk was 50.8 degrees F on the surveyor's thermometer. The regular side item, beans, were dried out. The Director of Dietetics (DD) acknowledged the low food temperatures and stated she expected the foods to be served to residents at an acceptable temperature and palatability (how pleasant a food or drink tastes and appeals to the senses). On 1/29/2025 at 9:33 a.m., a Resident Council meeting was conducted with residents. During the meeting, nine out of nine residents (Resident's 6, 11, 21, 38, 40, 60, 61, 73 and 75) stated the meals served to them was often cold, especially the breakfast foods. During a concurrent observation and interview on 1/30/2025 at 7:50 a.m. in the 400 Unit pod dining area with Resident 46, Resident 46 was seated at a table eating breakfast. Resident 46 stated some of his food was often cool when he receives his meal, and he would prefer to have his food served a little hotter. During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section 3-501.16 titled, Time/Temperature Control for Safety . Holding, the FDA Food Code indicated, Food shall be maintained . held at a temperature of 54 degrees Celsius (130 degrees F) or above. During a review of the facility's policy and procedure (P&P) titled, Food Preparation Guidelines, dated 8/7/2024, the P&P indicated, Food preparation and holding methods allow for maximum conservation of nutrients, flavor and appearance. Food will be served at required temperatures.

Based on observation, interview, and record review, the facility failed to ensure a dental appointment was scheduled for one of 44 sampled residents (Resident 72). This failure had the potential to result in Resident 72 experiencing infection, pain, or complications from ill-fitting dentures. Findings: During a review of Resident 72's Face Sheet (demographics), dated 1/30/2025, the Face Sheet indicated Resident 72 was admitted to the facility on [DATE] with diagnosis of dysphagia (difficulty swallowing foods and liquids). During a concurrent observation and interview on 1/28/2025 at 10:02 a.m., with Resident 72, Resident 72 was observed without any teeth or dentures in his mouth. Resident 72 stated he had dentures but did not wear them because the dentures were uncomfortable. Resident 72 stated, I haven't been seen by dentist in a while. During a concurrent interview and record review on 1/29/2025 at 2:45 p.m. with Registered Nurse 4 (RN 4), RN 4 stated Resident 72 had not been to the dentist since 10/23/2023. During a follow up interview and record review on 1/30/2025 at 9:53 a.m., with RN 4, Resident 72's Physician's Order, dated 11/10/2024, was reviewed and indicated, Dental evaluation and treatment. RN 4 stated, the Charge Nurse should have notified the Office Assistant (OA) to arrange a dental appointment for Resident 72 and documented the notification in the record. RN 4 confirmed there was no documentation in Resident 72's record which indicated a dental appointment was requested for Resident 72. RN 4 confirmed the Physician's Order was not followed and Resident 72 had not been evaluated by the dentist. During a review of the facility's policy and procedure (P&P) titled, Dental Services for Residents, dated 09/01/2024, the P&P indicated, Each resident shall have an initial dental screening examination, in conjunction with complete medical evaluation, on admission to the facility.

Based on observation, interview, and record review, the facility failed to ensure medications were appropriately labeled in accordance with accepted standards of practice and/or manufacturer's instructions when: 1. During an inspection of one of two medication rooms, one outdated insulin vial was stored and available for resident use. 2. During an inspection of one of two medication rooms, a bulk bottle of atovaquone (anti-infective drug) oral suspension (liquid) for Resident 39 was not stored in accordance with manufacturer's instructions and available for resident use. These failures had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes. Findings: 1. During a concurrent observation and interview on 1/27/2025 at 2:48 p.m., an inspection of the Unit 700 Medication Room was conducted with Pharmacist 1 (RPH 1). During a concurrent observation and interview on 1/27/2025 at 3:11 p.m., in the medication room, an insulin vial was observed stored with a pharmacy label indicating Do Not Use After 01/22/25. RPH 1 acknowledged the outdated insulin vial stored in the refrigerator with the pharmacy label indicating to not use the medication after January 22, 2025. RPH 1 stated the insulin vial should not go back into the medication room refrigerator. During a concurrent interview and record review on 1/29/2025 at 2:23 p.m., the facility's policy and procedure (P&P) titled, Drug Storage, dated 8/15/2022, was reviewed with the Director of Pharmacy (DOP). The DOP acknowledged the policy indicated Drugs will not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs will be available for use. The DOP stated the outdated insulin vial should have been removed from the medication refrigerator when the resident's medication was discontinued. 2. During a concurrent observation and interview on 1/27/2025 at 10:55 a.m., an inspection of the Unit 300 Medication Room was conducted with Pharmacist 1 (RPH 1). The medication room refrigerator was observed at a temperature of 38 degrees Fahrenheit (F - unit of temperature measurement) and RPH 1 acknowledged the refrigerator temperature. During a concurrent observation and interview on 1/27/2025, at 10:59 a.m., in the medication room, a bulk bottle of atovaquone oral suspension for Resident 39 was observed stored in the medication refrigerator with the manufacturer's product labeling indicated on the bottle Store at 20 to 25C [Celsius - Unit of temperature measurement] (68 to 77F); excursion permitted between 15 to 30C (59 to 86F). The atovaquone medication carton indicated Store at 20 to 25C (68 to 77F); excursion permitted between 15 to 30C (59 to 86F). RPH 1 acknowledged the manufacturer's product labeling on the medication bottle, the medication carton labeling, and the atovaquone oral suspension was stored in the refrigerator with a temperature of 38 degrees Fahrenheit. During a review of the Atovaquone oral suspension package insert (information on how to safely use a drug) dated December 2023, obtained from the facility, indicated HOW SUPPLIED/STORAGE AND HANDLING .Store at 20 to 25C (68 to 77F); excursion permitted between 15 to 30C (59 to 86F). During a concurrent interview and record review on 1/29/2025 at 2:28 p.m., the facility's policy and procedure (P&P) titled Drug Storage, dated 8/15/2022, was reviewed with the Director of Pharmacy (DOP). The DOP acknowledged the policy indicated, STORAGE TEMPERATURES A. Nursing staff will review manufacturer's recommendations for proper storage to ensure that drugs are stored in appropriate temperatures. Drugs required to be stored at room temperature will be stored at a temperature between 15C (59F) and 25C (77F).

Based on observation, interview, and record review, the facility did not ensure the medication error rate was less than 5% when three errors for Resident 9 and Resident 87 occurred out of 42 opportunities for a medication administration error rate of 7.14%. For Resident 9, the medication glipizide (drug to manage blood sugars) was not administered 30 minutes before meals. For Resident 87, one medication was omitted, and the medication fexofenadine (drug to manage allergies) was given to the resident at the same time as fruit juice. This failure had the potential to expose residents to preventable medication errors which could result in adverse health outcomes. Findings: a. During a concurrent observation and interview on 1/28/2025 at 9:27 a.m., Licensed Vocational Nurse 2 (LVN 2), at the medication cart outside of Resident 9's room, the medication glipizide was prepared at the medication cart. LVN 2 acknowledged glipizide tablet was poured into the medication cup for Resident 9. During an observation on 1/28/2025 at 9:40 a.m., in Resident 9's room, LVN 2 administered glipizide to Resident 9. During a concurrent interview and record review on 1/28/2025 at 10:54 a.m., the Nursing2020 Drug Handbook for the medication glipizide was reviewed with LVN 1, obtained from the facility's Unit 700 Nursing Station, indicated Give immediate-release tablet about 30 minutes before meals. LVN 1 stated the facility's drug handbook obtained from the nursing station indicated to give immediate release about 30 minutes before meals. LVN 2 was not available for interview. During an interview on 1/29/2025 at 10:14 a.m., the Director of Pharmacy (DOP) stated the facility staff uses Lexi-comp as their reference for drug information. During an interview on 1/29/2025 at 10:28 a.m., LVN 2 stated breakfast is served around 7:45 a.m. and residents eat between 8:00 a.m to 9:00 a.m. LVN 2 stated the resident needs food to take the diabetic medications glipizide and metformin. LVN 2 stated Resident 9 ate about 75% of breakfast on 1/28/2025. During an observation on 1/29/2025 at 10:30 a.m., at the medication cart outside of Resident 9's room, the glipizide medication bubblepack for Resident 9 was observed to be immediate-release tablets. During a concurrent interview and record review on 1/29/2025 at 3:05 p.m., the drug information for glipizide was reviewed with the DOP, obtained from the facility's Lexi-comp on 1/29/2025, indicated once daily 30 minutes before the first main meal. The DOP acknowledged Lexi-comp drug reference indicated the medication glipizide is to be administered 30 minutes before the first main meal. During a concurrent interview and record review on 1/29/2025 at 3:05 p.m., the Nursing 2020 Drug Handbook for the medication glipizide was reviewed with the DOP, obtained from the facility's Unit 700 Nursing Station, indicated Give immediate-release tablet about 30 minutes before meals. The DOP acknowledged the facility's drug handbook obtained from the nursing station indicated to give immediate release about 30 minutes before meals. During a review of the facility's policy and procedure (P&P) titled, Medication Pass dated 8/12/2024, the P&P indicated I. PRIOR TO PASSING MEDICATIONS . D. Review Medication Administration Records (MAR) for special time medications like .medications before and after meals . II. DURING THE PASS . H. Special considerations should be noted on the MAR. b. During a concurrent observation and interview on 1/29/2025 at 9:07 a.m., at the medication cart outside of Resident 87's room, Registered Nurse 3 (RN 3) prepared and poured Resident 87's medications into the medicine cup: 1. Amlodipine (blood pressure drug) 10 mg (milligrams - a unit of measurement for dose) x 1 tablet 2. Atorvastatin (cholesterol drug) 20 mg x 1 tablet 3. Fexofenadine (allergy drug) 180 mg x 1 tablet 4. Finasteride (prostate drug) 5 mg x 1 tablet 5. Metolazone (diuretic drug) 5 mg x 1 tablet 6. Fish Oil 1000 mg x 1 softgel 7. Calcium Oyster Shell (mineral) 500 mg x 1 tablet 8. Vitamin D3 IU (international unit - a unit of measurement for dose) x 1 tablet 9. Sodium Chloride (electrolyte) 1 gram (a unit of measurement for dose) x 1 tablet 10. Senna (laxative) 8.6 mg x 2 tablets 11. Telmisartan (blood pressure drug) 80 mg x 1 tablet 12. Hydroxyzine (antihistamine) 50 mg x 1 tablet 13. Furosemide (diuretic drug) 40 mg x 1 tablet 14. Potassium Chloride (drug to treat low potassium levels) 20 MEQ (milliequivalent - a unit of measurement) x 1 tablet 15. Gabapentin (chronic pain drug) 600 mg x 1 tablet 16. Ferrous Sulfate (iron supplement) 325 mg x 1 tablet During a concurrent observation and interview on 1/29/2025 at 9:27 a.m., at the medication cart outside of resident 87's room, RN 3 stated she had 17 pills in her medication cup including two senna tablets. During a concurrent observation and interview on 1/29/2025 at 9:30 a.m., at the medication cart outside of resident 87's room, RN 3 was observed pouring orange juice into a cup. RN 3 stated it was 120 milliliters (mL - a unit of measurement) of orange juice. During an observation on 1/29/2025 at 9:31 a.m., in Resident 87's room, RN 3 administered all 17 medications to Resident 87 including fexofenadine with the 120 mL's of orange juice. During an interview on 1/29/2025 at 9:32 a.m., RN 3 stated Resident 87 drank all 120 mL's of orange juice with all the medications. During an interview on 1/29/2025 at 9:38 a.m., RN 3 stated all medications due at this time were administered to Resident 87. During an interview on 1/29/2025 at 10:14 a.m., the Director of Pharmacy (DOP) stated the facility staff uses Lexi-comp as their reference for drug information. During a concurrent interview and record review on 1/29/2025 at 11:15 a.m., Resident 87's medical record and physician's orders were reviewed with RN 3. The physician's orders indicated a medication order for CEROVITE TAB SENIOR .TAKE ONE (1) TABLET BY MOUTH DAILY - SUPPLEMENT. RN 3 stated that they may not have given it. RN 3 stated they were going to go administered it to Resident 87 now and that it had already been signed off in the Medication Administration Record (MAR - section of the medical record where medications are documented after they have been administered). During a concurrent interview and record review on 1/29/2025 at 2:56 p.m., the drug information for fexofenadine was reviewed with the DOP, obtained from the facility's Lexi-comp on 1/29/2025, indicated Administration: Oral .do not administer with fruit juices. The DOP acknowledged the Lexi-comp drug reference indicated the medication fexofenadine should not be administered at the same time with fruit juice. During a concurrent interview and record review on 1/29/2025 at 2:56 p.m., the facility's policy and procedure (P&P), titled Medication Pass, dated 8/12/2024, the P&P indicated II. DURING THE PASS .H. Special considerations should be noted on the MAR. The DOP acknowledged the policy. During a review of the facility's policy and procedure (P&P) titled, Drug Administration, dated 9/24/2024, the P&P indicated, Medications and treatments shall be administered as prescribed. During a review of the facility's policy and procedure (P&P) titled, Medication Pass, dated 8/12/2024, the P&P indicated I. PRIOR TO PASSING MEDICATIONS . D. Review Medication Administration Records (MAR) for special time medications like .medications before and after meals . II. DURING THE PASS . H. Special considerations should be noted on the MAR . L. Medications must be given as prescribed. During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Administration, dated 4/15/2024, the P&P indicated, I. ADMINISTRATION OF MEDICATION . I. Doses shall be administered within (1) hour of prescribed time . IV. ROUTINE MEDICATIONS AND TREATMENT SCHEDULE .medication and treatments are administered according to the following schedule: QD [every day] -----0900 [9:00 a.m.]

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services for a universe of 103 residents when: 1. During an inspection of one of two medication rooms, outdated Procrit (drug to treat low red blood cell count), Mantoux (diagnostic test to detect tuberculosis infection which is a lung infection) vial, and insulin (drug to manage blood sugar levels) pen were observed stored and available for resident use. This failure had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes. 2. During an inspection of one of two medication carts, one expired nitroglycerin (drug to manage chest pain) vial was observed stored and available for resident use. This failure had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes. 3. For Resident 5, the facility could not demonstrate controlled drug (narcotics with potential for physical and psychological dependence) records were maintained in an organized and orderly manner to show the receipt to disposition (Chain of custody) of each dose was readily traced in sufficient detail. This failure had the potential for inadequate narcotic accountability and/or drug diversion (illegal use of medication unauthorized individuals), abuse, or misuse. Findings: 1. During a concurrent observation and interview on [DATE] at 10:55 a.m., an inspection of the Unit 300 Medication Room was conducted with Pharmacist 1 (RPH 1). 1A. During a concurrent observation and interview on [DATE], at 10:59 a.m., one vial of Procrit 10,000 units/mL (milliliter - a unit of measurement) was observed stored in the medication refrigerator with a manufacturer expiration date of ,d+[DATE] [[DATE]]. RPH 1 acknowledged the Procrit vial observed stored in the Unit 300 medication refrigerator expired in [DATE]. 1B. During a concurrent observation and interview on [DATE], at 10:59 a.m., one opened vial of Mantoux was observed stored in the medication refrigerator with O.D (Open Date): [DATE] and Exp. (expiration date) [DATE] handwritten in black ink. The manufacturer's product labeling on the vial indicated Discard opened product after 30 days. RPH 1 acknowledged the opened Mantoux vial with the manufacturer's product labeling observed stored in the Unit 300 medication refrigerator was labeled outdated on [DATE]. During a review of the Mantoux package insert (information on how to safely use a drug) dated [DATE], indicated A vial of TUBERSOL (also known as Mantoux) which has been entered and in use for 30 days should be discarded. 1C. During a concurrent observation and interview on [DATE] at 2:48 p.m., an inspection of the Unit 700 Medication Room was conducted with RPH 1. During a concurrent observation and interview on [DATE] at 2:48 p.m., one insulin pen labeled with a yellow sticker was observed stored in the medication refrigerator with a Date Opened ,d+[DATE] [[DATE]] and Exp Date ,d+[DATE] [[DATE]]. RPH 1 acknowledged the insulin pen was labeled outdated on [DATE]. During a concurrent interview and record review on [DATE] at 2:23 p.m., the facility's policy and procedure (P&P) titled Drug Storage dated [DATE] was reviewed with the Director of Pharmacy (DOP). The DOP acknowledged the policy indicated Drugs will not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs will be available for use. The DOP stated the outdated Procrit vial and insulin pen should have been removed from the medication refrigerator when the resident's medication was discontinued. During a concurrent interview and record review on [DATE] at 2:38 p.m., the facility's P&P titled Drug Storage dated [DATE] was reviewed with the DOP. The DOP acknowledged the policy indicated Drugs will not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs will be available for use. The DOP stated the outdated Mantoux vial should have been removed from the medication refrigerator. 2. During a concurrent interview and record review on [DATE] at 2:38 p.m., the facility's policy and procedure (P&P) titled Drug Storage dated [DATE] was reviewed with the Director of Pharmacy (DOP). The DOP acknowledged the policy indicated, Drugs will not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs will be available for use. The DOP stated that anything out of date should be removed. During a concurrent observation and interview on [DATE] at 9:32 a.m., an inspection of the Unit 700 Medication Cart ,d+[DATE] was conducted with the Assistant Director of Nursing (ADON). When the medication cart was opened, one nitroglycerin vial was observed stored with an expiration date of 07 24 [[DATE]]. The ADON acknowledged the nitroglycerin vial stored in the Unit 700 Medication Cart ,d+[DATE] expired in [DATE]. 3. During a concurrent observation and interview on [DATE] at 12:42 p.m., at Medication Cart 600, Resident 5's opioid (narcotic painkiller) medications were reviewed with Licensed Vocational Nurse 3 (LVN 3). The medical record was reviewed and LVN 3 retrieved the Controlled Drug Record (CDR - narcotic count sheet where licensed nurses log out narcotics from the drug supply for accounting) for the Resident 5's PRN (as needed) hydrocodone/acetaminophen (a strong opioid combining two pain medications) 5 milligrams / 325 milligrams (mg - a unit of measurement for dose) bubblepack (medication card) stored in the medication cart. The medication bubblepack indicated the prescription number Rx# 589768 and the corresponding Controlled Drug Record indicated the prescription number Rx# 587116. LVN 3 acknowledged the prescription number on Resident 5's PRN hydrocodone/acetaminophen 5 mg / 325 mg Rx# 589768 did not match the prescription number Rx# 587116 on the CDR. During a concurrent interview and record review on [DATE] at 1:17 p.m. with the Assistant Director of Nursing (ADON), Resident 5's medical record was reviewed. The physician's orders dated [DATE] indicated medication orders for PRN hydrocodone/acetaminophen 5 mg / 325 mg. The medication order indicated one tablet by mouth for mild to moderate pain. The medication order indicated two tablets by mouth for severe pain. The ADON acknowledged the two PRN hydrocodone/acetaminophen 5 mg/325 mg medication orders. During an interview on [DATE] at 4:16 p.m., Resident 5 stated it took some time for him to start receiving his PRN hydrocodone/acetaminophen medications. Resident 5 stated he has chronic pain in his ankles, knees, and shoulders. During a concurrent interview and record review on [DATE] at 3:15 p.m., Resident 5's PRN hydrocodone/acetaminophen medication orders, hydrocodone/acetaminophen bubblepack Rx# 589768, and the CDR hydrocodone/acetaminophen Rx# 587116 were reviewed with the DOP. The DOP acknowledged the prescription number on Resident 5's PRN hydrocodone/acetaminophen 5 mg / 325 mg Rx# 589768 did not match the prescription number Rx# 587116 on the Controlled Drug Record. The DOP stated to talk to the Supervisor Registered Nurse 1 (SRN 1) for clarification of prescription number discrepancies. During a concurrent interview and record review on [DATE] at 4:06 p.m., Resident 5's PRN hydrocodone/acetaminophen medication orders, hydrocodone/acetaminophen bubblepack Rx# 589768, and the CDR hydrocodone/acetaminophen Rx# 587116 were reviewed with Supervising Registered Nurse 1 (SRN 1). SRN 1 acknowledged the prescription number on Resident 5's PRN hydrocodone/acetaminophen 5 mg / 325 mg Rx# 589768 did not match the prescription number Rx# 587116 on the Controlled Drug Record. During a concurrent interview and record review on [DATE] at 9:54 a.m., Resident 5's narcotic drug records were reviewed with SRN 1. SRN 1 stated that nursing staff sometimes does not check to verify the prescription numbers match the narcotic supply in the bubblepack with the corresponding Controlled Drug Record. During a concurrent interview and record review on [DATE] at 10:21 a.m., Resident 5's narcotic drug records were reviewed with the DOP. The DOP stated, the key is excessive ordering and that there was a delay from when the Pharmacy dispensed the narcotic bubblepack to the nursing home to when the nursing staff starts using the narcotic supply from that bubblepack. During a concurrent interview and record review on [DATE] at 10:21 a.m., the facility's policy and procedure (P&P) titled Controlled Scheduled [degree of abuse potential] Drugs, dated [DATE] was reviewed with the DOP and the SRN 1. The policy indicated, RECEIPT OF CONTROLLED SCHEDULED DRUGS .When the controlled scheduled drugs are delivered from the pharmacy, there will be a Controlled Drug Record sheet created for each drug (see Attachment A). The DOP and SRN1 acknowledged the policy and both stated Attachment A was the narcotic count sheet (CDR). During a review of the facility's policy and procedure (P&P) titled, Controlled Scheduled [degree of abuse potential] Drugs, dated [DATE], the P&P indicated, The [name of facility] will establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and will ensure drug records are in order and that an account of all controlled scheduled drugs is maintained. RECEIPT OF CONTROLLED SCHEDULED DRUGS .When the controlled scheduled drugs are delivered from the pharmacy, there will be a Controlled Drug Record sheet created for each drug (see Attachment A) .STORAGE, SECURITY AND ACCOUNTABILITY OF CONTROLLED SCHEDULED DRUGS .Separate drug records will be maintained for all controlled scheduled drugs in such a way that the receipt and disposition of each dose of any such drug may be readily traced. During a review of the facility's policy and procedure (P&P) titled, Controlled Drugs, dated [DATE], the P&P indicated, A separate record will be maintained for all controlled scheduled drugs. It will include the name of the prescriber, the prescription number, the drug name, strength and dose administered, the date and time of administration and the signature of the person administering the drug (see Controlled Drug Record).

Based on observation, interview, and record review, the facility failed to ensure a comprehensive systematic approach for monitoring nutrition interventions was implemented for one of 44 sampled residents, (Resident 20), who experienced an unplanned unintentional weight loss of 7.79% in six months, according to facility policy. This failure had the potential for Resident 20 to experience additional unintentional weight loss, which could lead to further decline in the resident's health and nutrition status. Cross reference F657 Findings: During a review of an article titled, 2002 American Academy of Family Physicians Journal, indicated, Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, (the ability for the body to develop an immune response) depression and an increased rate of disease complications. Research has shown institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. (www.aafp.org/afp) During a review of the professional reference titled, The Academy of Nutrition and Dietetics Evidence Analysis Library, regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines, dated 2007-2009, indicated, The Registered Dietitian should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). During a review of Resident 20's Admission Face Sheet Record (demographics), [undated], the Face Sheet indicated Resident 20 was admitted on [DATE] with diagnoses of hypertension (HTN, high blood pressure), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 12/5/2024, the MDS indicated Resident 20 had a BIMS (brief interview of mental status) score of 10 (moderate cognitive impairment) in section C, indicating he was cognitively intact. The MDS further indicated Resident 20 experienced a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months but was not on a physician-prescribed weight-loss regimen. During a review of Resident 20's Monthly Weights, from 6/20/2024 -1/18/2025 indicated: 6/20/2024 -136.1 lbs. (pounds) 7/20/2024 -132.8 lbs. 8/17/2024 -128.4 lbs. 9/21/2024 -129.8 lbs. 10/19/2024 -128 lbs. 11/6/2024 - 126 lbs. 12/21/2024 - 121.8 lbs. 1/18/2025 - 118.4 lbs. Resident 20 experienced a 10.84% significant weight loss from July 2024 and January 2025, and a 7.79 % significant weight loss from August 2024 through January 2025. During a review of Resident 20's Physician Diet Order, dated 12/6/2024, indicated, Change Diet to: Regular/thin liquids per ST (Speech Therapy)/resident; nursing to help out PRN (as needed). During a review of Resident 20's Physician Orders, dated 1/17/2025, indicated, Prostat (a concentrated liquid protein drink supplement), 30 ml (milliliters), PO (by mouth), BID (twice a day). During a review of Resident 20's Medication Administration Record (MAR), from 1/1/2025- 1/31/2025, indicated 30 ml of Prostat supplement was given to Resident 20 at 9:00 a.m. and 5:00 p.m. on 1/18/2025 through 1/29/2025. Further review of the MAR indicated Resident 20 did not receive Prostat on 1/30/2025. During a review of the Facility's List of Resident's and Diets, dated 1/25/2025, indicated Resident 20's diet as Regular, No Yogurt at breakfast, lunch, and dinner. During a review of Resident 20's ADL (Activities of Daily Living) Supplemental Flow Sheet, indicated the following: For the Month of November 2024: Average Breakfast consumed: 62.5% Average Lunch consumed: 75% Average Dinner consumed: 50% For the Month of December 2024: Average Breakfast Consumed: 55% Average Lunch Consumed: 51% Average Dinner Consumed: 48% For the Month of January 2025: Average Breakfast Consumed: 49% Average Lunch Consumed: 51% Average Dinner Consumed: 44% During a concurrent observation and interview on 1/29/2025 at 9:42 a.m., Resident 20 was sitting in his wheelchair next to his bed in his room with a 1/2 cup of coffee on his bedside table in front of him. Resident 20 stated he ate most of his breakfast and liked the banana, sausage links, and some cereal along with fruit. Resident 20 further stated he's lost 40 pounds in two years and has not spoken with his doctor about his weight loss. Resident 20 stated some of his food preferences were sausages, pears, bananas, grilled cheese sandwiches, tuna sandwiches, and chicken meals. Resident 20 stated he did not like oatmeal or yogurt. During a concurrent observation and interview on 1/30/2025 at 10:00 a.m. with Resident 20, Resident 20 stated he did not like some foods and meals served at the facility. Resident 20 stated he does not receive any sandwiches at lunch or dinner, or other foods with meals but would like to have a grilled cheese sandwich sometimes. Resident 20 stated he also received a supplement shake three times a day. During an interview on 1/30/2025 at 10:11 a.m., with Registered Nurse 3 (RN 3), RN 3 stated Resident 20 had an order for Prostat. RN 3 further stated she would offer Resident 20 substitutions for his food but did not give it to Resident 20 for breakfast. During an interview on 1/30/2025 at 11:34 a.m., with the Resident 20's Physician (PHYS), the PHYS stated Resident 20 had a stroke a few years ago and received chemotherapy ten years ago for prostate cancer. The PHYS further stated he was aware of Resident 20's weight loss a month ago and believed the Registered Dietitian (RD) was giving the resident supplements to address it. The PHYS stated he wasn't aware Resident 20's weight loss was severe for six or seven months. The PHYS further stated severe weight loss was a priority and could potentially be treated with interventions. During a review of Resident 20's Nutrition Care Plan, created 1/5/2022 and updated 1/27/2025, indicated, Problems/Conclusions .9/9/2024-WT. (weight) LOSS OF 17.2#/6MOS AT 11% IS SIGNIFICANT, RESIDENT 20 IS SURPRISED BY Loss .9/9/2024 & 12/6/2024: Referred Resident 20 to MD (medical doctor) d/t (due to) ongoing weight loss . Measurable Goals .Weight, No significant variances: Resident 20 will maintain wt. greater than 121 pounds (+/- 5 pounds) every week x 3 months .Interventions .Diet, Document % consumed: Regular .Chop Meat. During a concurrent interview and record review on 1/29/2025 at 2:47 p.m. with Registered Dietitian (RD) and the Director of Dietetics (DD), Resident 20's care plan titled, Risk of Alteration in Nutrition, was reviewed. The RD stated she was responsible for entering information and updating the nutrition care plans for residents. The RD confirmed Resident 20's nutrition care plan was updated on 6/19/2022, 3/14/2024, 9/9/2024, and 12/6/2024 and was not sure when she last updated the nutrition and weight goals for Resident 20. The RD stated the Resident 20's weight loss was unintentional, and Resident 20's physician was notified of the weight loss in November 2024. The RD stated she assessed Resident 20 quarterly or as needed but the interventions were not always updated. The DD acknowledged the care plan was not updated to reflect the additional food or other items Resident 20 received which was recommended by the RD. The DD stated Resident 20's interventions should have been updated in the care plan. The DD acknowledged the care plans did not have a weight loss goal. During a review of Resident 20's Nutritional Assessment, dated 3/15/2024, completed by the RD indicated, Resident 20's current body weight 145.6 pounds, ideal body weight (IBW) 148 pounds, usual body weight (UBW) was 160 pounds; Estimated caloric needs: 1600 calories per day, 65 grams of protein; .Plan and Goals: Resident 20 reports good appetite and is aware of weight loss .Continue supplement at HS (evening) .no further changes at this time. During a review of Resident 20's Nutritional Assessment, dated 6/11/2024 completed by the RD indicated, Resident 20's current body weight 140 pounds, ideal body weight was 148 pounds; Estimated caloric needs: 1600 calories per day, 65 grams of protein; .Nutrition Diagnosis: Resident 20 with inadequate intake as evidenced by ongoing weight loss . Plan and Goals: Resident 20 reports good appetite and is aware of weight loss but surprised of total weight loss . Resident 20 indicates prefers weight of 160 pounds as his goal .Continue supplement TID (three times a day) and sandwich at 10 AM to increase calories. During a review of Resident 20's Nutritional Assessment, dated 11/27/2024 completed by the RD indicated, Resident 20's current weight was 126 pounds, IBW: 148 pounds, IBW: 86%; Oral supplementation/additional foods: Chocolate house supplement TID; .Nutrition Requirements: Total kcals (kilocalorie): 1800 per day .; protein: 68 grams/day; Plan: .Resident 20 Goals: weight > 126 pounds +/- 5 pounds as desired by resident .Comments: .Wt. loss of 14 pounds/6 months @ 10% change .RD recommend appetite stimulant High nutrition risk .Monitor changes and f/up prn (as needed) During a concurrent interview and record review on 1/30/2025 at 2:54 p.m., with Registered Dietitian (RD) and the Director of Dietetics (DD), the DD stated the RD was responsible for attending the Nutritional At Risk (NAR) monthly meetings and reporting to the interdisciplinary NAR committee the resident's nutrition interventions. The August 2024 through December 2024 NAR meeting minutes indicated added Super Suds to L/D (lunch/dinner). The RD stated she mentioned fortified food items to Resident 20 like super suds (buttered mashed potatoes), and per Resident 20 he told her he would try them. The RD stated she did not recommend Resident 20 be placed on a fortified diet, which could have provided up to 300 to 500 additional calories per day at every meal. The RD stated she was unsure if Resident 20 was regularly receiving the super suds (mashed potatoes) at lunch and dinner after she informed the kitchen in August. The RD further stated Resident 20 could have benefitted from the extra calories and acknowledged she could have followed up with Resident 20 on the different interventions. The RD stated she should have updated Resident 20's nutrition calorie goals in the assessment to reflect the resident's continuous weight loss. The RD further stated Resident 20's food preferences were taken a while ago, but she did not know where they were in the medical record system because the facility had a new system last year. The DD acknowledged Resident 20's nutrition assessment did not have the additional foods recommended by the RD for Resident 20. The DD stated Resident 20's interventions should have been updated and included. During an interview on 1/30/2025 at 4:15 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the RD was responsible for updating the care plan of the residents after dietary meetings and should be followed up every month. The ADON stated dietary notes were separated from nursing notes and the nursing staff did not have access to the dietary notes. The ADON stated his expectation for the RD was to document their goals clearly to communicate to the rest of the staff. The ADON further stated the documented goals were important so the nursing staff can carry out interventions correctly. During a review of the facility's job description titled, Registered Dietitian, dated 2/23/2018 indicated, Complete nutrition assessments for assigned residents within specified time frames. Identify risk factors and nutrition-related problems; coordinate MNT for residents; communicate recommendations to appropriate health care team members and monitor response to plan of care. Provide follow-up care and documentation as needed according to nutritional risk, nutrition care plan (NCP), and IDT meetings. Provide nutrition counseling, diet intervention, and resident education regarding disease/disability management, food medication interactions, weight management, health promotion, wellness, and other education as needed. Monitor quality control as assigned to evaluate effectiveness of resident nutritional care and food service. Communicate with appropriate staff any problems, changes, or recommendations found through meal observations; .Provider will complete documentation in a thorough and timely manner. During a review of the facility's policy & procedure (P&P) titled, Food & Nutrition Services- Assessments and Care/ Treatment Plans, dated 1/2/2025, the P&P indicated, The [name of the facility] will ensure the resident maintains acceptable parameters of nutritional status (such as usual body weight range, protein) .D. Significant Change of Status Assessment (SCSA): 1. The dietitian will complete a comprehensive reassessment. 2. Within fourteen (14) days of change of condition. 3. Examples of significant changes are not limited to: a. Unplanned weight loss of 5% change in 30 days, 7.5% change in 90 days, or 10% change in 180 days. b. Chronic unplanned weight loss. E. Quarterly Nutrition Assessment: 2. Review and revision of the resident's care plan to ensure the continued accuracy of the resident's assessment. G. Care Plan: A comprehensive person-centered care plan including measurable objectives and time frames to meet resident's needs, preferences and goals that are identified in the comprehensive assessment. During a review of the facility's policy & procedure (P&P) titled, Food & Nutrition Services- Weight Policy SNF/ICF, dated 6/12/2024, the P&P indicated, Body weight and laboratory results can often be stabilized with time. I. Monitoring Weights and Weight Variances .A. The Registered Dietitian (RD) will monitor weights and significant weight changes. C. The RD will assess each Resident with a monthly significant weight change and determine if weight loss was planned or unplanned. II. Systemic approach. C. Developing and consistently implementing pertinent approaches. D. Monitoring the effectiveness of interventions and revising them, as necessary. V. Significant Weight Change is defined as: B. decrease of 5% or more body weight in 30 days. C. decrease of 7.5% or more body weight in 90 days. D. decrease of 10% or more of body weight in 180 days. VII. Nutrition Care Planning. C. On-going monitoring of care planned interventions is necessary for all residents. 50674

50674 Based on observation, interview, and record review, the facility failed to ensure a person-centered care plan for weight loss was updated for one of 44 sampled residents (Resident 20). This failure had the potential for Resident 20 not to receive nutrition interventions and treatments according to evaluation of his needs and contributing to continued weight loss. Cross reference F692 Findings: During a review of Resident 20's Admission Face Sheet Record (demographics), [undated], the Face Sheet indicated Resident 20 was admitted on [DATE] with diagnoses of Hypertension (HTN, high blood pressure), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool), dated 12/5/2024, the MDS indicated the Resident 20 had a BIMS (brief interview of mental status) score of 10 (moderate impairment) and experienced a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, but was not on a physician-prescribed weight-loss regimen. During a review of Resident 20's Monthly Weights, from 6/20/2024 -1/18/2025 indicated: 6/20/2024 -136.1 lbs. (pounds) 7/20/2024 -132.8 lbs. 8/17/2024 -128.4 lbs. 9/21/2024 -129.8 lbs. 10/19/2024 -128 lbs. 11/6/2024 - 126 lbs. 12/21/2024 - 121.8 lbs. 1/18/2025 - 118.4 lbs. Resident 20 experienced an unintentional weight loss of 7.79% from August 2024 through January 2025. During a concurrent observation and interview on 1/29/2025 at 9:30 a.m., with Resident 20 in the resident's room, Resident 20 was sitting in his wheelchair next to his bed watching television. Resident 20 stated that he ate breakfast, but he was not a heavy eater. Resident 20 stated he preferred eating vegetables and fruits, and he liked grilled cheese and tuna sandwiches. Resident 20 stated he was aware that he had lost weight because he remembered he was 160 pounds in 2023 and has lost 40 pounds, but did not know how. Resident 20 further stated the Dietitian was aware of his food preferences. During a review of Resident 20's ADL (Activities of Daily Living) Supplemental Flow Sheet, indicated the following: For the Month of December 2024: Average Breakfast Consumed was 55% Average Lunch Consumed was 51% Average Dinner Consumed was 48% For the Month of January 2025: Average Breakfast Consumed was 49% Average Lunch Consumed was 51% Average Dinner Consumed was 44% During an interview on 1/30/2025 at 10:11 a.m., with Registered Nurse 3 (RN 3), RN 3 stated Resident 20 had an order for Prostat (a concentrated liquid protein drink). RN 3 further stated she would offer Resident 20 substitutions for his food but she did not give it to Resident 20 for breakfast. During a review of the Resident 20's Physician Orders, dated 1/17/2025, indicated Prostat supplement 30 ml (milliliters), PO (by mouth), BID (twice a day). During a review of Resident 20's Medication Administration Record (MAR), dated 1/1/2025- 1/31/2025, the MAR indicated, 30 milliliters of Prostat supplement was given to Resident 20 at 9:00 AM and at 5:00 PM on 1/18/2025 through 1/29/2025. Resident 20 did not receive Prostat on 1/30/25 at 9:00 AM. During a review of Resident 20's Nutrition Care plan created 1-5-22 and updated 1-27-25 indicated Problems/Conclusions .9/9/24-WT LOSS OF 17.2#/6MOS AT 11% IS SIGNIFICANT, RESIDENT IS SURPRISED BY Loss .9/9/24 & 12/6/24: Referred resident to MD d/t (due to) ongoing weight loss . Measurable Goals .Weight, No significant variances: Resident will maintain wt greater than 121 pounds (+/- 5 pounds) every week x 3 months .Interventions .Diet, Document % consumed: Regular .Chop Meat . During a concurrent interview and record review on 1/30/2025 at 2:47 p.m. with Registered Dietitian (RD) and the Director of Dietetics (DD), Resident 20's care plan titled, Risk of Alteration in Nutrition, was reviewed. The RD stated she was responsible for entering information and updating the nutrition care plans for residents. The RD confirmed Resident 20's nutrition care plan was updated on 6/19/2022, 3/14/2024, 9/9/2024, and 12/6/2024 and was not sure when she last updated the goal for Resident 20. The RD stated she notified Resident 20's physician of the weight loss and she sees Resident 20 quarterly or as needed but, the care plan did not reflect those dates. The DD confirmed, the care plan was not updated to reflect the additional food or other items Resident 20 received which was recommended by the RD. The DD stated Resident 20's interventions should have been updated in the care plan. During an interview on 1/30/2025 at 4:15 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the RD was responsible for updating the care plan of the residents after dietary meetings and should be followed up every month. The ADON stated dietary notes were separated from nursing notes and the nursing staff did not have access to the dietary notes. The ADON stated his expectation for the RD was to document their goals clearly to communicate to the rest of the staff. The ADON further stated the documented goals were important so nursing staff can carry out interventions correctly. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 8/12/2024, the P&P indicated, Resident care plans will be reviewed, evaluated and updated as necessary by professional personnel involved in the care of the resident at least quarterly. Implementation: Delivery of actual resident care, IDT [interdisciplinary] activities, putting approaches or solutions to work. Services provided must meet professional standards of quality and be provided by qualified persons. Evaluation: Consists of reassessment and comparing the observed resident goals/outcomes of the interventions with the expected outcomes established during the planning phase; this is an on-going process. During a review of the facility's policy & procedure (P&P) titled, Food & Nutrition Services- Assessments and Care/ Treatment Plans, dated 1/2/2025, the P&P indicated, The home will ensure the resident maintains acceptable parameters of nutritional status (such as usual body weight range, protein). D. Significant Change of Status Assessment (SCSA): 1. The dietitian will complete a comprehensive reassessment. 2. Within fourteen (14) days of change of condition. 3. Examples of significant changes are not limited to: a. Unplanned weight loss of 5% change in 30 days, 7.5% change in 90 days, or 10% change in 180 days. b. Chronic unplanned weight loss. E. Quarterly Nutrition Assessment: 2. Review and revision of the resident's care plan to ensure the continued accuracy of the resident's assessment. G. Care Plan: A comprehensive person-centered care plan including measurable objectives and time frames to meet resident's needs, preferences and goals that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to provide a written bed hold policy notification to one of 44 sampled residents (Resident 47) and/or his representative upon Resident 47's transfer to an acute care hospital on 8/27/2024. This failure had the potential for Resident 44 and/or his representative to not be informed of his rights to return to the facility following hospitalization . Findings: During a review of Resident 47's Physician's Progress Note, dated 12/9/2024, the Physician's Progress Note indicated Resident 47 was readmitted to the facility from the hospital on 12/7/2024 with a diagnosis of status post right above knee amputation. The Physician's Progress Note further indicated Resident 47 was hospitalized from 8/27/2024 - 12/6/2024. During a review of Resident 47's Nursing Notes, dated 8/27/2024 at 10:46 p.m., the Nursing Notes indicated the facility placed a call to [hospital's name] and was informed that Resident 47 will be admitted . Further review of Resident 47's medical record indicated there was no documented evidence of a bed hold notification to Resident 47 and/or his representative. During an interview on 1/29/2025 at 3:27 p.m., with Registered Nurse 5 (RN 5), RN 5 stated a bed hold notification was not completed for Resident 47 when he transferred to the hospital on 8/27/2024. During an interview on 1/30/2025 at 12:01 p.m., with RN 6, RN 6 stated the facility should have completed a bed hold notification form for Resident 47 when he transferred to the hospital on 8/27/2024. During a review of the facility's policy and procedure (P&P) titled, Bed Hold Policy, dated 1/29/2025, the P&P indicated, If a Resident is transferred to a general acute hospital, the facility will afford the Resident a bed hold of seven (7) days, which may be exercised by the Resident or the Resident's representative . II. Transfer/Discharge To Acute A. When a Resident is transferred to an acute hospital the licensed nurse will: 1. Notify the Resident, family or legal representative of the reason for the transfer in a language and manner they understand. 2. If a Resident is alert, discuss bed hold notification/election form and provide a copy and file the original form in the medical record. 3. If the Resident has a responsible party, notify and discuss the bed hold notification/election form. Explain that the form will be mailed to him/her by the Veterans Home designated department for his/her signature and must be mailed back as soon as possible.

Based on observation, interview, and record review, the facility failed to implement an accurate comprehensive person-centered care plan for one of three sampled residents (Resident 1), when Resident 1's exhibited behaviors were not monitored or documented. This failure had the potential to result in Resident 1 not receiving interventions necessary to maintain mental and psychosocial well-being. Findings: During a review of Resident 1's Admission Face Sheet Record (face sheet), dated 10/13/2023, the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder (mood disorder causing persistently low or depressed mood and a loss of interest in activities), Panic Disorder (disorder with unexpected and repeated episodes of intense fear), and Post-Traumatic Stress Disorder (disorder that develops in some people who have experienced a shocking, scary, or dangerous event). During a concurrent observation and interview on 9/30/2024 at 10:45 a.m. with Resident 1, Resident 1 was observed in bed with a manual wheelchair at his bedside. Resident 1 stated that he was in the process of obtaining a power motorized wheelchair (wheelchair that is propelled by and electric motor), for easier mobility around the facility and its grounds. Resident 1 stated there was a meeting with his Interdisciplinary Team (IDT-team of professional and direct care staff that have primary responsibility for the development of a plan of care and treatment) on 7/22/2024, which the resident believed was to discuss obtaining the power motorized wheelchair, but instead, the team discussed Resident 1's aggressive behavior towards staff. During an interview on 9/30/24 4:45 p.m. with Director of Physical Therapy (DPT) 1, DPT 1 stated Resident 1 had a history of harassing behavior and was verbally aggressive toward her for the past two years which caused her to fear for her safety. DPT 1 stated Resident 1 approached her while she was alone in her office 4-5 times over the past two years yelling at her and calling her names. DPT 1 stated she did not document Resident 1's behaviors in the medical record and did not notify the IDT. DPT 1 stated she notified the psychiatrist of the resident's behaviors in July 2024 which prompted an IDT meeting. During an interview on 9/30/2024 at 4:30 p.m. with Social Services Director (SSD) 1, SSD 1 stated Resident 1 had a history of having verbally aggressive behaviors but has not had any episodes since Resident 1's readmission on 3/21/2024. SSD 1 was not aware of any behavior issues. SSD 1 further stated she was not aware Resident 1 was verbally aggressive toward DPT 1 until the IDT meeting on 7/22/2024. SSD 1 stated the Social Services Department should be the first point of contact when behavior issues occured so that the IDT could develop a plan to address the resident's mental health needs. During an interview on 10/1/2024 at 9 a.m. with Supervising Registered Nurse (SRN) 1, SRN 1 stated behavior monitoring should be documented as indicated in Resident 1's care plan and nursing staff should document any behaviors noticed on their shift. SRN 1 stated other departments should notify nursing staff when a resident exhibits aggressive behavior so that the behaviors could be documented, and the resident could be monitored. SRN 1 stated she was not aware of Resident 1's aggressive behavior toward DPT 1 until a few days before Resident 1's IDT meeting on 7/22/2024. During an interview on 10/1/2024 at 9:35 a.m. with Medical Doctor (MD) 1, MD 1 stated the IDT depended on the documentation in the medical record for an accurate assessment of the resident. MD 1 stated Resident 1's exhibited pattern of behavior were traits of Resident 1's diagnoses and should have been documented in the medical record for the treatment team to effectively address the resident's mental health needs. During a review of Resident 1's care plan (CP) titled, PSYCO16A: CP#6A . Alteration in Mood/Behavior ., dated 10/7/2023 and updated 9/23/2024, the CP indicated interventions included, Monitor and Record Episodes of Targeted behaviors Every Shift on Monthly Drug Summary Sheet. During a review of the facility's policy and procedure (P&P) titled, Care Planning, updated 8/12/2024, the P&P indicated, . identify care needs based on an initial written and continuing assessment of the residents needs with input, as necessary, from health professionals involved in the care of the resident.

Based on observation, interview and record review, the facility failed to provide adequate/ necessary supervision to prevent elopement (when a resident leaves the premises or safe area without the facility's knowledge and supervision) with injury for one of three sampled residents (Resident 1), when the facility staff failed to assess level of supervision required for safety for Resident 1, who was cognitively impaired, for elopement risk when he attempted to leave the facility and fell at the facility's back gate on 6/5/2023. In addition, the facility staff did not follow the facility expectation as directed to visualize the resident every two hours. Resident 1 eloped and fell approximately one mile from the facility, and was missing for approximately 9 hours, on 1/24/2024. These failures resulted in a two-centimeter forehead laceration that required five sutures for Resident 1 and had the potential to result in serious impairment and death. Findings: During a review of the Minimum Data Set (MDS- assessment tool that measures health status in nursing home residents), dated 12/10/2023, the MDS indicated Resident 1 had a BIMS (Brief Interview for Mental Status- a tool to measure and track a resident's cognitive decline or improvement) score of 9 out of 15 (a score of 8 to 12 suggests moderate cognitive decline). During a review of the Physician Order (PO), dated 9/29/2023, indicated Resident 1 may go out of the facility on pass with a responsible party. During a review of the History and Physical (H&P), dated 5/22/2023, the H&P indicated Resident 1 was readmitted to the facility on [DATE]. Resident 1's diagnoses included dementia (the loss of cognitive function-thinking, remembering, and reasoning, which interferes with a person's daily life) and paranoid schizophrenia (serious mental illness that causes disorganized thinking). During an interview with the Facility Administrator (FM) on 1/26/2024 at 10 AM, the FM stated the facility's staff did not know Resident 1's whereabouts on 1/24/2024 after 9:12 AM until he was returned to the facility via ambulance from the hospital at 6:40 PM. (Resident 1 was missing for approximately 9 hours). During a concurrent observation and interview on 1/26/2024 at 10:19 AM, in the facility's Activity Room, Resident 1 was observed with a bandage on his forehead, dark purple discoloration on the skin under both eyes, and an abrasion/scab along the entire length of his nose. Resident 1 was ambulatory with a walker. He had on a red color-coded identification (ID) badge. Resident 1 was alert and oriented. Resident 1 stated he walked without his walker to the nearby shopping center (approximately a one mile walk from the facility), tripped, and fell on his face in the parking lot, on 1/24/2024. He stated he was taken by ambulance to the hospital for his injuries. Resident 1 stated that he did not notify staff that he was leaving the campus, and he did not sign out when he left. Resident 1 further stated he attempted to go to the same shopping center a few months ago (on 6/5/2023) but he could not control his walker going downhill and fell by the facility's back gate (South Gate). During a review of Resident 1's Nursing Note, dated 6/5/2023, indicated the facility's Security Guard called at 8:50 AM to report that Resident 1 fell on the pavement at the facility's South Gate (back gate). Resident 1 sustained a forehead abrasion, and skin tears on his left elbow and right fourth finger. Resident 1 stated, I tripped from my walker, and I lost my balance. During a review of the Interdisciplinary Team (IDT) Meeting Note for Resident 1's fall on 6/5/2023, the IDT Meeting Note indicated Resident 1 was alert and oriented x2, with intermittent confusion and forgetfulness. Resident 1 was found by nursing staff on the pavement outside of the South Gate (back gate). Per the resident, he wanted to go to the store to buy reading glasses, but had difficulty maneuvering his walker going downhill, lost his balance on the pavement and fell . During a concurrent interview and review with the Standards Compliance Coordinator (SCC) on 2/14/2024 at 5:32 PM, the facility's Security Video Surveillance Record, dated 1/24/2024, indicated Resident 1's physical locations as follows: a. At 9:07 AM - walking through the facility's lobby past the Pharmacy. b. At 9:10 AM - walking on campus towards the South Gate (back gate leads to public roads). c. At 9:12 AM - walking toward the South Gate (back gate), and then he walked out of camera view. The SCC stated Resident 1 left the facility's campus unsupervised on 1/24/2024 at 9:12 AM. During a review of the acute care hospital's Emergency Department (ED) Record, dated 1/24/2024 at 10:40 AM, the ED Record indicated Resident 1 arrived via ambulance after he fell down in the parking lot, face forward and sustained a two-centimeter forehead laceration that required five sutures. During a concurrent interview and record review with the Certified Nurse Assistant (CNA 1), on 3/6/2024 at 2:55 PM, the AM Shift Resident Monitoring Sheet, dated 1/24/2024, included documentation of Resident 1's physical locations as follows: a. At 7 AM -documented as [in] Room. b. At 9 AM -documented as [in] Room. c. At 11 AM -documented as Around/out of POD [common area]. CNA 1 stated she did not look for Resident 1 on 1/24/2024 at 11 AM because she knew his routine. She stated that he usually went to the Canteen to buy ice cream, and then he would go back to the POD. CNA 1 stated that when she went to deliver Resident 1's lunch on 1/24/2024 at around 12:15 PM, he was not in his room, but his walker was there. CNA 1 stated she looked for him but could not find him, so she notified the nurse. During an interview with the Registered Nurse (RN 1) on 6/5/2024 at 3:20 PM, RN 1 stated she expected CNA 1 to visualize Resident 1 when she monitored and documented his whereabouts. RN 1 stated it was unacceptable to document Around/out of POD, without the actual visualization on 1/24/2024 at 11 AM. During an interview with the Director of Nursing (DON) on 6/5/2024 at 10 AM, the DON stated CNAs were directed to observe and document the residents' whereabouts every two hours, as a Best practice. The DON further stated it was unacceptable for CNA 1 to document Resident 1's location without direct visualization on 1/24/2024 at 11 AM. During a review of Resident 1's Safety/Fall Risk Care Plan (CP) initiated on admission included Red ID badge, initiated on 3/27/2020, without an end date. The CP was updated after Resident 1's attempted elopement and fall with injuries on 6/5/2023. The interventions included to monitor resident's whereabout frequently, remind resident for safety precautions, and to not go out of the campus without a responsible party. During an interview with the Director of Nursing (DON) on 2/23/2024 at 11:58 AM, the DON stated that after Resident 1's attempt to leave the facility's campus without staff knowledge on 6/5/2023, the IDT Team agreed that Resident 1 was still able to travel safely throughout the campus and should continue to have [NAME] ID badge privileges. She stated there was no documented assessment, rather a discussion among IDT members. During a review the medical record, there was no documented evidence to show an order or an assessment for [NAME] ID badge privileges for Resident 1 after 6/5/2023 when Resident 1 attempted to go to the store (off of the facility's premises) by himself to buy reading glasses. During a follow-up interview on 2/23/2024 at 1 PM, with the DON, the DON stated they did not develop policies and procedures to prevent elopements because they were an unlocked facility, and residents had the right to leave the facility. The DON also stated an Elopement Risk Assessment was not conducted for Resident 1, after incident 6/5/2023 when he attempted to go to the store by himself. During a review of Resident 1's medical record, the medical record failed to show documented evidence of an Elopement Risk assessment was completed when Resident 1 attempted to elope on 6/5/2023, to prevent the elopement and fall with injuries on 1/24/2024. During a review of the facility Policy and Procedure (P&P), Campus Access Identification of (Facility) Residents, dated 5/30/2023, the P&P included, the purpose of identification (ID) badge color codes was to communicate to staff the primary care provider recommended safety protocols for all residents. [NAME] was for residents deemed able to safely travel throughout the campus without assistance, and Red was for residents with Physician recommendations to limit unsupervised travel within Building A and the sidewalks around Building A (facility's campus). During a review of the facility Policy and Procedure (P&P), Elder Abuse, Prevention and Reporting, dated 6/6/2022, the P&P included Neglect- the failure of the facility to provide services to the Resident necessary to avoid physical harm, and to identify, correct and intervene in situations in which neglect is more likely to occur.

Based on observation, interview, and record review, the facility failed to ensure the contracted providers providing dental services and biomedical equipment maintenance in the Skilled Nursing Facility (SNF) conformed and implemented signed agreements that meet professional standards in providing services by failing to: 1. Ensure that the dental autoclave machine used to sterilize dental instruments was properly maintained. 2. Ensure to submit a complete report to the Contract Manager of the services provided, including necessary repairs. 3. Ensure that contractor made every attempt to complete repairs the same working day. 4. Ensure that contractor responded to requests for emergency repair within eight (8) hours of telephone notification by the Contract Manager. 5. Ensure that contractor provide loan equipment, repair(s) [MEDICATION NAME] more than five working days. 6. Ensure that all sterilization tests results provided by a provider were reviewed to ensure that all dental instruments are free from cross contamination and safe for residents and other patients' use. 7. Ensure that proper infection control practices were implemented in the dental clinic to ensure the health and safety of the residents and other patients. 8. Ensure that a policy and procedure on infection control was established and implemented in the dental clinic. These failures resulted in failed dental instruments sterilization tests from February 2013 through April 2013 where dental services continued during that period that jeopardized the health and safety of 54 Skilled Nursing Facility (SNF) residents. Findings: On 5/2/13 at 9:45 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of a failed sterilization of a dental autoclave machine (used for the sterilization of dental instruments) in the Ambulatory Care Clinic (ACC), an out-patient clinic, which is located inside the Skilled Nursing Facility (SNF) building, owned and operated by the facility. On 5/2/13 at 10 a.m., an interview with the Standard Compliance Coordinator (SCC) was conducted. The SCC was employed by the facility as a full time employee of the SNF. According to the SCC, on 4/29/13 before lunch time, the dental clinic received a notification that one of the sterilization tests failed. The dental clinic immediately stopped all appointments on 4/29/13. She also stated that it was later found out that there was more than one test that failed. On 5/2/13 at 10:15 a.m., an interview with the Administrator was conducted. The Administrator was employed as a full-time employee of the SNF. He stated that the Chief Medical Officer was in charge of the dental clinic and that he (Administrator) had never been involved in the oversight. He also stated that it was unknown to them that the sterilization tests of the dental instruments failed numerous times and that there was almost no involvement or monitoring of the Infection Control Nurse (ICN) in the dental clinic. On 5/2/13 at 10:45 a.m., an interview with the Chief Medical Officer (CMO) was conducted. The CMO also known as the Medical Director, was employed as a full-time employee by the facility and had oversight of the SNF and clinics. He stated that he was in charge of the dental clinic. He also stated that a contracted Dentist and a Dental Assistant came in to provide services in the dental clinic. According to him, there were two failed sterilization tests in February and three failed sterilization tests in March 2013 reported by a provider (Sterilizer Monitoring System). The Health Safety Officer's (HSO) phone received messages for failed results; however, when the HSO left in June of 2011, her phone number was not deactivated and it continued to receive messages. The new HSO hired in 2012 did not receive any failed test results because the phone number previously designated to receive reports was not transferred to him (HSO), according to the CMO. The CMO further stated that when the February 2013 failed sterilization test results was received by the Office Technician (OT), she did not notify the clinic Supervising Registered Nurse (SRN). The SRN had the responsibility to read the sterilization test results. The Dentist was not informed of the failed results until 4/26/13. He also added that 54 Skilled Nursing Facility residents were seen from the periods of February thru April 2013 when the sterilization tests failed, in which the dental procedures where classified as "no blood, minimal blood, and moderate blood." The dental clinic's operation ceased on 4/29/13 and all appointments were cancelled. Blood borne disease tests (Human Immunodeficiency Virus, [MEDICAL CONDITION] and C) will be conducted for all patients who had been identified and affected, according to him. On 5/2/13 at 12:12 p.m., an observation was conducted inside the dental clinic. The clinic was located in the ACC, inside the building of the SNF. The dental clinic was observed without any patients. One dental autoclave machine was observed on top of a counter with a preventive maintenance sticker attached to it. The sticker indicated that the machine is due for maintenance in July 2013. There were multiple dental instruments wrapped in a plastic container observed in the upper and lower cabinet where the machine was located, and inside a brown box located on top of a counter across the autoclave machine. A log book was also observed on top of the counter that contained SMS sterilization test results from April 2011 thru April 2013. On 5/2/13 at 12:15 p.m., a review of the SMS sterilization test results log was conducted. The review indicated that the "STATEMENT OF TEST RESULTS" was specifically addressed to the SRN of the clinic. It also indicated that a steam was used as a type of sterilizer when it was submitted to SMS for the spore testing (to determine presence of microorganism). The review further indicated the following: a. For the month ending 2/28/13, two tests that were conducted in February (2/1/13 and 2/8/13) failed. b. For the month ending 3/31/13, three tests that were conducted in March (3/1/13, 3/11/13, and 3/15/13) failed. c. For the month ending 4/30/13, three tests that were conducted in April (4/11/13, 4/22/13, and 4/26/13). The test conducted in 4/11/13 passed the sterilization test. However, 4/22/13 and 4/26/13 tests failed. Overall, seven sterilization tests failed between the periods of February 2013 thru April 2013, before it was discovered on 4/26/13. On 5/2/13 at 12:19 p.m., an interview with the Office Technician (OT) was conducted. The OT was employed as a full-time employee of the facility, who worked in the dental clinic and reported directly to the CMO. She stated that she receives the mail from the mailroom and opens it if it was addressed to the clinic. She indicated that the Sterilizer Monitoring System (SMS) sterilization test reports are specifically addressed to the dental clinic Supervising registered Nurse (SRN). According to her, she opened mails from SMS and just filed it. She was not told to show the results to anyone, because she was instructed by the SRN to just file it (SMS sterilization test results log). She had been receiving test reports via mail since 2011 when the Health Safety Officer (HSO) left. She also stated that when she saw the failed sterilization test result for March 2013, she showed it to the SRN and she was instructed to show it to the Dentist on 4/26/13. According to her, she taped the results on the autoclave machine and verbally alerted the Dentist on 4/26/13 of the failed sterilization tests. On 5/2/13 at 3 p.m. a review of the Dentist's contract signed 5/31/11 was conducted. The review indicated that the she signed an agreement to provide dental services from 7/1/11 thru 7/30/14. The review also indicated, "SCOPE OF WORK...4. Contractor shall provide Dental Services in the Dental Clinic of the Ambulatory Care Clinic...6. Contractor shall provide bedside dental screening for Skilled Nursing Facility (SNF) residents...7. Services shall be in accordance with Medi-Cal (Denti-Cal) standards and requirements and shall include, but not limited to, the following responsibilities:...e) Provide all dental services as required by OBRA (Omnibus Budget Reconciliation Act) 483.5; California Code of Regulations, Title 22 for Skilled Nursing Facility (SNF)...i)...approve oral hygiene policies and practices for the care of residents..." On 5/2/13 at 3:30 p.m., a review of the facility's "PURCHASE ORDER" dated 8/21/12 was conducted. The review indicated that SMS (Sterilizer Monitoring Systems) signed an agreement with the facility to provide a weekly spore testing of the facility's autoclave sterilizer monitoring system. The agreement was signed on 7/23/12. The purchase order did not include how test results will be reported and did not identify the person responsible for receiving the reports. On 5/2/13 at 4:30 p.m., an Immediate Jeopardy was called to protect the health and safety of the residents. The Administrator was notified and informed of the following issues that led to the determination of Immediate Jeopardy: a. Failure to properly sterilize the dental instruments for three consecutive months. b. Failure to ensure that there was a proper reporting process of the failed sterilization tests results. c. Failure to review sterilization tests provided by a provider to ensure that all dental instruments were free from cross contamination and safe for residents and other patients' use. d. Failure to notify the responsible authority of the failed sterilization tests results. e. Failure to ensure that proper infection control practices were implemented in the dental clinic. f. Failure to ensure that a policy and procedure on infection control was established and implemented in the dental clinic. g. Possible and potential exposure to bloodborne infectious diseases of patients seen in the dental clinic. On 5/2/13 at 5:30 p.m., the facility presented an initial plan of correction. The plan of correction indicated the following: 1. The dental clinic ceased operations effective 4/29/13. 2. Affected residents and other patients will be identified and notified of possible risk due to failed sterilization test results. 3. The facility will asked for consents on blood screening test to all patients that were affected. 4. The use of the autoclave machine was discontinued. On 5/2/13, the Immediate Jeopardy remained in effect, although the facility presented an initial plan of correction. The plan of correction submitted lacked the components needed to abate the Immediate Jeopardy. On 5/6/13 at 9:12 a.m., an interview with SMS Business Manager was conducted. SMS was a company contracted by the facility to provide services in sterilizing dental equipments. According to her, they conducted weekly spore testing of the facility's autoclave sterilizer monitoring system. The facility's dental clinic will send the sterilization strips, SMS will incubate it for seven days to evaluate for any microorganism growth at 55-57 degree Celsius (131-135 degree Fahrenheit). Positive results for microorganism means failed sterilization test. The facility will be notified immediately via phone of the failed sterilization test results and hard copy was mailed as well. She stated that the test results were addressed to the SRN. She was unaware that the phone number provided by the facility to receive reports of failed result was changed and not being monitored, although it was still active. The facility did not contact SMS to give notification of the phone number change and the authorized person responsible to receive the report, especially failed sterilization tests. On 5/6/13 at 11:42 a.m., an interview with the Dentist was provided. The Dentist was employed by the facility as a contracted provider, who reported directly to the CMO. She indicated that she had been a contracted provider since 2008, in-charge of the dental clinic, and directly reports to the CMO. She was asked if she reviews or oversee the reports of the sterilization test results, she replied, "It's not my duty to oversee the reports of the sterilization result, because I just provide dental care. On the SMS document results, stated (name of SRN) on it. The dental assistant doesn't read the report either, that's not our duty." When she was asked if the failed test results will be reported to her via phone or mail, she stated, "I wouldn't know how the reports will come in, it's not my duty." The sterilization process was always done by the Registered Dental Assistant (RDA) on duty once or sometimes twice per week according to her. The Dentist became aware of the failed sterilization test on 4/26/13 when the OT posted a paper note on the autoclave machine. She also stated that the staff in the dental clinic never reported any results to her. She didn't know that the sterilization tests failed in February thru April 2013 when she provided dental services; in which 100 plus patients were exposed to bloodborne pathogens (blood contamination). She also added, "I trusted the VA (Veterans Administration) that they're doing their job, looking at results and maintaining their equipment. Reading the result was not my duty." She indicated that she didn't have any policies and procedures for infection control and sterilization of dental instruments in the dental clinic of the ACC. On 5/6/13 at 12:34 p.m., an interview with the RDA was conducted. The RDA was employed by the facility as a contracted worker, who reported directly to the contracted Dentist. He stated that he was responsible for autoclaving or sterilizing the dental instruments after use. According to him, the dirty dental instruments will be placed inside the ultrasonic bath machine for 10 to 15 minutes to be washed. Once washed and dried, the instruments will be individually packaged in a plastic container prior to placing it inside the autoclave machine. The packaged dental instrument will be placed inside the autoclave machine along with a sterilization test strip inside a plastic container. The plastic container had a pink dot outside the plastic, as an indicator that the dental instrument was sterilized. He stated, "The color of the dot is pink, when the machine is done, the color will change to a dark color indicating that it is done (sterilization process completed), but not necessarily indicating it passed or failed for bacteria testing." The sterilization test strip inside a plastic container will be removed, placed inside an envelope, and mailed to SMS by the RDA for testing. The RDA mentioned that he conducted random checks when the autoclave machine was running. He didn't keep track of the machine's temperature and/or maintained any logs of the sterilization process of the autoclave machine. He was not aware of who's responsible for reading the results, whether passed or failed, and stated that he doesn't read the sterilization report when it comes back from SMS. When he was asked, "How did you know that the dental instruments were safe to use?" He stated, "Because I sterilized the instruments, that's my duty." He also stated that he never looked at the SMS results log book located in the dental clinic, stating, "It's not my duty to read it. The results are addressed to the homes. Nobody in the dental clinic had provided the results." He further explained that there were no steps, procedures, or manufacturer's recommendation on how to perform the autoclaving process in the dental clinic, stating, "I learned it (autoclaving) from school. The machine was pre-programmed." On 5/6/13 at 2:50 pm., a review of the "Work Order Request" for the autoclave machine dated 4/5/13 was conducted. The review indicated that there was a work order generated due to a leaking problem of the autoclave machine. The work order did not indicate who made the request and/or any completion date when it was generated. There were no other documents found to indicate that the problem was resolved or completed. On 5/6/13 at 3:40 p.m., an interview with the Stationary Engineer of Plant Operations was conducted. The Stationary Engineer of Plant Operations was employed as a full-time employee of the facility who was responsible for operating, maintaining, inspecting and repairing mechanical, electrical, electronic, and manufacturing systems. He stated that (contracted company's name) was the contracted company responsible for maintaining the autoclave machine in the dental clinic. According to him, on 4/5/13 the autoclave was leaking. He was not certified to repair the autoclave machine, so he decided to call three vendors to get a bid for the repair on 4/8/13, although the facility already had a contract in place. On 4/18/13, (contracted company's name) repaired the gasket of the leaking autoclave machine. On the following day (4/19/13), the autoclave machine was noted to be leaking again. On 4/22/13, (contracted company's name) came back and checked the machine. The technician wanted to take the machine with him to be repaired, but he did not allow it, according to the Stationary Engineer. The (contracted company's name) did not provide any documentation when they diagnosed and/or attempted to repair the autoclave machine on 4/18/13 and 4/22/13. The Stationary engineer stated, "I don't normally ask for documentation." When he was asked, "How did you know that they checked the machine?" He stated, "Most of the time, we just relied on them, when they tagged the machine, that it was inspected and it passed." There were no documented evidence found that the autoclave machine was repaired when it was discovered leaking on 4/5/13. During the period of 4/5/13 thru 4/26/13, the dental clinic continued to provide dental services. There were 87 patients identified to have dental procedures done when the autoclave machine was not in a proper operating condition. The autoclaving of dental instruments continued (as evidenced by the date test received by SMS for 4/11/13, 4/22/13, and 4/26/13), knowing that the autoclave machine was not in proper operating condition. On 5/6/13 at 4 p.m., a review of the "STANDARD AGREEMENT" signed on 5/21/12 between the facility and the contracted company responsible for maintaining the autoclave machine in the dental clinic was conducted. The review indicated that the contract was valid from 7/1/12 thru 6/30/15. The contracted provider agreed to provide an annual medical equipment certification and repair services. The review also indicated, "SCOPE OF WORK...7. Unscheduled Repair Service: Contractor shall provide unlimited visits for any repair services requested or necessary to keep the equipment fully operational...Contractor shall make every attempt to complete repairs the same working day...8. Emergency Repair Service:...Contractor shall respond to requests for emergency repair within eight (8) hours of telephone notification by the Contract Manager...9. Loan Equipment: For approved repair(s) [MEDICATION NAME] more than five working days, the State reserves the right to require the Contractor to provide loan equipment, as available...14. Documentation Requirements: After completion of service, the Contractor shall submit a complete report to the Contract Manager of the services provided, including necessary repairs. Reports shall include: a) Date of Service, b) Description of services provided, c) name and signature of service technician, d) Location of equipment, e) Equipment make, model, and serial number, f) Description of any noted deficiencies and suggestive corrective action, g) Total labor hours expended, h) Signature of State employee certifying indicated services were performed." On 5/6/13 at 4:15 p.m., a review of the facility's Policy and Procedure (P&P) titled "Biomedical Equipment maintenance" with a revision date of 9/20/12 was conducted. The review indicated, "PROCEDURES: 1. CONTRACTOR QUALIFICATIONS AND RESPONSIBILITIES - A. Medical equipment used in the facility must be inspected per the manufacturer's recommendation for safety, operational performance, and preventive maintenance....B...1. Contractor shall respond to requests for service within 48 hours or 8 hours if an emergency...5. When a piece of equipment is not functional and is required for the health and safety of the resident, a loaner will be obtained (if available) until item has been repaired...II. STAFF RESPONSIBILITIES - A. Equipment failures - Defective equipment shall be removed from its designated area. 1. An equipment tag will be completed to include sanitation and repair." On 5/7/13 at 1:20 p.m., another interview with the RDA was conducted to clarify the wait time for the result before using the dental equipment. He stated that they don ' t wait for the sterilization test results. He confirmed that he used the dental equipment he sterilized without waiting or knowing the sterilization test results. On 5/7/13 at 3:16 p.m., the facility presented a revised plan of correction. The plan of correction consisted of the following components: 1. ACC ceased the operation of the Dental Clinic effective 4/29/2013. 2. ACC physicians started to verbally notify residents at risk. During this time, physicians responded to questions and explained the process of screening blood tests. 3. Requested that residents provide consent to be tested . 4. Residents and family members were referred to the Homes Social Services for counseling and support services regarding this incident. 5. Social Workers will assess and monitor resident ' s level of anxiety and depression with regards to resident safety and will provide counseling and supportive services as needed. 6. The facility recommended the following blood tests to identified residents who provided consent: [MEDICAL CONDITION], [MEDICAL CONDITIONS].CBC (Complete Blood Count), and CMP (Comprehensive Metabolic Panel). 7. All residents will be initially screened for [MEDICAL CONDITION], [MEDICAL CONDITIONS].CBC and a CMP. 8. All residents that were initially screened will be rescreened for [MEDICAL CONDITIONS] 6 months. 9. Resident'[MEDICAL CONDITION] test came back "indeterminate". The interpretation came back "Inconclusive for HIV-1 antibodies ". CMO and pathology Lab recommend a repeat of the Western Blot test in one month. 10. Any positive test will be investigated immediately to determine whether it was a pre-existing condition or whether it was a result of exposure to contaminated dental instruments. 11. If test results demonstrate that a resident has been infected with a blood-borne pathogen as a result of contaminated dental instruments, those results will be immediately reported to California Department of Public Health. 12. Residents with dental needs will be seen by our contract dentist in the off-site office. Residents also have the option to go to the VA Medical Center 13. The facility has removed the autoclave machine in question from the dental clinic as of 4/29/2013 for disposal. 14. All previous " processed " instrument packs have been removed from the dental clinic on 5/3/2013 and will be re-sterilized prior to resuming operations in the dental clinic. 15. A new Ritter M9 autoclave machine has been purchased. 16. The Chief of Plant Operations will monitor the contract for compliance. 17. The dental technician of the ACC will be responsible for monitoring the machine's functionality and conducting weekly sterilization tests of the autoclave machine by using the spore testing method. 18. SMS personnel will immediately provide the result of any failed tests via phone and fax separately to the Infection Control Specialist, contract dentist, and the Supervising Registered Nurse. The CMO or designee will be contacted within an hour upon notification of failed test results. 19. Monthly test results will be mailed to the Infection Control Specialist and the ACC SRN. 20. The Home's existing policy on the Cleaning and Disinfecting Non-critical Resident Equipment" has been revised to include the "Infection Control Guideline - Dental Service". 21. In-Service Training of the "Infection Control Guideline - Dental Service" policy will be completed on May 7, 2013 for all pertinent staff (Dental staff and ACC staff). 22. Dental and ACC staff will also be trained on the new process of notification of sterilization test, which will be completed by May 7, 2013. 23. A log is being developed to ensure proper communication and review of all sterilization test results. 24. Any variances or failed test results will be reported to the Chief Medical Officer or designee within one hour of notification. 25. The Infection Control Specialist will monitor for compliance and will report to the Quality Assurance Committee. On 5/7/13 at 3:30 p.m., a meeting was conducted with the Administrator, Director of Nursing, Standard Compliance Coordinator, Supervising Registered Nurses, and members of the administrative staff to informed them that the Immediate Jeopardy was abated. The facility failed to ensure the contracted providers providing dental services and biomedical equipment maintenance in the Skilled Nursing Facility (SNF) conformed and implemented signed agreements that meet professional standards in providing services by failing to: 1. Ensure that the dental autoclave machine used to sterilize dental instruments was properly maintained. 2. Ensure to submit a complete report to the Contract Manager of the services provided, including necessary repairs. 3. Ensure that contractor made every attempt to complete repairs the same working day. 4. Ensure that contractor responded to requests for emergency repair within eight (8) hours of telephone notification by the Contract Manager. 5. Ensure that contractor provide loan equipment, repair(s) [MEDICATION NAME] more than five working days. 6. Ensure that all sterilization tests results provided by a provider were reviewed to ensure that all dental instruments are free from cross contamination and safe for residents and other patients' use. 7. Ensure that proper infection control practices were implemented in the dental clinic to ensure the health and safety of the residents and other patients. 8. Ensure that a policy and procedure on infection control was established and implemented in the dental clinic.

Based on observation, interview, and record review, the Governing Body failed to ensure that the facility established and implemented policies regarding the management of the facility by failing to: 1. Ensure that the dental autoclave machine used to sterilize dental instruments was properly maintained. 2. Ensure that there was a proper reporting process of the sterilization tests results. 3. Ensure that all sterilization tests results provided by a provider were reviewed to ensure that all dental instruments were free from cross contamination and safe for residents and other patients' use. 4. Ensure that a policy and procedure on infection control was established in the dental clinic. 5. Ensure that proper infection control practices were implemented in the dental clinic to ensure the health and safety of the residents and other patients. These failures resulted in failed dental instruments sterilization tests from February 2013 through April 2013 where dental services continued during that period that jeopardized the health and safety of 54 Skilled Nursing Facility (SNF) residents. Findings: On 5/2/13 at 9:45 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of a failed sterilization of a dental autoclave machine (used for the sterilization of dental instruments) in the Ambulatory Care Clinic (ACC), an out-patient clinic, which is located inside the Skilled Nursing Facility (SNF) building, owned and operated by the facility. On 5/2/13 at 10 a.m., an interview with the Standard Compliance Coordinator (SCC) was conducted. The SCC was employed by the facility as a full time employee of the SNF. According to the SCC, on 4/29/13 before lunch time, the dental clinic received a notification that one of the sterilization tests failed. The dental clinic immediately stopped all appointments on 4/29/13. She also stated that it was later found out that there was more than one test that failed. On 5/2/13 at 10:15 a.m., an interview with the Administrator was conducted. The Administrator was employed as a full-time employee of the SNF. He stated that the Chief Medical Officer was in charge of the dental clinic and that he (Administrator) had never been involved in the oversight. He also stated that it was unknown to them that the sterilization tests of the dental instruments failed numerous times and that there was almost no involvement or monitoring of the Infection Control Nurse (ICN) in the dental clinic. On 5/2/13 at 10:45 a.m., an interview with the Chief Medical Officer (CMO) was conducted. The CMO also known as the Medical Director, was employed as a full-time employee by the facility and had oversight of the SNF and clinics. He stated that he was in charge of the dental clinic. He also stated that a contracted Dentist and a Dental Assistant came in to provide services in the dental clinic. According to him, there were two failed sterilization tests in February and three failed sterilization tests in March 2013 reported by a provider (Sterilizer Monitoring System). The Health Safety Officer's (HSO) phone received messages for failed results; however, when the HSO left in June of 2011, her phone number was not deactivated and it continued to receive messages. The new HSO hired in 2012 did not receive any failed test results because the phone number previously designated to receive reports was not transferred to him (HSO), according to the CMO. The CMO further stated that when the February 2013 failed sterilization test results was received by the Office Technician (OT), she did not notify the clinic Supervising Registered Nurse (SRN). The SRN had the responsibility to read the sterilization test results. The Dentist was not informed of the failed results until 4/26/13. He also added that 54 Skilled Nursing Facility residents were seen from the periods of February thru April 2013 when the sterilization tests failed, in which the dental procedures where classified as "no blood, minimal blood, and moderate blood." The dental clinic's operation ceased on 4/29/13 and all appointments were cancelled. Blood borne disease tests (Human Immunodeficiency Virus, [MEDICAL CONDITION] and C) will be conducted for all patients who had been identified and affected, according to him. On 5/2/13 at 11:36 a.m., an interview with the ICN was conducted. The ICN was employed as a full-time employee of the SNF. She stated that she tracked the infection control practices in the SNF and dental clinic. According to her, there was a surveillance log in the dental clinic and that she worked with the SRN of the dental clinic, because sterilization of the dental instruments was part of her (ICN) tracking infection control practices. She indicated that when the HSO left in 2011, the dental clinic SRN told her that she'll (SRN) track the sterilization procedures and results, because it's addressed to her. She (ICN) also stated that the results were part of her tracking and that she depended on the SRN of the results. However, she stated that she did not receive any report whether normal or abnormal since 2000, because she was not part of the reporting process even though she was the ICN. She was not aware of the failed sterilization tests of the dental instruments in February, March, and April 2013. She stated that the dental clinic SRN did not report any results to her and that she assumed that there were no abnormal results because she relied on the SRN. On 5/2/13 at 12:12 p.m., an observation was conducted inside the dental clinic. The clinic was located in the ACC, inside the building of the SNF. The dental clinic was observed without any patients. One dental autoclave machine was observed on top of a counter with a preventive maintenance sticker attached to it. The sticker indicated that the machine is due for maintenance in July 2013. There were multiple dental instruments wrapped in a plastic container observed in the upper and lower cabinet where the machine was located, and inside a brown box located on top of a counter across the autoclave machine. A log book was also observed on top of the counter that contained SMS sterilization test results from April 2011 thru April 2013. On 5/2/13 at 12:15 p.m., a review of the SMS sterilization test results log was conducted. The review indicated that the "STATEMENT OF TEST RESULTS" was specifically addressed to the SRN of the clinic. It also indicated that a steam was used as a type of sterilizer when it was submitted to SMS for the spore testing (to determine presence of microorganism). The review further indicated the following: a. For the month ending 2/28/13, two tests that were conducted in February (2/1/13 and 2/8/13) failed. b. For the month ending 3/31/13, three tests that were conducted in March (3/1/13, 3/11/13, and 3/15/13) failed. c. For the month ending 4/30/13, three tests that were conducted in April (4/11/13, 4/22/13, and 4/26/13). The test conducted in 4/11/13 passed the sterilization test. However, 4/22/13 and 4/26/13 tests failed. Overall, seven sterilization tests failed between the periods of February 2013 thru April 2013, before it was discovered on 4/26/13. On 5/2/13 at 12:17 p.m., a review of the dental clinic's appointment book was conducted. The review indicated that between the periods of February 1, 2013 thru April 26, 2013 there were a total of 112 patients seen in the dental clinic. 54 out of 122 patients were SNF (Skilled Nursing Facility) residents. There were 167 total procedures performed on patients (71 no blood, 70 minimal blood, and 26 moderate blood) and 61of 167 procedures were performed on SNF residents (13 no blood, 28 minimal blood, and 20 moderate blood). The clinic continued to provide dental services to patients as indicated in the appointment logs when the result of the sterilization tests indicated that it failed during that period. On 5/2/13 at 12:19 p.m., an interview with the Office Technician (OT) was conducted. The OT was employed as a full-time employee of the facility, who worked in the dental clinic and reported directly to the CMO. She stated that she receives the mail from the mailroom and opens it if it was addressed to the clinic. She indicated that the Sterilizer Monitoring System (SMS) sterilization test reports are specifically addressed to the dental clinic Supervising registered Nurse (SRN). According to her, she opened mails from SMS and just filed it. She was not told to show the results to anyone, because she was instructed by the SRN to just file it (SMS sterilization test results log). She had been receiving test reports via mail since 2011 when the Health Safety Officer (HSO) left. She also stated that when she saw the failed sterilization test result for March 2013, she showed it to the SRN and she was instructed to show it to the Dentist on 4/26/13. According to her, she taped the results on the autoclave machine and verbally alerted the Dentist on 4/26/13 of the failed sterilization tests. On 5/2/13 at 2 p.m., a review of the Medical Director, Infection Control Nurse, Supervising Registered Nurse, and Office Technician's "Duty Statement" was conducted. The review indicated the following: 1. Chief Medical Officer, "ESSENTIAL FUNCTIONS...oversight to attain the medical care standards...Monitors the Infection Control Program and policies. Directs the work of the Infection Control Coordinator..." 2. Infection Control Specialist, "ESSENTIAL FUNCTIONS...develops, implements, and administers facility-wide systems for the prevention and control of infection and diseases; assures compliance with regulations governing infection control...develop, implement, and monitor infectious control systems for hospital and domiciliary areas through observation consultation, and evaluation of statistical and medical reports..." 3. Supervising Registered Nurse, "...in charge of the Ambulatory Care Clinic...will provide supervision and direction for the operation of the clinic ...ESSENTIAL FUNCTIONS...will develop and enforce policies that govern the day-to-day operation of the clinic..." 4. Office Technician, "...tracks and monitors reports from contracted services..." On 5/2/13 at 3 p.m. a review of the Dentist's contract signed 5/31/11 was conducted. The review indicated that the she signed an agreement to provide dental services from 7/1/11 thru 7/30/14. The review also indicated, "SCOPE OF WORK...4. Contractor shall provide Dental Services in the Dental Clinic of the Ambulatory Care Clinic...6. Contractor shall provide bedside dental screening for Skilled Nursing Facility (SNF) residents...7. Services shall be in accordance with Medi-Cal (Denti-Cal) standards and requirements and shall include, but not limited to, the following responsibilities:...e) Provide all dental services as required by OBRA (Omnibus Budget Reconciliation Act) 483.5; California Code of Regulations, Title 22 for Skilled Nursing Facility (SNF)...i)...approve oral hygiene policies and practices for the care of residents..." On 5/2/13 at 3:30 p.m., a review of the facility's "PURCHASE ORDER" dated 8/21/12 was conducted. The review indicated that SMS (Sterilizer Monitoring Systems) signed an agreement with the facility to provide a weekly spore testing of the facility's autoclave sterilizer monitoring system. The agreement was signed on 7/23/12. The purchase order did not include how test results will be reported and did not identify the person responsible for receiving the reports. On 5/2/13 at 4:30 p.m., an Immediate Jeopardy was called to protect the health and safety of the residents. The Administrator was notified and informed of the following issues that led to the determination of Immediate Jeopardy: a. Failure to properly sterilize the dental instruments for three consecutive months. b. Failure to ensure that there was a proper reporting process of the failed sterilization tests results. c. Failure to review sterilization tests provided by a provider to ensure that all dental instruments were free from cross contamination and safe for residents and other patients' use. d. Failure to notify the responsible authority of the failed sterilization tests results. e. Failure to ensure that proper infection control practices were implemented in the dental clinic. f. Failure to ensure that a policy and procedure on infection control was established and implemented in the dental clinic. g. Possible and potential exposure to bloodborne infectious diseases of patients seen in the dental clinic. On 5/2/13 at 5:30 p.m., the facility presented an initial plan of correction. The plan of correction indicated the following: 1. The dental clinic ceased operations effective 4/29/13. 2. Affected residents and other patients will be identified and notified of possible risk due to failed sterilization test results. 3. The facility will asked for consents on blood screening test to all patients that were affected. 4. The use of the autoclave machine was discontinued. On 5/2/13, the Immediate Jeopardy remained in effect, although the facility presented an initial plan of correction. The plan of correction submitted lacked the components needed to abate the Immediate Jeopardy. On 5/4/13 at 11:13 a.m., an interview with the CMO was conducted. He indicated that the laboratory results for Human [MEDICAL CONDITIONS] and C (bloodborne infectious diseases due to exposures to blood and other body fluids) conducted on 5/2/13 for SNF residents who consented for the test were reviewed. He stated that two residents tested positive [MEDICAL CONDITION]. Resident 1, a [AGE] year old male who was seen in the dental clinic on 3/22/13 for an oral exam showed a highly reactive result [MEDICAL CONDITION]. He spoke to the resident and informed him of [MEDICAL CONDITION] result. The resident was not surprised of the result, according to the CMO, stating, "He kind of knew that he'[MEDICAL CONDITION]." He also stated that based on his medical opinion, Resident 1 was not infected in the clinic and could have [MEDICAL CONDITION] already when he was admitted in the facility on January 31, 2013. He further stated that the way the instruments were processed in the dental clinic using an ultrasonic emulsifier and autoclaving, and a blood less exam provided for Resident 1, he's doubtful that it was acquired in the clinic. A secondary confirmatory test (Western Blot) was conducted with pending results. A third test ([MEDICAL CONDITION] load) to measure the amount of virus particle in the blood was ordered on [DATE] with pending results. Resident 2, an [AGE] year old male who was seen in the dental clinic twice at the end of January 2013 for a general oral exam and filling, showed a minimally reactive result [MEDICAL CONDITION]. According to the CMO, Resident 2 had no identified risk factor and behavior. He believed that the laboratory test was a false positive result because the pieces [MEDICAL CONDITION] particles were minimal. He also stated that based on his medical opinion, Resident 2 was not infected in the clinic, because of how the instruments were processed in the dental clinic. A secondary confirmatory test (Western Blot) was conducted with pending results. A third test ([MEDICAL CONDITION] load) to measure the amount of virus particle in the blood was also ordered on [DATE] with pending results. On 5/6/13 at 9:12 a.m., an interview with SMS Business Manager was conducted. SMS was a company contracted by the facility to provide services in sterilizing dental equipments. According to her, they conducted weekly spore testing of the facility's autoclave sterilizer monitoring system. The facility's dental clinic will send the sterilization strips, SMS will incubate it for seven days to evaluate for any microorganism growth at 55-57 degree Celsius (131-135 degree Fahrenheit). Positive results for microorganism means failed sterilization test. The facility will be notified immediately via phone of the failed sterilization test results and hard copy was mailed as well. She stated that the test results were addressed to the SRN. She was unaware that the phone number provided by the facility to receive reports of failed result was changed and not being monitored, although it was still active. The facility did not contact SMS to give notification of the phone number change and the authorized person responsible to receive the report, especially failed sterilization tests. On 5/6/13 at 11:42 a.m., an interview with the Dentist was provided. The Dentist was employed by the facility as a contracted provider, who reported directly to the CMO. She indicated that she had been a contracted provider since 2008, in-charge of the dental clinic, and directly reports to the CMO. She was asked if she reviews or oversee the reports of the sterilization test results, she replied, "It's not my duty to oversee the reports of the sterilization result, because I just provide dental care. On the SMS document results, stated (name of SRN) on it. The dental assistant doesn't read the report either, that's not our duty." When she was asked if the failed test results will be reported to her via phone or mail, she stated, "I wouldn't know how the reports will come in, it's not my duty." The sterilization process was always done by the Registered Dental Assistant (RDA) on duty once or sometimes twice per week according to her. She explained how she categorized the procedures performed on patients: 1. Category I (no blood) - oral exams, denture placements, and fittings. Instruments used were mouth mirror and explorer. No periodontal exams or digging of gums. Majority of the time, there were no blood involved. 2. Category II (minimal blood) - fillings, cleaning, cementing. Instruments used were restorative instruments, packing instruments, and instrument made out of metal. Blood was always involved. 3. Category III (moderate bleeding) - extractions and periodontal maintenance. Instruments used were forceps, scalers, etc. Blood was always involved. The Dentist became aware of the failed sterilization test on 4/26/13 when the OT posted a paper note on the autoclave machine. She also stated that the staff in the dental clinic never reported any results to her. She didn't know that the sterilization tests failed in February thru April 2013 when she provided dental services; in which 100 plus patients were exposed to bloodborne pathogens (blood contamination). She also added, "I trusted the VA (Veterans Administration) that they're doing their job, looking at results and maintaining their equipment. Reading the result was not my duty." She indicated that she didn't have any policies and procedures for infection control and sterilization of dental instruments in the dental clinic of the ACC. On 5/6/13 at 12:34 p.m., an interview with the RDA was conducted. The RDA was employed by the facility as a contracted worker, who reported directly to the contracted Dentist. He stated that he was responsible for autoclaving or sterilizing the dental instruments after use. According to him, the dirty dental instruments will be placed inside the ultrasonic bath machine for 10 to 15 minutes to be washed. Once washed and dried, the instruments will be individually packaged in a plastic container prior to placing it inside the autoclave machine. The packaged dental instrument will be placed inside the autoclave machine along with a sterilization test strip inside a plastic container. The plastic container had a pink dot outside the plastic, as an indicator that the dental instrument was sterilized. He stated, "The color of the dot is pink, when the machine is done, the color will change to a dark color indicating that it is done (sterilization process completed), but not necessarily indicating it passed or failed for bacteria testing." The sterilization test strip inside a plastic container will be removed, placed inside an envelope, and mailed to SMS by the RDA for testing. The RDA mentioned that he conducted random checks when the autoclave machine was running. He didn't keep track of the machine's temperature and/or maintained any logs of the sterilization process of the autoclave machine. He was not aware of who's responsible for reading the results, whether passed or failed, and stated that he doesn't read the sterilization report when it comes back from SMS. When he was asked, "How did you know that the dental instruments were safe to use?" He stated, "Because I sterilized the instruments, that's my duty." He also stated that he never looked at the SMS results log book located in the dental clinic, stating, "It's not my duty to read it. The results are addressed to the homes. Nobody in the dental clinic had provided the results." He further explained that there were no steps, procedures, or manufacturer's recommendation on how to perform the autoclaving process in the dental clinic, stating, "I learned it (autoclaving) from school. The machine was pre-programmed." On 5/6/13 at 2:05 p.m., an interview with Resident 1 was conducted. According to him, the CMO spoke to him about his positive test result [MEDICAL CONDITION]. He also stated, "I was surprised, I didn't expect to become positive." He stated that he gave wrong information to the HMO when he initially told him that he had an unprotected sex in November 2012. He further stated, "I had a funny feeling in October, in my mind that I had caught something. I asked the mobile doctor to draw blood [MEDICAL CONDITION] also told him to let me know. The doctor said, "If I don't call you, you're ok." Resident never heard from the doctor and was not aware of any results. He expressed his feelings of anxiety after learning the results from the CMO. He stated that he had lost interest in painting portraits. On 5/6/13 at 2:50 pm., a review of the "Work Order Request" for the autoclave machine dated 4/5/13 was conducted. The review indicated that there was a work order generated due to a leaking problem of the autoclave machine. The work order did not indicate who made the request and/or any completion date when it was generated. There were no other documents found to indicate that the problem was resolved or completed. On 5/6/13 at 3:40 p.m., an interview with the Stationary Engineer of Plant Operations was conducted. The Stationary Engineer of Plant Operations was employed as a full-time employee of the facility who was responsible for operating, maintaining, inspecting and repairing mechanical, electrical, electronic, and manufacturing systems. He stated that (contracted company's name) was the contracted company responsible for maintaining the autoclave machine in the dental clinic. According to him, on 4/5/13 the autoclave was leaking. He was not certified to repair the autoclave machine, so he decided to call three vendors to get a bid for the repair on 4/8/13, although the facility already had a contract in place. On 4/18/13, (contracted company's name) repaired the gasket of the leaking autoclave machine. On the following day (4/19/13), the autoclave machine was noted to be leaking again. On 4/22/13, (contracted company's name) came back and checked the machine. The technician wanted to take the machine with him to be repaired, but he did not allow it, according to the Stationary Engineer. The (contracted company's name) did not provide any documentation when they diagnosed and/or attempted to repair the autoclave machine on 4/18/13 and 4/22/13. The Stationary engineer stated, "I don't normally ask for documentation." When he was asked, "How did you know that they checked the machine?" He stated, "Most of the time, we just relied on them, when they tagged the machine, that it was inspected and it passed." There were no documented evidence found that the autoclave machine was repaired when it was discovered leaking on 4/5/13. During the period of 4/5/13 thru 4/26/13, the dental clinic continued to provide dental services. There were 87 patients identified to have dental procedures done when the autoclave machine was not in a proper operating condition. The autoclaving of dental instruments continued (as evidenced by the date test received by SMS for 4/11/13, 4/22/13, and 4/26/13), knowing that the autoclave machine was not in proper operating condition. On 5/6/13 at 4 p.m., a review of the "STANDARD AGREEMENT" signed on 5/21/12 between the facility and the contracted company responsible for maintaining the autoclave machine in the dental clinic was conducted. The review indicated that the contract was valid from 7/1/12 thru 6/30/15. The contracted provider agreed to provide an annual medical equipment certification and repair services. The review also indicated, "SCOPE OF WORK...7. Unscheduled Repair Service: Contractor shall provide unlimited visits for any repair services requested or necessary to keep the equipment fully operational...Contractor shall make every attempt to complete repairs the same working day...8. Emergency Repair Service:...Contractor shall respond to requests for emergency repair within eight (8) hours of telephone notification by the Contract Manager...9. Loan Equipment: For approved repair(s) [MEDICATION NAME] more than five working days, the State reserves the right to require the Contractor to provide loan equipment, as available...14. Documentation Requirements: After completion of service, the Contractor shall submit a complete report to the Contract Manager of the services provided, including necessary repairs. Reports shall include: a) Date of Service, b) Description of services provided, c) name and signature of service technician, d) Location of equipment, e) Equipment make, model, and serial number, f) Description of any noted deficiencies and suggestive corrective action, g) Total labor hours expended, h) Signature of State employee certifying indicated services were performed." On 5/6/13 at 4:15 p.m., a review of the facility's Policy and Procedure (P&P) titled "Biomedical Equipment maintenance" with a revision date of 9/20/12 was conducted. The review indicated, "PROCEDURES: 1. CONTRACTOR QUALIFICATIONS AND RESPONSIBILITIES - A. Medical equipment used in the facility must be inspected per the manufacturer's recommendation for safety, operational performance, and preventive maintenance....B...1. Contractor shall respond to requests for service within 48 hours or 8 hours if an emergency...5. When a piece of equipment is not functional and is required for the health and safety of the resident, a loaner will be obtained (if available) until item has been repaired...II. STAFF RESPONSIBILITIES - A. Equipment failures - Defective equipment shall be removed from its designated area. 1. An equipment tag will be completed to include sanitation and repair." On 5/7/13 at 9:50 a.m., a review of the facility's P&P titled "Infection Prevention and Control Surveillance" with a review date of 7/18/12 was conducted. The review indicated, "POLICY STATEMENT: It is the policy of the Home to have systems in place to conduct Infection Prevention and Control surveillance activities as an integral component of the Infection Prevention and Control Program...THE PROCESS OF SURVEILLANCE:...B. Process Surveillance - reviews staff practices directly related to resident care in order to identify whether the practices comply with established Home prevention control procedures and policies...SCOPE OF SURVEILLANCE: A. infection Control surveillance shall be done in all areas of the Home... " There were no P&P found regarding Infection Control practices in dental services and P&P on reporting of sterilization test and sterilization of dental instruments. On 5/7/13 at 10:46 a.m., another interview with the CMO was conducted. The CMO provided an update of the laboratory results on the residents who gave consents to be tested [MEDICAL CONDITION].[MEDICAL CONDITION] and C. According to him, Resident 1's Polymerase Chain Reaction (PCR) came back negative and that there was [MEDICAL CONDITION] found in the blood. He stated that he was still waiting for the Western Blot result at this time. Resident 2's Western Blot test came back negative on 5/6/13. The initial result, he stated was a false positive. One resident's (Resident 3) test result for [MEDICAL CONDITION] collected on 5/2/13 came back positive. He further stated that a PCR test was still pending to confirm the initial finding. There were no other residents identified to have positive results on the laboratory tests ordered by the CMO. At 11:15 a.m., the CMO presented the Western Blot test for Resident 1. He stated that the test result was indeterminate and inconclusive for HIV. On 5/7/13 at 11:30 a.m., a review of Resident 1's clinical record was conducted. The review indicated that he's a [AGE] year old male who was admitted in the facility on 1/31/13 with [DIAGNOSES REDACTED]. He scored 30 out of 30 on his Mini Mental State Examination conducted on 2/1/13, which indicated that he was alert and responsive. The Minimum Data Set assessment done on 2/20/13 indicated that he had no cognitive impairment and was able to make decisions for himself. There was no documented evidence found in the clinical record suggesting that Resident 1 had a history of [REDACTED]. Resident 1's laboratory test for [MEDICAL CONDITION] and C collected on 5/2/13 indicated a negative result for [MEDICAL CONDITION]. The HIV-1 and HIV-2 test collected on the same date indicated that he was reactive (HIV antibodies found in blood) to [MEDICAL CONDITION]. The Western Blot test collected on 5/2/13 indicated a result of "Indeterminate". The interpretation of the test result was, "INCONCLUSIVE for HIV-I antibodies, possibly infected." On 5/4/13, a blood sample was collected to test Resident 1's blood for a Quantitative Real Time Polymerase Chain Reaction (technique to identify with high probability, disease causing viruses and/or bacteria). The result indicated, "Not Detected". On 5/7/13 at 1:05 p.m., another interview with Resident 1 was conducted. According to the resident, the CMO told him that another test came back and he didn't have the any virus. He stated that he felt good about it, "It reduced my anxiety and I will be able to paint again." On 5/7/13 at 1:20 p.m., another interview with the RDA was conducted to clarify the wait time for the result before using the dental equipment. He stated that they don ' t wait for the sterilization test results. He confirmed that he used the dental equipment he sterilized without waiting or knowing the sterilization test results. On 5/7/13 at 2:05 p.m., an interview with Resident 2 was conducted. According to him, the CMO spoke to him about his positive test result [MEDICAL CONDITION] was unable to provide details of their conversation. There was no other information collected from Resident 2. On 5/7/13 at 2:29 a.m., a review of Resident 2's clinical record was conducted. The review indicated that he's an [AGE] year old male who was admitted in the facility on 9/17/10 with [DIAGNOSES REDACTED]. He scored 17 out of 30 on his Mini Mental State Examination conducted on 11/16/12, which indicated that he had a moderate cognitive Impairment. There was no documented evidence found in the clinical record suggesting that Resident 2 had a history of [REDACTED]. Resident 2's laboratory test for [MEDICAL CONDITION] and C collected on 5/2/13 indicated a negative result for [MEDICAL CONDITION]. The HIV-1 and HIV-2 test collected on the same date indicated that he was reactive (HIV antibodies found in blood) to [MEDICAL CONDITION]. The Western Blot test collected on 5/2/13 indicated a result of "NEGATIVE for HIV-1 antibodies". On 5/7/13 at 3:16 p.m., the facility presented a revised plan of correction. The plan of correction consisted of the following components: 1. ACC ceased the operation of the Dental Clinic effective 4/29/2013. 2. ACC physicians started to verbally notify residents at risk. During this time, physicians responded to questions and explained the process of screening blood tests. 3. Requested that residents provide consent to be tested . 4. Residents and family members were referred to the Homes Social Services for counseling and support services regarding this incident. 5. So

Based on observation, interview, and record review, the facility failed to ensure that the policy and procedure for falls was implemented when the Registered Nurse (RN) left Resident 1 to obtain a bed sheet after an incident of fall. Findings: On 4/25/13 at 9:30 a.m., an unannounced visit was made to the facility to investigate an entity reported incident involving Resident 1who suffered a fall on 4/13/13 at 11:45 a.m., while being assisted by an RN inside the bathroom of room [ROOM NUMBER]-2. On 4/25/13 at 9:45 a.m., a review of Resident 1's clinical record was conducted. The review indicated that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His "Fall Risk Assessment" dated 1/27/13 indicated a score of 11, suggesting that he was at high risk for fall. The Minimum Data Set ((MDS) dated [DATE] indicated that there was no identified cognitive issue or short and long term memory problem. However, he was assessed to have some difficulty in new situations for his daily decision-making. He required extensive assistance during transfers and was totally dependent to staff in toilet use, requiring one staff to physically assist him. He was not able to walk, but he utilized a motorized wheelchair to move between locations in the facility. On 4/25/13 at 10 a.m., an observation and interview of Resident 1 was conducted. Resident 1 was observed sitting in a motorized wheelchair in his room. A tab alarm was observed connected to his shirt. He was awake, alert and oriented. He was unable to speak due to his stroke, but was able to make sounds and gestures. Resident 1 gestured that he wheeled himself in the bathroom located inside his room. When he was asked, if he called for assistance, he responded by shaking his head from side to side, indicating, "No." He indicated that he fell from his wheelchair while in the bathroom; he tried to get up but fell on his left side. When he was asked if any staff was present at the time, he shook his head, indicating "No." He gestured that he tried to get up again but could not remember if he was able to hold onto the grab bar to pull himself up. He was not sure when staff arrived, but he indicated that he was assisted and assessed. On 4/30/13 at 11:35 a.m., an interview with the RN who responded and helped the resident was conducted. She stated that she noticed a red light on the bathroom of room [ROOM NUMBER]. She went in and saw Resident 1 standing up inside the bathroom, holding on to the grab bar. She assisted the resident by pulling his pants down to the buttocks area, because he wanted to use the toilet. While she was holding the resident's pants, the resident suddenly let go of the grab bar. She prompted the resident to keep holding on but the resident was not able to. The RN told the resident, "You have to go down" because she stated that he was heavy. She supported the resident by placing her left leg in between the resident's leg and eased him down on the floor. The resident did not hit the floor, according to her, because she supported him. She then left the resident to get a bed sheet located outside the resident's room. The resident was assessed after the incident and denied any pain. There were no obvious injuries noted during the assessment, according to her. The resident's daughter was notified of the incident on the same day at around 12 noon. On 5/1/13 at 3:41 p.m., an interview with the resident's daughter was conducted. She stated that she was notified of the incident on 4/14/13 at 12:30 p.m. by the RN. She stated that they left the facility with her father (Resident 1), drove around and came back to the facility. She stated that they were gone for approximately one and a half hours and had not heard any complaint of pain or discomfort from his father. On 5/2/13 at 3:15 p.m., a review of the facility's policy and procedure (P&P) titled "Falls" with an effective date of 7/10/10 was conducted. The review indicated, "POLICY STATEMENT: It is the policy of the facility t provide adequate supervision and assistive device to prevent accidents ...PROCEDURE: I. RESIDENT FALL:...B. Stay with the resident and call for assistance immediately..."