Every finding on record at Veterans Home of California - Yountville - SNF

Based on observation, interviews, and record review, the facility failed to ensure that food safety and sanitation guidelines were followed when multiple expired food items were found in the dry storage and refrigerator of the main and satellite kitchen. These failures posed the risk for food-borne illnesses (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 162.Findings: During a concurrent observation and interview on 3/23/26 at 2:01 PM in the Main Kitchen- G07 Refrigerator with the Food Manager (FM) 1, one large tray labeled Orzo Pasta had an expiration date of 3/11/26. FM 1 stated the orzo pasta needed to be thrown away because it was only good for 7 days.During a concurrent observation and interview on 3/23/26 at 2:28 PM in the Main Kitchen- Dry Storage Room with FM 1, the following food items were found expired:One container of chorizo seasoning had an expiration date of 12/31/25Eight packages of ranch dressing/dip had expiration dates of 2/14/26.Three bottles of browning seasoning sauce had expiration dates of 8/29/25.Four bags of vanilla artificial flavor instant pudding had expiration dates of 3/17/23.Nine bags of marshmallows had expiration dates of 2/27/26.Two bags of vanilla puddings had expiration dates of 11/3/21.FM 1 confirmed all the items were expired and stated all expired foods needed to be discarded.During a concurrent observation and interview on 3/23/26 at 2:59 PM in the Satellite Kitchen- Refrigerator with FM 2, the following food items were found expired: - One box of Sweet n Sour sauce had an expiration date of 3/14/26. - Two boxes of Plant-Based baked tofu had expiration dates of 2/26/26.FM 2 confirmed the items were expired and stated they should have been thrown away.During a review of the U.S [United States] Food and Drug Administration (FDA) Food Code dated 2022, the U.S FDA Food Code indicated, . foods that exceed the use-by date . must be disposed of .

Based on observation, interview, and record review, the facility failed to ensure the recommendations identified in the Level II PASRR (Preadmission Screening and Resident Review- used to ensure individuals are placed in an appropriate setting and receive needed mental health services) evaluation were implemented into the comprehensive care plan and resident care for one of 33 sampled residents (Resident 15). This failure resulted in Resident 15 not receiving the necessary specialized services and support identified through the PASRR process, placing Resident 15 at risk for unmet mental health needs, decline in Activities of Daily Living's (ADL- essential, basic self-care tasks done every day such as bathing, dressing, eating and moving around.) and diminished quality of care.Findings:During a review of Resident 15's admission Summary, undated, the admission Summary indicated Resident 15 was admitted to the facility on [DATE] for diagnosis to include bipolar disorder (mental health condition characterized by extreme, alternating shifts in mood, energy and activity levels). The admission Summary further indicated Resident 15 had generalized weakness. Patient will require assistance with meals, medications, clothing, dressing self. During a concurrent observation and interview on 3/24/26 at 8:57 AM in Resident 15's room with Resident 15, Resident 15 was sitting on the edge of his bed with his breakfast tray on the bedside table in front of him. Resident 15 was unable to reach his coffee and attempted to lean forward with mouth open to try and reach the straw with his lips, was unsuccessful and requested assistance. Resident 15 attempted to open a napkin, to wipe his nose, and fell backwards laying horizontal across his bed. Resident 15 stated he was not receiving any therapy and I should be, but I don't.During a concurrent interview and record review on 3/26/26 at 9:58 AM with Supervising Registered Nurse (SRN) 2, Resident 15's PASRR Level II Notice of Individual Determination, dated 10/25/25 was reviewed, the document indicated, Are Specialized Add-on Services Needed: Yes. This Individualized Determination Report is based on a review of the applicant's medical and social history, which reveals a significant medical condition with mental stressors that require nursing care. Recommended Specialized Add-on Services. Occupational Therapy [OT] Consultation- services to improve independence in activities of daily living. SRN 2 reviewed Resident 15's entire medical record and stated an OT consultation was not completed after the PASRR Level II recommendation was received.During an interview on 3/26/26 at 10:21 AM with the Chief of Rehabilitation Services (CRS), the CRS stated she cancelled Resident 15's OT consultation without evaluation and was not aware of the PASRR Level II recommendation.During an interview on 3/26/26 at 2:20 PM with the Medical Director (MD), MD confirmed with Resident 15's PASRR Level II Notice of Individual Determination, dated 10/25/25, that an OT consultation was recommended and stated Resident 15 should have received the OT consultation in accordance with PASRR Level II recommendation.The facility was unable to provide a policy and procedure for PASRR.

Based on interview and record review, the facility failed to ensure the Care Plan was updated on one (1) of 33 sampled residents, when Resident 160 complained of swallowing difficulty. This failure had the potential to result in life-threatening outcomes including fatal aspiration pneumonia, choking, severe dehydration, and malnutrition.Findings: During a review of Resident 160's Face Sheet indicated he was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnosis including atrial fibrillation (a common heart rhythm disorder where the heart's upper chambers beat irregularly), chronic obstructive pulmonary disease (a progressive, incurable lung disease), and respiratory failure. During a review of Resident 160's Minimum Data Set (MDS) [standard assessment used in long-term care] Section C1000 - Cognitive Skills for Daily Decision Making, indicated a score of 0 meaning Resident 160 was independent with decisions regarding tasks of daily life. Also, in MDS Section K - Swallowing/Nutritional Status indicated Resident 160 complaints of difficulty or pain with swallowing. During a review of Resident 160's Care Plan indicated a problem for nutrition alteration related to dysphagia, chewing difficulty that was initiated on 7/17/25. Goal for the said problem included no signs and symptoms of aspiration. Resident 160 complained of swallowing difficulty on 2/11/26 and it was not documented on the care plan. During a concurrent observation and interview on 3/24/26 at 10:11 AM with Resident 160, Resident 160 was observed sitting on his wheelchair next to his bed with supplemental oxygen via nasal cannula (flexible tube used to deliver oxygen). Resident 160 stated he feelt like he had mucus build up and sore throat and sometimes had difficulty swallowing pills and food. Resident 160 also stated PM head nurse was aware about the swallowing issue and he brought it up numerous times. During a concurrent interview and record review on 3/24/26 at 9:39 AM with Desk Clerk (DC), Resident 160's Physician Orders from January to March 2026 were reviewed. DC stated there was no physician order found for swallow evaluation. During a concurrent interview and record review on 3/25/26 at 9:50 AM with Registered Dietitian (RD), Dietary Follow-Up Report dated 2/25/26 was reviewed. The report indicated Resident 160 reported difficulty swallowing water. Resident stated it gets stuck in his throat and he has to burp it up. Wrote recommendation for swallow eval in MD book. Nursing and SLP were notified. RD stated she recall notifying the nurse and speech pathologist on 2/11/26 about Resident 160's swallowing difficulty. During an interview on 3/25/26 at 9 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated during emergency or urgent situations, physician needed to be notified right away and assess the resident. LVN 1 also stated that swallowing difficulty was considered change of condition which required immediate attention. LVN 1 stated licensed staff were required to document assessments, vital signs, signs and symptoms in the nursing progress notes. LVN 1 stated Resident 160's care plan should have been updated if resident complained of swallowing difficulty. During an interview on 3/25/26 at 9:06 AM with Supervising Registered Nurse (SRN) 1, SRN 1 stated swallowing difficulty was considered a change of condition which required resident assessment, physician notification, updated care plan and documentation on nursing progress notes because swallowing difficulty can affect resident's respiratory system and required urgent attention. During a concurrent interview and record review on 3/25/26 at 9:09 AM with Registered Nurse Case Manager (RNCM) 1, Resident 160's Care Plan and Nursing Progress Notes were reviewed. Resident 160's care plan was not updated when he reported swallowing difficulty on 2/11/26 and there were no nursing progress notes found indicating Resident 160's complaints of swallowing difficulty on 2/11/26. RNCM 1 stated the care plan should have been updated and there should have been a nursing progress note on 2/11/26 when Resident 160 reported swallowing difficulty. During a review of the facility's policy and procedure (P&P) titled, Change of Condition and Notification, dated 9/12/24, the P&P indicated, Urgent Situations a. Any sudden and/or marked adverse change in signs, symptoms . exhibited by a patient . D. Documentation 1. The Licensed Nurse will: a. Record all attempts to notify and communicate with the DOC or PCP regarding resident change of condition or status whether verbally communicated or placed in the communication book requires a note by the nurse including the date, time, and method of communication in the Nurses Notes in the resident's health record. b. Document date, time, condition and pertinent details of incident and assessment in the interdisciplinary Progress Notes . e. Update care plan to reflect current status. During a review of the facility's P&P titled, Care Plans - SNF/ICF (All Homes), dated 1/15/26, the P&P indicated, the baseline care plan must reflect changes to approaches or interventions, when there is/are significant changes) in condition or need(s).

Based on observation, interview, and record review, the facility failed to ensure residents received the necessary care and services to maintain or improve Activities of Daily Living (ADLs- essential, basic self-care tasks done every day such as bathing, dressing, eating and moving around) for five (5) of 33 sampled residents (Residents 15, 105, 97, 40, and 69) when:1. Resident 15 did not receive Occupational Therapy (OT) services in accordance with the physician order. This failure resulted in functional decline in ADLs.2. Residents 105, 97, 40, and 69 did not receive daily partial baths in accordance with the facility's policy and procedure (P&P). This failure placed residents at risk for poor hygiene, including body odors that can lead to social withdrawal, depression and significant emotional distress. 1. During a review of Resident 15's Face Sheet (demographics), undated, the Face Sheet indicated Resident 15 was admitted to the facility on [DATE] with diagnosis to include bipolar disorder (mental health condition characterized by extreme, alternating shifts in mood, energy and activity levels). During a concurrent observation and interview on 3/24/26 at 8:57 AM in Resident 15's room with Resident 15, Resident 15 was sitting on the edge of his bed with his breakfast tray on the bedside table in front of him. Resident 15 was unable to reach his coffee and attempted to lean forward with mouth open to try and reach the straw with his lips, he was unsuccessful and requested assistance. Resident 15 attempted to open a napkin, to wipe his nose, and fell backwards, laying horizontal across his bed. Resident 15 stated he was not receiving any therapy and I should be, but I don't. During a concurrent interview and record review on 3/26/26 at 9:58 AM with Supervising Registered Nurse (SRN) 1, Resident 15's medical record was reviewed. A physician order for Occupational Therapy (OT) was ordered on 10/21/25 but there was no OT evaluation completed. SRN 1 stated she does not know why the OT evaluation was not completed and she was aware of Resident 15 requiring moderate assistance for ADLs. During a concurrent interview and record review on 3/26/26 at 10:21 AM with the Chief of Rehabilitation Services (CRS), the following documents of Resident 15 were reviewed: - Physician Orders (PO), dated 10/21/25, indicated an evaluation and screening of OT was to be completed. - ADL Flow Sheet, dated October 2025, indicated Resident 15 was independent (resident completes the activity by himself with no assistant from staff) for toileting hygiene, putting on/taking off footwear, and majority of the time for lower body dressing. The ADL Flow Sheet further indicated he required moderate assistance (staff does less than half of the task) for personal hygiene. - ADL Flow Sheet, dated March 2026, indicated Resident 15 was dependent (staff does all the effort, resident does none of the effort to complete the activity) for toileting and personal hygiene, and required moderate assistance for putting on/taking off footwear. The ADL Flow Sheet further indicated he required moderate assistance for lower body dressing. The CRS stated Resident 15 had a decline in his ADL's and required an immediate evaluation of OT. During an interview on 3/26/26 at 10:40 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 15 was more independent when he was first admitted to the facility, but now he needed a lot more help with all ADLs. LVN 2 stated Resident 15 needed more help with administering medications, drinking, feeding, hygiene, lying to sitting, and getting dressed. During an interview on 3/26/26 at 10:42 AM with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 15 needed maximum assistance with ADLs to include: putting on shoes, straightening/sitting up in bed, getting dressed, brushing his teeth, and feeding. CNA 3 further stated he has declined more noticeably in the past month. During an interview on 3/26/26 at 2:25 PM with the Medical Director (MD), the MD stated he was not aware prior to the survey of Resident 15 declining with ADL's and not receiving OT. The MD stated after he was made aware by the CRS, he reviewed Resident 15's medical record and confirmed Resident 15 had a decline in ADL's and required an OT evaluation/ therapy. During an interview on 3/26/26 at 3:03 PM with the Administrator, the Administrator confirmed with Resident 15's medical record he had a decline in ADL's and stated there was a possibility that the ADL decline would have been prevented if Resident 15 received the occupational therapy and followed the recommendations. During an interview on 3/26/26 at 3:27 PM with Occupational Therapist, Occupational Therapist stated he had not seen Resident 15 for OT. Occupational Therapist further stated OT was provided to help with ADLs to include bathing, toileting, eating and dressing. During a review of Resident 15's History and Physical (H&P), undated, the H&P indicated Resident 15 was transferred from a lower level of care unit due to needing increased assistance with ADLs. The admission Summary further indicated Resident 15 had diagnosis of, generalized weakness. Patient will require assistance with meals, medications, clothing, dressing self. During a review of Resident 15's Interdisciplinary Team Conference (IDTC), dated 10/29/25, the IDTC indicated Resident 15 had a problem with ADL function and the team recommendation was Resident 15 needed an OT evaluation/therapy for muscle and strengthening. The IDTC further indicated Resident 15 was independent for toileting and hygiene and required set up assistance with showering and partial assistance for lower body dressing. During a review of Resident 15's Interdisciplinary Team Conference (IDTC), dated 1/20/26, the IDTC indicated Resident 15 had a problem with ADL function and required partial assistance with toileting, hygiene and substantial assistance for lower body dressing. During a review of the Facility Assessment, dated 3/2/26, the Facility Assessment indicated, .The list below provides general categories of services and care the facility offers residents based on needs identified through the assessment process. Activities of daily living: Bathing, showers, oral/denture care, dressing, eating, supporting resident independence in doing as many of these activities by themselves as possible. Occupational therapy (OT). During a review of the facility's policy and procedure (P&P) titled, ADL, dated 9/8/25, the P&P indicated, .each resident will be encouraged and/or assisted to achieve and maintain their highest level of self-care and independence. During a review of the facility's P&P titled, Physical & Occupational Therapy Services, dated 2/24/26, the P&P indicated, .Occupational therapy services will be provided to residents of the skilled nursing facility. according to primary care provider (PCP) orders. Occupational therapy service: those services ordered by a physician for a resident or upon a physician's referral and provided to a resident. Occupational Therapists will respond timely to PCP's order. Requests for therapy evaluations will be completed as soon as possible. Occupational Therapy Services. ADL Training. 2. During a review of Resident 105's Face Sheet, the Face Sheet indicated Resident 105 was originally admitted on [DATE] and was re-admitted on [DATE] with diagnosis that included heart disease, nicotine dependence, gait abnormalities, and muscle weakness. During a review of Resident 105's Minimum Data Set (MDS) [ standard assessment used in long-term care] Section C – Cognitive Patterns, dated 2/26/26, the MDS indicated Resident 105's Brief Interview for Mental Status (BIMS) [15-point cognitive screening tool used in long-term care to assess memory and orientation] total score of 12. In the MDS Section GG0130 – Self-Care functional abilities (assessment period was day the assessment was performed plus two (2) previous calendar days), the MDS indicated Resident 105's shower/bathe self was Coded 09 (indicating the activity was not applicable - not attempted and the resident did not perform this activity). During a review of the facility's Smokers List, dated 3/20/26, the list indicated Resident 105 and Resident 97 were smokers and both go off ward daily on their own time. During a concurrent observation and interview on 3/23/26 at 3:08 PM with Resident 105, Resident 105 was observed lying in bed with strong nicotine smell in the room. Resident 105 said Monday was his scheduled shower day, but the assigned staff ignored him this morning. Resident 105 stated his last shower was about 5 weeks ago before moving to this unit from another ward. Resident 105 stated he did not want to complain but really wanted to shower because he smoked every day. During an interview on 3/23/26 at 4:23 PM with Registered Nurse Quality Assurance (RNQA) 1, RNQA 1 stated Resident 105 moved from another ward to his current location on 1/16/26. RNQA stated Resident 105 was independent with shower. During a concurrent interview and record review on 3/25/26 at 10:24 AM with Certified Nurse Assistant (CNA) 1, Resident 105's Activities of Daily Living Flowsheets (ADL Flowsheet) were reviewed. The flowsheet for Resident 105's shower/bathe self, dated from 1/16/26 to 1/31/26, indicated 14 out of the 16 days for the month of January were documented as Code 09 (indicating the activity was not applicable - not attempted and the resident did not perform this activity). The flowsheet for Resident 105's shower/bathe self, dated from 2/1/26 to 2/28/26, indicated 18 out of the 28 days for the month of February were documented as Code 09. And on the flowsheet for Resident 105's shower/bathe self, dated from 3/1/26 to 3/22/26, indicated 19 out of the 22 days for the month of March were documented as Code 09. CNA 1 stated we were supposed to shower or bath each resident or offer it to the resident daily. During a concurrent interview and record review on 3/25/26 at 10:38 AM with CNA 1, Resident 97's ADL Flowsheets were reviewed. The flowsheet for Resident 97's shower/bathe self, dated 1/1/26 to 1/31/26, indicated 28 out of the 31 days for the month of January were documented as Code 09. The flowsheet for Resident 97's shower/bathe self, dated 2/16/26 to 2/28/26, indicated 11 out of the 13 days for the month of February were documented as Code 09. And on the flowsheet for Resident 97's shower/bathe self, dated from 3/1/26 to 3/24/26, indicated 15 out of the 24 days for the month of March were documented as Code 09. CNA 1 stated a Code 09 meant the activity was not attempted or resident did not do the activity. CNA 1 also stated shower, or bath should have been offered daily to Resident 97. During a concurrent interview and record review on 3/25/26 at 10:52 AM with CNA 1, Resident 40's ADL flowsheets were reviewed. The flowsheet for Resident 40's shower/bathe self, dated 1/1/26 to 1/31/26, indicated 29 out of the 31 days for the month of January were documented as Code 09. The flowsheet for Resident 40's shower/bathe self, dated 2/1/26 to 2/28/26, indicated 25 out of 28 days for the month of February were documented as Code 09. And on the flowsheet for Resident 97's shower/bathe self, dated from 3/1/26 to 3/24/26, indicated 20 out of the 24 days for the month of March were documented as Code 09. CNA 1 stated we should have attempted or offered a daily bath to Resident 40. During a concurrent interview and record review on 3/25/26 at 11:05 AM with CNA 1, Resident 69's ADL flowsheets were reviewed. The flowsheet for Resident 69's shower/bathe self, dated 1/1/26 to 1/31/26, indicated 1 out of the 31 days for the month of January was documented as Code 09. The flowsheet for Resident 69's shower/bathe self, dated 2/1/26 to 2/28/26, indicated 16 out of the 28 days for the month of February were documented as Code 09. And on the flowsheet for Resident 69's shower/bathe self, dated from 3/1/26 to 3/24/26, indicated 20 out of the 24 days for the month of March were documented as Code 09. CNA 1 stated daily baths should have been attempted or offered to Resident 69. During an interview on 3/26/26 at 7:51 AM with Assistant Director of Nursing (ADON) 1, ADON 1 stated residents hygiene shower or partial baths should have been offered or attempted to provide daily. During a review of the facility's P&P titled, ADL, STANDARDS, dated 9/8/25, the P&P indicated, Staff will ensure residents are free of offensive odors by providing daily partial baths .

Based on observation, interview, and record review, the facility failed to ensure one (1) of 33 sampled residents (Resident 97), Resident 97's food tray matched the meal ticket. This failure had the potential to result in malnutrition and weight loss.Findings: During a review of Resident 97's Face Sheet, the Face Sheet indicated Resident 97 was originally admitted on [DATE] and was re-admitted on [DATE] with diagnoses including traumatic subdural hematoma (a life-threatening collection of blood between the brain's surface and its outer covering) without loss of consciousness, atrial fibrillation (a common heart rhythm disorder where the heart's upper chambers beat irregularly), chronic obstructive pulmonary disease (a progressive, incurable lung disease), and abnormalities of the gait. During a concurrent observation and interview on 3/23/26 at 5:14 PM with Resident 97, Resident 97 was observed sitting at the edge of his bed with his dinner tray on top of the bedside table. Verbal consent was obtained and granted to compare the food on his tray with the meal ticket. There was no grilled ham and cheese sandwich found on the tray. A tomato soup was found on the tray instead which was not on the meal ticket. During a review of Resident 97's Meal Ticket for 3/23/26 Supper, the meal ticket indicated regular diet with the following food items: salt pepper sugar, pudding variety, ice cream, gel strawberry with peaches, salad Caesar, juice v-8, mighty shake chocolate, and grill ham and cheese sandwich. During a concurrent observation, interview and record review on 3/23/26 at 5:42 PM with Registered Nurse Quality Assurance (RNQA) 1, Resident 97's meal ticket was reviewed. The grill ham and cheese sandwich was missing, and tomato soup was served on the food tray. RNQA 1 stated the meal ticket should have matched what was on the Resident 97's food tray. During an interview on 3/26/26 at 9:11 AM with Assistant Director of Nursing (ADON) 1, ADON 1 stated licensed nurses checked both the diet order and also the food tray for accuracy during mealtimes prior to serving the food trays to the residents. During a review of the facility's policy and procedure (P&P) titled, Diet, Meals and Snacks, dated 2/4/26, the P&P indicated, Licensed nurse personnel ensure patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his/her professional licensure. During a review of the facility's P&P titled, Meal Observations, dated 1/2/26, the P&P indicated, B. Meal Observations . 1. Tray Accuracy - Did the resident receive what is on the meal ticket .?

Based on observation, interview, and record review, the facility failed to implement infection control and prevention practices for two of 33 sampled residents (Resident 16 and 171) when:1. Certified Nursing Assistant (CNA) 3 was observed in Resident 171's room without the required Personnel Protective Equipment (PPE-gear worn to minimize exposure to illnesses) for Enhanced Droplet Precaution (EDP- strict rules used to prevent spread of serious illnesses that travel through the air).2. Certified Nursing Assistant (CNA) 4 was observed transferring Resident 16 from the bed to the wheelchair without the required Personnel Protective Equipment (PPE-gear worn to minimize exposure to illnesses) for Enhanced Barrier Precaution (EBP- infection control intervention designed to reduce the transmission of infections in nursing homes).Findings:1. During a review of Resident 171's Face Sheet (demographics), the Face Sheet indicated Resident 171 was admitted to the facility on [DATE] with diagnosis that included acute bronchitis (inflammation in respiratory system) due to rhinovirus (highly contagious cold that infects nose and throat).During a concurrent observation and interview on 3/24/26 at 4:23 PM in Resident 171's room with CNA 4, EDP signage that indicated, To prevent the spread of infections, Staff entering this room must wear: N95 Mask, Face Shield, Gown, Gloves. was posted outside of the door with a PPE cart. CNA 3 was observed walking away from Resident 171's bed and cleaning the vital signs machine while wearing gown, gloves and surgical mask. CNA 3 confirmed he was not wearing an N95 and face shield and stated he was unaware of the required PPE for EDP rooms.During an interview on 3/25/26 at 2:36 PM with Infection Preventionist (IP) 1, IP 1 stated Resident 171 was on EDP for respiratory symptoms associated with a positive test result of rhinovirus, enterovirus (contagious virus) and Methicillin-resistant Staphylococcus Aureus (MRSA-bacteria that causes infections that are resistant to many antibiotics) of the nose. IP 1 further stated all staff were to wear gloves, gowns, face shield and an N95 when entering Resident 171's room.During a review of Resident 171's Physician Orders (PO), dated 3/20/26, the PO indicated Resident 171 had an order for Enhanced Droplet Precaution.During a review of the facility's policy and procedure (P&P) titled, Infection Control- Viral Respiratory Illnesses, dated 3/20/26, the P&P indicated, All staff must wear appropriate PPE as required. Signs will be posted outside of resident rooms indicating appropriate infection control, prevention and precautions, including required PPE.2. During a review of Resident 16's Face Sheet (demographics), undated, the Face Sheet indicated Resident 16 was admitted to the facility on [DATE], with diagnosis that included neuromuscular dysfunction of bladder (lost control of bladder due to nerve damage).During a concurrent observation and interview on 3/24/26 at 9:36 AM in Resident 16's Room with CNA 4, EBP signage that indicated, Anyone participating in any of these movements must also: [NAME] [put on] gown and gloves. transferring. was posted outside of the door with a PPE cart. CNA 4 was observed assisting another CNA with transferring Resident 16 from his bed to the wheelchair with a Hoyer lift (mechanical device used by caregivers to safely transfer residents with limited mobility). CNA 4 was not wearing a gown or gloves. CNA 4 confirmed she was not wearing a gown or gloves and stated she did not have to wear the required PPE listed on the sign because Resident 16 was not exposed (unclothed/naked).During an interview on 3/25/26 at 2:45 PM with Infection Preventionist (IP) 1, IP 1 stated Resident 16 was on EBP for an indwelling catheter (flexible tube placed into the bladder to drain urine). IP 1 further stated all staff assisting in high contact activities, including transferring, were required to wear PPE such as gown, gloves and mask.During a review of the facility's tracking log of Precautions, dated 3/26/26, the tracking log indicated Resident 16 was on EBP for indwelling catheter device.During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 12/30/25, the P&P indicated EBP was defined as Infection control interventions requiring gown and glove use during high-contact resident care activities. The P&P further indicated the facility should implement EBP for residents with indwelling medical devices and that High-Contact Activities included . transferring.

Based on interview and record review, the facility failed to ensure there was a designated full-time qualified person who met the qualifications specified in established State statute (California Code, Health and Safety Code - HSC § 1265.4) for food service managers, to carry out the functions of food and nutrition services (FNS) for the licensed care facility. The failure to have qualified day-to-day oversight of FNS elevated the risk of dietetic services not being carried out in accordance with professional standards for food service safety placing 144 residents, who received food from the kitchen at risk for potential food related medical complications. Findings: Dietetic services is defined as the provision of safe, satisfying and nutritionally adequate food for patients with appropriate staff, space, equipment and supplies (westlaw.gov) California Code of Regulations describes the staffing requirements for Dietetic Service Staff. The California Code, Health, and Safety Code - HSC § 1265.4 describes the qualifications a licensed health facility shall designate as full-time qualified position to manage the day-to-day operations of the skilled nursing facility when there is not a full-time Registered Dietitian to provide oversight to the dietetic services operation. The following are the seven different pathways to be qualified: 1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). During an interview with the Director of Dietary Services (DD) on 3/5/25 at 3:08 p.m., DD summarized her role in relation to dietary services. DD stated she was responsible for overseeing all of Food and Nutrition Services (FNS) for the multilevel campus which included skilled nursing/memory care, assisted living, and independent living. The licensed care kitchen (dietetic service space) served the skilled nursing facility and memory care residents. The main dining/kitchen which was not part of the licensed facility, was used to prepare food for the licensed care kitchen as well as other residents residing on the campus. DD stated she walked over to the licensed care kitchen from her office which was located in the main kitchen/dining area (about a ten minute walk minimum) to check in with staff as needed, and confirmed she was not full-time just for the licensed care FNS. During an interview with the DD on 3/6/25 at 9:25 a.m., DD stated the position which satisfied the requirement for the full-time qualified oversight of the licensed care kitchen was an Assistant Director of Dietetics (ADD) position which became vacant, then reclassified to a Food Manager position. The Food Manager position provided full-time, day-to-day oversight in the licensed care kitchen. DD stated the Food Manager position did not include qualifications which would meet the required regulations related to the oversight of food service operation of the licensed care kitchen. DD explained the Assistant Director of Dietetics/Clinical (ADDC) provided some oversight to the licensed care kitchen. DD confirmed ADDC's position was mainly clinical oriented. Review of the undated undated duty statement titled, Director of Dietetics, showed the Director of Dietetics was responsible for the day-to-day operation of the FNS Department, including, but not limited to planning, directing, organizing, and coordinating all FNS and medical nutrition therapy activities; providing the full range of supervision to assigned FNS Department staff; conducting staff meetings. While the duty statement showed the position was for the day-to-day operation of FNS, it was determined the position was not full time for the licensed care kitchen. Review of the duty statement titled, Assistant Director of Dietetics and signed by DD and ADDC on 3/14/24, showed this position assisted in the general operation of the food service and dietary activities and performed assigned responsibilities in the area of clinical or administrative dietetic practice. While this position showed it assisted with general operation of the food service and dietary activities, it was determined ADDC's position was mostly clinical with minimal oversight over the licensed care kitchen. Review of the undated duty statement titled, Food Manager showed under the general direction of the Director of Dietetics and/or Assistant of Dietetics, plan, direct, and coordinate food service activities; develop, interpret, and apply standards and procedures governing the operation of the FNS; prepare reports, and do other related work. While this position was meant to provide oversight of the licensed care kitchen, the position qualifications did not meet the State statutory requirements.

Based on observation, interview, and facility document review, the facility failed to ensure food was palatable in regard to temperature, flavor, and texture. This failure had the potential to result in decreased food intake resulting in food related medical complications for 144 residents, who received food from the kitchen. Findings: During the initial screening of residents on 3/3/25, multiple residents complained about the facility food when they were interviewed including: 1. at 9:35 a.m., Unsampled Resident 100 stated the food served at the facility was flavorless and cold., 2. at 11:43 a.m., Unsampled Resident 4 stated food was frequently served cold, and 3. at 11:50 a.m., Resident 39 stated the food served at the facility was not too good and was sometimes cold. Observation, interview, and document reviews conducted from 3/3/25 to 3/5/25 showed the rethermalization (retherm) carts (mobile units designed to reheat precooked, chilled foods to a desired reheating temperature, as well as maintain cold food at a desired temperature) were not consistently reheating hot food to the desired temperature and not holding cold foods at desired temperatures (Cross-reference F812). Review of the facility document titled, Diet Spreadsheet, dated 3/5/25, showed lunch served on 3/5/25 included Orange Chicken and Asian Vegetable Blend for regular textured diets (no texture modifications), ground Asian Vegetable Blend for Mechanical Soft textured diets (a modified textured diet consisting of soft, easily chewed foods), and Pureed Orange Chicken and Whipped Potatoes for pureed textured diets (modified textured diet consisting of smooth, pudding like consistency foods). An observation on 3/5/25 at 12:05 p.m., showed retherm cart labeled 1D was unplugged by staff from the docking station and was ready to be transported to the resident ward for lunch food service. On 3/5/25 at 12:07 p.m., a test-tray observation was conducted. The temperature of food was measured with a calibrated thermometer for three test trays. Test tray 1 included pureed foods and the temperatures showed pureed chicken was 116.6 degrees Fahrenheit (F), and mashed potatoes were 109.4 degrees F. The pureed chicken and mashed potatoes were just barely warm when tasted. In addition, the regular textured vegetables and the mechanical textured vegetables tasted bland. Food Service Supervisor (FSS) 1 tasted the vegetables and stated they had no flavor. Also, the regular and mechanical vegetables had a fibrous, unappealing texture. FSS 1 stated the vegetables were a little crunchy for a regular person. When the regular textured Orange Chicken was tasted, it felt dry and a bit tough. FSS 1 stated the chicken was a little dry. It is the position of the American Dietetic Association (ADA; currently known as the Academy of Nutrition and Dietetics) that the quality of life and nutritional status of older residents in long-term care facilities may be enhanced by a liberalized diet. A diet that is not palatable or acceptable to the individual can lead to poor food and fluid intake, which results in weight loss and undernutrition, followed by a spiral of negative health effects. [NAME], B., [NAME] K. C., & [NAME] P.K. (2002). Position of the American Dietetic Association: Liberalized Diets for Older Adults in Long-Term Care. Journal of the American Dietetic Association 102(9), 1316-1323. https://doi.org/10.1016/S0002-8223(02)90289-0

Based on observation, interview, and facility document review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when: 1. The facility did not have a system in place to ensure all hot food was reheated to a minimum of 165 degrees Fahrenheit (F) and all cold food was held at or below 41 degrees F; 2. Three air vents located in the dish room and food production area in the Main Kitchen (where food was prepared for the licensed care kitchen), were not clean; 3. Supervisory staff did not cover facial hair in the kitchen where food was stored and handled; 4. Trays used for food service were in poor condition; and 5. An industrial can opener was not clean and stored available for use. These failures had the potential to contaminate food and/or utensils for resident use and/or consumption, leading to food borne illness and/or illness from cross-contamination for 144 residents who received food from the kitchen. Findings: 1. During an observation and interview on 3/3/25 at 9:16 a.m., staff placed chilled food on trays and placed the trays in food carts. Food Service Supervisor (FSS) 1 explained the facility used a cook chill rethermalization (retherm) process for resident meals. Food was prepared and chilled in the Main Kitchen, then transferred to the licensed care facility kitchen where the chilled food was plated, placed on trays, placed in a cart, then stored in a cooler. The carts were plugged into docking stations for retherm about 45 minutes prior to food service. These carts were designed to reheat hot food and maintain cold food on the same tray. An observation and interview on 3/3/25 at 11:55 a.m., showed the retherm carts were labeled with ward numbers. The 1C cart was unplugged and staff began to transport the cart out of the kitchen to the resident ward for lunch food service. The surveyor measured food temperatures on two random trays with a calibrated thermometer before the cart was taken out of the kitchen. The hot food temperatures on the first tray were above 165 degrees F. The temperatures on second tray were as follows: milk 46.6 degrees F, ground green bean medley 126 degrees F, chopped beer battered cod 147.7 degrees F, and rice 138.2 degrees F. FSS 1 stated the hot food needed to be at least 165 degrees F and the tray observed with food less than 165 degrees F had to be reheated. In a consecutive interview on 3/3/25 at 12:05 p.m., when asked how the staff monitored temperatures of the food before it was served, Food Service Technician (FST) 1 stated temperatures were measured on one test tray on one of the five retherm carts. An observation on 3/3/25 at 12:10 p.m., showed cart 1D was unplugged and pushed by a staff toward the door out of the kitchen. The surveyor measured the temperature of food on three random trays, with FSS 1, before it was transported out of the kitchen and the temperatures were as follows: Tray 1: pureed fish filet patty 138.2 degrees F; pureed green beans 148.5 degrees F; pureed corn 155.7 degrees F. Tray 2: chopped beer battered Cod: 147.4 degrees F, mashed potatoes 140.9 degrees F, ground green bean medley 134.8 degrees F. Tray 3: hot food temperatures were above 165 degrees F. The cart was transported out of the kitchen by kitchen staff without reheating any food on the cart. Review of the test tray documentation log titled Food and Nutrition Services HACCP [Hazard Analysis Critical Control Point] Data Collection .], dated 3/3/25, showed FST 1 documented food temperatures were as follows: Beer Battered Cod: 167 degrees F, Crinkle Fry: 169 degrees F, [NAME] Bean Medley: 168 degrees F, Chicken Noodle Soup: 178 degrees F, Milk: 37 degrees F. Although, the temperatures on the facility's test tray were appropriate, it was identified the test tray temperatures did not reflect the temperature of the food on all the trays in the carts. On 3/5/25 beginning at 11:30 a.m., surveyors measured the temperatures of food on requested test trays on three retherm carts with a calibrated thermometer. The test tray food temperatures on carts 2C and 2D were above 165 degrees F. On 3/5/25 at 12:07 p.m., food temperatures were measured with a calibrated thermometer on the third requested test tray for ward 1D. These temperatures were measured immediately when the cart was unplugged from the docking station and before the cart was transported to the ward. The temperatures were as follows: Tray 1: pureed orange chicken 116.6 degrees F, whipped potatoes 109.4 degrees F, pureed pees 122.2 degrees F. Tray 2: jasmine rice with ground orange chicken 127.8 degrees F, ground Asian vegetable blend 136.6 degrees F. Tray 3: orange chicken 161.6 degrees F, Asian vegetable blend 154.2 degrees F. During an interview on 3/5/25 at 3:08 p.m., the Director of Dietetics (DD) stated hot food was required to be reheated to 165 degrees F and cold food had to be held at 41 degrees or below. DD stated the HACCP temperature log for the retherm carts was the policy and procedure used for retherm of food. DD confirmed in the licensed kitchen only one test tray was conducted on one retherm cart per meal. DD stated the test tray was rotated on different retherm carts. Review of the test tray documentation log titled, Food and Nutrition Services HACCP [Hazard Analysis Critical Control Point] Data Collection .] showed the minimum temperature for hot food including entree, starch/cereal, vegetables, and soup, after retherm was 165 degrees F. The maximum temperature for cold food including salad and milk was 41 degrees. 2. An observation in the Main Kitchen on 3/4/25 at 10:47 a.m., showed two ceiling air vents in the ware wash area had a black, fuzzy substance resembling dust on the vent cover and the ceiling surrounding the vent. One vent was located above a tall storage rack used to store clean pots and pans. The black substance observed around this vent extended to and down the wall to the top of the storage rack. An observation in the Main kitchen on 3/4/25 at 10:49 a.m., showed a black, fuzzy substance resembling dust spread out from a wall air vent located in the hallway/food preparation area adjacent to the warewashing room. In a consecutive interview with Food Manager (FM) 1 on 3/4/25 at 10:50 a.m., FM1 confirmed the air vents needed to be cleaned. When FM 1 was asked what the process was for having the air vents cleaned, FM 1 stated maybe kitchen staff needed to put in a work order for cleaning. In an interview with the Housekeeping Custodian (HC) on 3/4/25 at 2:35 p.m., HC stated he was responsible for cleaning the outside of the vents in the Main Kitchen. HC stated Plant Operations was responsible for cleaning the inside of the vents because tools were needed to remove the vent covers. HC stated cleaning of the outside of the air vents was not on a schedule and he did not receive work orders for cleaning the vents, however HC stated he usually went into the Main Kitchen monthly and cleaned the outside of the vents. HC stated the air vents were always dirty when he went into the Main Kitchen to clean them. In an interview with the Direct Construction Supervisor (DCS) on 3/4/25 at 3:10 p.m., DCS stated he was temporarily doing the duties of the Chief Direct Operation Supervisor because the position was vacant. DCS stated the inside of vents were cleaned one time per year. DCS stated the janitor placed a work order when the vents needed cleaning. DCS stated he thought a work order was received a couple of weeks ago, but the vents had not been cleaned yet because of a staffing shortage. DCS stated air filters in the air handlers (a part of a heating, ventilation, and air conditioning [HVAC] system that circulated conditioned air throughout a building) were replaced twice a year. On 3/4/25 at 3:32 p.m., documentation of the most current work order for cleaning of the vents, the last cleaning of the air vents, and changing air filters for the air handling units was requested from DCS. In an interview with the Infection Control Preventionist (IP) on 3/5/25 at 9:51 p.m., IP stated he inspected all areas, mostly nursing areas, for infection control prevention. IP stated sometimes he inspected other areas such as the kitchen but stated he never went into the Main Kitchen. IP stated he only inspected licensed areas. Review of documentation titled, Annual Air Handler Maintenance Log showed air filters were changed throughout the kitchen from 12/23/24 to 12/29/24. No work orders or documentation to show the last cleaning of the air vents was provided. Review of the Policy and Procedure (P&P) titled, Food & [and] Nutrition Services - Equipment (All Homes), dated 8/7/24, showed all kitchen areas shall be kept clean. According to the 2022 Federal Food Code, physical facilities, including air conditioning systems, shall be cleaned as often as necessary to keep them clean. 3. An observation on 3/5/25 at 11:30 a.m., showed FSS 3 was working in the kitchen, monitoring food carts in the trayline area. FSS 3 did not have his beard covered with a hair restraint. In an interview with DD on 3/6/25 at 9:25 a.m., DD stated everyone in the kitchen needs to have hair and beards covered. Review of the P&P titled Food & [and] Nutrition Services - Staff Operations and Training (All Homes) last revised 1/23/24, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair . beards and mustaches must be covered. 4. An observation on 3/3/25 at 10 a.m., showed a stack of trays, in multiple colors, on a storage rack for clean equipment. The trays were cracked and chipped. In addition, the trays had a build-up of worn and frayed tape on the tray surfaces. During a concurrent interview on 3/3/25 at 10 a.m., FSS 1 stated the trays were used to hold desserts on trayline food service. FSS 1 confirmed the trays were cracked and had tape build-up. According to the 2022 Federal Food Code, multi-use food-contact surfaces are to be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Equipment and utensil food-contact surfaces are to be clean to sight and touch. Nonfood-contact surfaces are to be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of food residue and debris. 5. An observation on 3/3/25 at 9:53 a.m., showed an industrial can opener stored in a holder attached to a food preparation table. There was orange and black, sticky residue on the surface of the blade. The residue transferred to a paper towel when the blade was wiped. During a concurrent interview on 3/3/25 at 9:53 a.m., FSS 1 stated the can opener was supposed to be cleaned after each use. FSS 1 confirmed the can opener was not clean. According to the 2022 Federal Food Code, equipment and utensil food-contact surfaces are to be clean to sight and touch. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of food residue and debris.

Based on observation, interview and record review, the facility failed to ensure 1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR) for four of five randomly selected residents (Residents 16, 75, 81, and 128); 2. To establish an accurate system to limit the diversion of narcotic medications designated for destruction by nursing staff; 3. To follow its policy and procedure (P&P) for the management of resident medications for out-on-pass (OOP) status and develop a system to include reconciliation of the last administered dose of medications upon the resident's return. These failures created the potential for medication diversion, mismanagement of controlled substances, lack of accurate medication administration, placing residents at risk for excessive sedation, increase risk of falls and overdose. Findings: 1. The CDRs for five randomly selected residents receiving as-needed controlled medications were requested for review during the survey. During a concurrent observation, interview and record review on 3/3/25 at 11:08 a.m. with Registered Nurse Supervisor [NAME] 3 (RNS 1), Resident 75's medical record, CDR and physical count for lorazepam were reviewed. Resident 75's medical record indicated a physician's order dated 7/17/24, for lorazepam (a medication to treat anxiety) 0.5 milligrams (mg- unit of measurement) give 1 tablet orally every 4 hours as needed for anxiety/agitation. RNS 1 confirmed the MAR indicated 1 tablet was administered on 3/2/25 at 9:25 p.m. but its removal from the medication cart was not documented by the nurse. She stated the nurse was expected to document on the MAR and the CDR right away after preparing and administering the medication. A review of Resident 81's medical record indicated physician's orders for oxycodone (a medication to treat pain) 5 mg IR (immediate release), ordered 12/24/24 and 1/27/25, take one tablet by mouth every 6 hours, as needed for severe pain not relieved by acetaminophen. The CDR indicated one tablet was removed from the medication cart on 1/15/25 at 9 a.m. and 1 tablet on 2/25 at 10 p.m. however their respective administrations to Resident 81 were not documented on the MAR. During a concurrent interview and record review on 3/4/25 at 2:31 p.m. with the Director of Nursing (DON), Resident 81's MAR dated 1/2025 to 2/2025 and CDR for oxycodone were reviewed. DON stated nursing staff were expected to document the administration of controlled medications on both the MAR and the CDR. He stated he hoped that nursing staff would document on both and not just one. The DON acknowledged the oxycodone doses identified as removed but not documented as administered to Resident 81 on the MAR were not signed by the nurse. He stated it was preferred for the nurse to initial the MAR on the front (where it indicated, Charting for 1/1/25- 1/31/25 PRN Medications'). A review of the facility's policy and procedure (P&P) titled, Medication, Administration Standards, dated 11/21/24, the P&P indicated, E. Documentation 1. Medication name, administration time, route and dose of the drug or treatment administered to the Resident will be recorded in the MAR . by the licensed nurse who administers the drug . During a concurrent interview and record review on 3/4/25 at 2:46 p.m. with DON, Resident 128's medical record was review. Resident 128's medical record indicated physician's orders dated 2/3/25 and 2/24/25, for oxycodone 5 mg, take one half (0.5) tablets by mouth every 8 hours, as needed. The MAR indicated 1 tablet was administered to Resident 128 on 2/25/25 at 5:30 a.m. but its removal from the medication cart was not documented on the CDR. Review of the CDR indicated 1 tablet was removed on 2/28/25 at 5 a.m., 3/1/25 at 8:30 p.m., and 3/2/25 at 8 a.m. and 8:30 p.m. but their administrations were not documented on the MAR. DON acknowledged the finding and confirmed there were discrepancies between the MAR and CDR. A review of Resident 16's medical record indicated a physician's order dated 2/3/25, for oxycodone 5 mg IR, take one tablet by mouth every 6 hours as needed for severe breakthrough pain (>8/10). Resident 16's MAR indicated oxycodone was administered on the following dates and times but their removal from the medication cart was not documented: 1 tablet on 2/3/25 at 1:30 a.m.,1 tablet on 2/5/25 at 10 p.m., 1 tablet on 2/8/25 at 7 p.m., 1 tablet on 2/14/25 at 5:30 a.m., and 1 tablet on 2/21/25 at 7:06 a.m. Resident 16's CDR indicated oxycodone was removed from the medication cart on the following dates and times but their respective administrations were not documented: 1 tablet on 2/10 at 12 a.m., and 1 tablet on 2/13/25 at 2 a.m. and 4 a.m. During a concurrent interview and record review on 3/4/25 at 4:18 p.m. with Nursing Supervisor 2 (NS 2), Resident 16's MAR dated February 2025 and CDR for oxycodone 5 mg IR were reviewed. NS 2 confirmed the identified discrepancies and stated all doses of controlled medication administered to a resident needed to be documented on the front of the MAR. During a review of the facility's P&P titled, Controlled Substances, dated 12/3/24, the P&P indicated, VI. Storage, Security and Accountability of Controlled Substances for Licensed Care . B. Record Keeping and Accountability 1. Controlled Substances must be reconciled at least every shift by counting and verifying the number of each drug on corresponding CDR by a Licensed Nurse. 2. Pharmacy will verify accuracy of Narcotic count on nursing unit during monthly nursing unit inspection . C. Administration Records 1. Administration of controlled substance, will be documented on the Medication Administration Record (MAR) and on the Controlled Drug Record . 2. During an interview on 3/3/25 at 11:34 a.m. with Registered Nurse 4 (RN 4) in [NAME] 1, RN 4 stated controlled medications that needed to be destructed were stored in the separately locked compartment in the medication carts and picked up by the Quality Assurance (QA) Nurse once weekly on Wednesdays. During a telephone interview on 3/4/25 at 10:43 a.m. with Pharmacy Services Manager (PSM), PSM stated nursing staff were expected to sequester controlled medication that required destruction in the medication cart for the once weekly pick up by the nurse and the pharmacist. She stated the nurse did the once weekly destruction with the pharmacist. During an interview on 3/4/25 at 10:57 a.m. with NS 2 in [NAME] 1, NS 2 stated controlled drugs that needed to be destructed were placed in a clear plastic pouch then put into the locked narcotic section of the medication cart. She stated these medications were still counted during the narcotic inventory counts completed between nursing shift changes until picked up on Wednesdays. During an interview on 3/4/25 at 10:59 a.m. with RN 8 in [NAME] 2, RN 8 stated controlled medications were destroyed by calling the nursing supervisor, crushing the pill, then dumping it into a plastic receptable designated for medication waste in the medication storage room. He stated the destruction was signed by both nurses on the CDR. During an interview on 3/4/25 at 11:05 am. with RN 1 in [NAME] 4, RN 1 stated controlled drugs for destruction were placed inside a clear plastic pouch then put into the locked narcotic section of the medication cart. She stated they did not count the medication during nursing shift changes but just eyeballed it. During an interview on 3/4/25 at 11:11 a.m. with DON, DON stated controlled medications that were dropped by the nurse or denied by the resident were placed into a disposal bin containing a solution. He stated two nurses were expected to sign for the destruction. The DON stated each ward had a bin in the medication storage rooms. During an interview on 3/4/25 at 11:25 a.m. with Registered Nurse Quality Assurance (RN 7), RN 7 explained the process she followed for narcotic medication destruction. She stated she called each ward once a week on Wednesdays to see if they had any medications that required destruction. She stated that was how she was made aware of medications that needed to be destructed, otherwise the medication stayed in the cart until reported by nursing staff. RN 7 stated nursing staff were expected to place pills that required destruction into a clear plastic pouch labeled with the name of the resident, the date and the time, along with a second nurse as a witness. She stated when the medication was picked up on Wednesdays, the pouch and the information written on it was compared to the CDR before destruction with the pharmacist. She stated nursing staff were expected to include the medication during the shift-to-shift narcotic counts until the destruction took place. RN 7 stated the pill was not to be crushed prior to placing it into the pouch. During a review of the facility's P&P titled, Disposal of Pharmaceutical Waste- SNF/ICF (All Homes), reviewed 7/9/24, the P&P indicated, Policy Details and Implementation I. Residents' Medications No Longer In Use A. Controlled Drugs 1. Destruction: Drugs listed in Schedules II, III, IV, or V of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 will be destroyed on the unit . Drugs may be destroyed to render them irretrievable . II. Facility Storage of Unusable Drugs . B. Controlled Drug Inventory/Facility Storage . 2. Drug Count: Nurses will verify the inventory at each change of shift until proper disposition of the drug. 3. During a concurrent interview and record review on 3/3/25 at 11:58 a.m. with NS 2 in [NAME] 1, Resident 81's record titled, Pass Medication Release, dated 2/28/25, was reviewed. NS 2 stated whenever a resident went OOP, before they left the nurse counted the medications they were taking with them with the family. She stated the medications and quantities were documented on the form and the count was completed with the family upon the resident's return. NS 2 confirmed nursing staff did not indicate the quantity of medication returned upon the return of the Resident 81 to the facility. She stated unfortunately nursing staff should have counted them when they came back. NS 2 confirmed one of the medications that was given to Resident 81 when he was OOP was oxycodone 5 mg, quantity of 4. NS 2 reviewed the CDR for Resident 81's oxycodone, scheduled to be given as needed every six hours, and confirmed the resident took one tablet while on pass. She stated she did not know when that tablet was taken by the resident and that information was not collected by nursing staff upon the resident's return to know when the next dose could be safely administered. During an interview on 3/3/25 at approximately 12 p.m. with RN 4 in [NAME] 3, RN 4 stated nursing staff relied on the narcotic count to determine what time the next dose could be given to a resident. A review of the front and back of Resident 81's MAR, dated 2/2025, indicated the nurse did not document whether Resident 81 took oxycodone while he was OOP on 2/2/8/25. During an interview on 3/3/25 at 4:16 p.m. with RN 6 in [NAME] 1, RN 6 stated when a resident went OOP, nursing staff documented OOP on the MAR for any doses of medication that were scheduled but not administered by nursing staff in the facility. During an interview on 3/4/25 at 2:50 p.m. with DON, DON stated nursing staff were expected to know when the last dose was taken by a resident when they were OOP. During a review of the facility's P&P titled, Medications, Pass/Leave (SNF, ICF, RCFE), reviewed 1/29/24, the P&P indicated, Policy Details and Implementation . D. Medication Administration Record (MAR) Documentation: 1. The out-on-pass/leave medications taken by resident are recorded on the reverse side of the resident's current medication administration record MAR or similar form. 2. Doses are not documented on the front of the MAR unless the nurse administers the medications . 3. The licensed nurse will circle their initials on the MAR for each dose of regularly scheduled medications that would normally have been administered by the facility while a resident is out on pass/lease. The reason for the circled initial is explained in the nursing comments section on the back of the MAR for each medication dose due . G. Returning to Facility Upon: Upon return to the facility, the licensed staff will document the quantity returned and report any discrepancies to the nursing supervisor.

Based on observation, interview, and record review, the facility failed to: 1. Ensure expired medications were not available for resident use; 2. Opened multi-dose biologicals were dated with an opened or discard date to ensure they were not used beyond the expiration date. The deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their expiration date. Findings: 1. During an inspection on 3/3/25 at 10:04 a.m. of the medication storage room in [NAME] 5 and [NAME] 6 with Nursing Supervisor 1 (NS 1), the following were identified: two tubes Desitin Max Strength (ointment used to treat rash) expired 6/2024, one bottle hydrogen peroxide (a topical antiseptic) 3% expired 12/2024, two tubes terbinafine (a medication to treat fungal infections) 1% cream expired 12/2024, one bottle aspirin 325 milligrams (mg, a unit of measurement) tablets expired 12/24, three bottles Move + Vision + Bones Pureflex (a supplement for joint, eye and bone health) capsules expired 10/2024, one bottle Move Pureflex (a supplement for mobility and joint health) capsules expired 7/2024, and three tubes Insta-Glucose (used to treat low blood sugar) gel expired 2/2025. NS 1 confirmed the medications were expired and should have been removed from the facility's stock. NS 1 stated nursing and pharmacy staff were responsible for regularly checking expiration dates on the medications in the storage room to ensure all items were in date. During an inspection on 3/3/25 at 10:50 a.m. of the medication cart in [NAME] 2 with RN 2, one bottle of magnesium 250 mg tablets was identified without an expiration date. RN 2 stated if a medication did not have an expiration date on it, nursing staff were expected to check with the pharmacy then put a sticker on it that stated what the expiration date was. During a review of the facility's policy and procedure (P&P) titled, Disposal of Pharmaceutical Waste- SNF/ICF (All Homes), reviewed 7/9/24, the P&P indicated, Unneeded, expired, or deteriorated medications will be disposed of . The Home will maintain a process whereby expired or deteriorated pharmaceuticals are removed from use . Definitions . Pharmaceutical Waste includes medications that are: Expired . Mislabeled (improper, illegible, missing, or worn). 2. During an inspection on 3/3/25 at 11:19 a.m. of the medication storage room refrigerator in [NAME] 3 with RN 3, one vial Tubersol (an injectable solution used to aid in the diagnosis of tuberculosis infection, a bacterial disease that affects the lungs) opened and unlabeled with an open date was identified. RN 3 confirmed the finding and stated the vial should have been labeled with the date it was opened. She stated the manufacturer's labeling on the product indicated to discard it 30 days once punctured. During a review of the manufacturer's labeling for Tubersol, revised 3/18/22, the labeling indicated, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. During an interview on 3/4/25 at 2:55 p.m. with the Director of Nursing (DON), DON confirmed the Tubersol should have been labeled with an open date once used since it was only stable for 30 days after. DON stated it was the expectation that expired medications were removed from the facility's medication storage rooms and not available for resident use. During a review of the facility's P&P titled, Medication, Storage & Labels, reviewed 11/21/24, the P&P indicated, Policy Details and Implementation . J. Date Opened Label: The nurse will label multi-dose vials with the date the vial was opened and the date it will expire. Multi-dose vials are discarded as recommended by manufacturer or Pharmacy Services .

39795 Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment when: 1. Three of five staff (Contract Staff [CS] 1, Certified Nursing Assistant [CNA] 6, and Custodian Worker [HSK] 1) did not perform hand hygiene or utilize personal protective equipment (PPE- equipment worn to minimize exposure to infectious or hazardous materials, e.g. gown, gloves, mask, eye protection) in accordance with policy and procedure and nationally recognized infection prevention and control guidelines. 2. One of one custodian worker (HSK 1) did not follow facility procedure for the cleaning and disinfection of an occupied room. 3. Five of five staff (Laundry Supervisor [LS] 1, LW 1, LW 2, LW 3, and HSK 1) did not know the dwell time (the amount of time a disinfectant must remain visibly wet on a surface to effectively kill specific germs) of facility products used for disinfection. 4. Enhanced Barrier Precautions was not identified and effectively implemented for one of three sampled residents (Resident 16) who had an indwelling urinary catheter (thin flexible tube inserted into the bladder through the urethra to drain urine continuously) in place. 5. Enhanced Barrier Precautions was not effectively implemented for two of two sampled residents (Resident 35 and Resident 64) having a Gastrostomy Tube (G-tube, a small, flexible tube inserted through the abdominal wall and into the stomach used to provide nutrition and medication to individuals who cannot eat or drink adequately on their own) during nutritional tube feeding administration. 6. Sterile technique (the practice of eliminating microorganisms from an environment or object to prevent infection) was not implemented for one of one sampled residents with a nephrostomy tube (a long, thin, plastic tube inserted through the skin directly into the kidney which drains fluid), when sodium chloride was injected into Resident 71's nephrostomy tube using non-sterile supplies. These failures placed residents at risk for cross contamination and infection and could result in health-related disease. Findings: 1. During an observation on 3/3/25 at 11:06 a.m., in [NAME] 2's hallway, CS 1 exited a resident's room holding a laundry bag with ungloved hands and used a paper tissue as a barrier between his hand and laundry bag. CS 1 emptied the contents of the laundry bag in the biohazard room (room designated to dispose or store infectious or potentially infectious materials and waste) and returned into Resident 109's room. CS 1 did not perform hand hygiene after handling the linen. During an interview on 3/3/25 at 11:13 a.m., with CS 1, CS 1 stated he bathed Resident 109 and changed the linen on Resident 109's bed before transporting the soiled linen to the biohazard room. CS 1 acknowledged he did not wear gloves to carry the soiled linen bag and did not perform hand hygiene when he exited Resident 109 and biohazard rooms. CS 1 stated his failure to wear gloves and preform hand hygiene was an oversight and hand hygiene should have occurred upon exit of both rooms to reduce the risk of cross contamination. During an interview on 3/4/25 at 2:03 p.m., with the Infection Preventionist (IP), the IP stated all staff were expected to follow facility infection prevention and control policies and procedures, contracted staff included. The IP stated hand hygiene should occur anytime staff entered or left a resident's room or area that stored potentially soiled items. The IP stated although CS 1 used paper tissue as a barrier between the soiled linen bag and hands, staff were expected to wear gloves and perform hand hygiene when handling soiled linen to prevent the spread of disease and illness. During an observation on 3/4/25 at 3:13 p.m., in Resident 57's room, CNA 6 obtained the blood pressure and body temperature of Resident 57. Signage posted on Resident 57's door indicated Enhanced Barrier Precautions (EBP- an infection control intervention to reduce the spread of germs) must be implemented prior to entrance into Resident 57's room. The sign also indicated staff must perform hand hygiene and wear at minimum a gown and gloves for high-contact activities. CNA 6 did not wear a gown or gloves and did not perform hand hygiene before handling another resident's privacy curtain. During an interview on 3/4/25 at 3:20 p.m., with CNA 6, CNA 6 acknowledged she provided care to resident 57 without wearing gown and gloves. CNA 6 stated she was aware of Resident 57's EBP status due to a wound infection on Resident 57's leg. CNA 6 stated she should have worn gloves but forgot. CNA 6 stated EBP required staff wear mask and gloves and perform hand hygiene when providing resident care to prevent cross contamination to other residents, staff, and self. During an observation on 3/6/25 at 8:49 a.m., in [NAME] 2's hallway, HSK 1 performed the cleaning of an occupied resident room (RM 1). HSK 1 wore gloves and face mask to perform the task. After cleaning RM 1, HSK 1 returned the mop used in RM 1 to the housekeeping cart and crossed the hallway to a second occupied resident room (RM 2). HSK 1 entered RM 2 and proceeded to clean RM 2. HSK 1 did not change his gloves during the cleaning process nor was hand hygiene performed in between tasks and the two rooms. HSK 1 touched his clothing, face mask, cleaning equipment, and cart with his contaminated gloves. During an interview on 3/6/25 at 8:53 a.m., with HSK 1, HSK 1 stated he cleaned rooms on [NAME] 2 daily and the procedure observed was his process for cleaning occupied rooms. HSK 1 stated gloves were changed when visibly soiled, however he could not provide additional times hand hygiene should occur. During an interview on 3/6/25 at 9:31 a.m., with the IP, the IP stated all staff were expected to implement standard precautions with resident care tasks, including housekeeping. The IP stated gown use was no longer required for daily cleaning of rooms and bathrooms, unless the room was an isolation room (separate room for residents with a contagious disease) or the risk for self-contamination existed. The IP reinforced the expectation for hand hygiene when entering and exiting resident rooms and in between tasks and glove changes. The IP also stated staff were required to use additional PPE (e.g. gown) for care provided to residents on EBP. The IP stated HSK 1 and CNA 6 did not follow facility policy and procedure for hand hygiene and PPE use. During a review of the facility's policy and procedure (P&P) Hand Hygiene Procedure . dated 12/24/18, the P&P indicated, . Per the Centers for Disease Control (CDC- a national health protection agency and regulating bodies of infection control, prevention, and awareness) keeping hands clean through improved hand hygiene is one of the most important steps we can take to avoid getting sick and spreading germs . Preform Hand Hygiene . Before and after caring for someone who is sick . Before and after removing gloves when caring for a resident . After coming into contact with blood or body fluids or open skin . During review of the CDC document Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, the document indicated, .Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with . Handwashing with water and soap (e.g., plain soap or with an antiseptic) . Antiseptic hand rub (alcohol-based foam or gel hand sanitizer) . Cleaning your hands reduces . The potential spread of deadly germs to patients . including those resistant to antibiotics .clean your hands . Immediately before touching a patient . After touching a patient or patient's surroundings . After contact with blood, body fluids, or contaminated surfaces . Immediately after glove removal .wear gloves . When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment) . change gloves and clean hands . If gloves become soiled with blood or body fluids after a task . Before exiting a patient room . During a review of the facility's Infection Control Guidelines 2.0- Isolation Precautions approved 4/15/08, the guidelines indicated, . Standard precautions constitute the primary strategy for the prevention of healthcare associated transmit function of infectious agents among patients and health care personnel. Standard precaution assumes that every person is potentially infected or colonized with an Organism that could be transmitted in the healthcare setting and applies the following infection control practices during the delivery of healthcare . wear gloves when it can be reasonable to anticipate contact with blood or other potentially infectious materials . During concurrent observation and interview on 3/6/25 at 7:45 a.m., with Laundry Supervisor (LS), LW 1, and LW 2, in the Laundry Service Building, LW 1 and LW 2 demonstrated their process for doffing (remove) contaminated PPE. LW 1 discarded her gloves, unsnapped the overcoat (in place of gown) and placed the overcoat in the staff soiled linen bin, then grasped the front of her face mask and hair net for removal. LW 2 confirmed the sequence of LW 1's PPE removal procedure and stated she followed the same doffing procedure. LS stated LW 1 did not demonstrate proper technique for removal of contaminated PPE and the sequence demonstrated increased the risk for self-contamination and possible transmission of disease. LS stated the overcoat buttoned in the front which required extra handling and LW 1 should have performed hand hygiene prior to removing her mask to prevent self-contamination. During a review of the CDC document How to Safely Remove Personal Protective Equipment (PPE) Example 2, undated, the document indicated, . Gown front and sleeves and the outside of gloves are contaminated . If your hands get contaminated during gown or glove removal, immediately wash your hands or use an alcohol-based hand sanitizer . Front of mask/respirator is contaminated- Do Not Touch . Perform Hand Hygiene Between Steps If Hands Become Contaminated and Immediately After Removing All PPE . 2. During an observation on 3/6/25 at 8:49 a.m., in [NAME] 2's hallway, HSK 1 performed the cleaning of an occupied resident room (RM 1). The housekeeping cart, stationed outside the room, had four buckets (B1, B2, B3, and B4); three of the buckets (B1, B2, and B3) were half filled with a liquid solution. B4 was empty. The bucket used for mopping floors (B3) had cloudy water with a gray grainy sediment at the bottom of the bucket. The two remaining buckets (B1 and B2) were unlabeled and had a johnny mop (a type of toilet bowl cleaning tool with a fuzzy or soft, absorbent head) placed in the liquid solution. Small brown/ gray particles floated in B1 and B2's liquid. HSK 1 used a string mop to clean RM 1's bathroom and floor. HSK 1 swept the mop in and out of the bathroom onto the RM 1's floor in a series of repeated actions. After completion of the task, HSK 1 returned the mop to B3 and crossed the hallway to a second resident occupied room (RM 2). HSK 1 retrieved a johnny mop from B1 and wiped down the inside of RM 2's toilet bowel, toilet riser, and toilet seat, then returned the johnny mop to B1. Next, HSK 1 retrieved the mop from B3 and mopped RM 2's floor and bathroom, using the same procedure as in RM 1 (repeatedly mopping in and out of the room and bathroom). HSK 1 did not wipe any high touch surfaces nor furniture in RM 2. During concurrent observation and interview on 3/6/25 at 8:53 a.m., with HSK 1, in [NAME] 2's hallway and janitorial room, HSK 1 stated the cleaning procedure demonstrated was the method he used for cleaning resident rooms on [NAME] 2. HSK 1 stated the liquid solution in B1, B2, and B3 were the same, two ounces of floor mop cleaner mixed with three quarters of a bucket of water. HSK 1 stated he used the same liquid until all rooms on [NAME] 2 were cleaned. HSK 1 showed the floor cleaner product used for cleaning resident rooms. One gallon bottle of [Name of Product] Floor Cleaner Concentrate solution sat on the floor of the janitorial room. HSK 1 stated it was the only product available for him to use. HSK 1 stated he did not know if the solution had disinfecting properties. During an interview on 3/6/25 at 9:31 a.m., with the IP, the IP stated the facility's floor cleaner was not a disinfectant (chemical product that destroys germs) and not acceptable for cleaning and disinfecting resident room surfaces and bathrooms. The IP stated HSK 1's practice of using a neutral floor cleaner to clean resident bathrooms placed residents at risk for gastrointestinal (relating to stomach and intestines) diseases and illnesses. The IP stated a diluted bleach solution should be used to clean and disinfect environmental surfaces in resident rooms and bathrooms. The IP also stated reuse of cleaning solutions had limitations; that cleaning and disinfecting solutions became less effective each time used equipment was placed into the solutions becoming a potential source and reservoir for germs. The IP stated dirty bucket water should be changed at regular intervals to ensure cleaning solution products remained clean and effective. During an interview on 3/6/25 at 2 p.m., with the Housekeeping Supervisor (HSKS) and HSK 2, HSKS stated the facility followed CDC's guidelines for environmental cleaning and described the procedure for cleaning resident rooms in the facility. HSKS stated housekeepers were expected to sweep dusty air vents, clean and disinfect doorknobs, high touch surface areas, and mop daily. HSKS stated housekeepers were expected to use two johnny mops and two string mops for the various cleaning tasks in each room. The HSKS stated one string mop should be used for a resident's bathroom floor and another for the room's floor. It was not acceptable to use one string mop for both resident bathroom and room floors. The HSKS stated the facility used bleach and [Name of Product] disinfectant solutions to clean and disinfect resident rooms and bathrooms, and floor cleaner was not an acceptable product to use for disinfection. The HSKS stated bucket water should be changed every third room to avoid neutralizing solutions and spreading germs throughout the facility. HSKS stated HSK 1 did not follow facility policy and procedure for the cleaning of occupied resident rooms. During review of [Name of Product] Floor Cleaner Concentrate Solution Material Safety Data Sheet, indicated, . Product Use: Floor Cleaner . During a review of the facility P&P Cleaning, Occupied Resident Room, approved 8/22/24, the P&P indicated, . dust all surfaces with disinfectant solution . Wipe bedside tables with disinfecting solution . Clean mirrors and interior surfaces of glass . Empty and reline trash cans . vacuum or dust mop depending on area . remove cobwebs . clean and disinfect toilet and sink. Scrub with cleanser as needed . Wash doors and handles with disinfectant . completely mop floor and baseboards with disinfectant . During a review of CDC's document Best Practices for Environmental Cleaning in Healthcare Facilities Version 2, the document indicated, . Environmental cleaning is part of Standard Precautions, which should be applied to all patients in all healthcare facilities . The cart should have enough cleaning cloths to complete the required cleaning session, with a clean cloth for each patient zone to prevent cross-contamination . It is best practice to use a two- or three-bucket system for mopping . Two-bucket system (routine cleaning): one bucket contains a detergent or cleaning solution and the other contains rinse water . The rinse water bucket allows the mop to be rinsed and wrung out before it is re-dipped into the prepared solution . Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms [germs] . clean low-touch surfaces before high-touch surfaces . Clean patient areas (e.g., patient zones) before patient toilets . Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas . Never double-dip cleaning cloths into portable containers (e.g., bottles, small buckets) used for storing environmental cleaning products (or solutions) . Never leave soiled mop heads and cleaning cloths soaking in buckets . Common high-touch surfaces include . bedrails . sink handles . bedside tables . edges of privacy curtains . transport equipment (e.g., wheelchair handles) . call bells . doorknobs . light switches . Toilets in patient care areas . have high patient exposure (i.e., high-touch surfaces) and are frequently contaminated. Therefore, they pose a higher risk of pathogen transmission than in general patient areas . Mop from cleaner to dirtier areas . Mop in a systematic manner, proceeding from area farthest from the exit and working towards the exit . Change mop heads/floor cloths and buckets of cleaning and disinfectant solutions as often as needed (e.g., when visibly soiled, after every isolation room, every 1-2 hours) and at the end of each cleaning session . 3. During concurrent interviews on 3/6/25 at 7:39 a.m., LS, LW 1, and LW 2 stated they used germicidal bleach wipes to clean and disinfect the sorting table to prevent transmission of disease and cross contamination during the sorting of soiled laundry. The LS stated the disinfectant was effective against communicable diseases as long as it was allowed to airdry after being applied. The LS, LW 1 and LW 2 stated they did not measure how much time the surface of the table took to airdry and/ or remained wet to effectively kill germs. The LS acknowledged dry times and time the surface remained wet varied based on weather conditions which could potentially affect the effectiveness of the disinfectant. During an interview on 3/6/25 at 7:54 a.m., with LW 3, LW 3 stated his department used [Name of Product- hydrogen peroxide) disinfectant to clean high touch surface areas and equipment at the end of his shift. LW 3 stated he was not aware how long the product had to remain on the surfaces to be effective. LW 3 stated, it [disinfectant] just airdries. LW 3 stated he did not know how long the product took to airdry. During and interview on 3/6/25 at 8:53 a.m., with HSK 1, HSK 1 stated he used various cleaners and disinfectants throughout the day. HSK 1 stated he applied the disinfectant products and allowed them to airdry. HSK 1 stated he was not familiar with dwell times. During an interview on 3/6/25 at 2 p.m., with the HSKS and HSK 2, HSKS stated disinfectants utilized in the facility were under the supervision of the facility IP. The HSKS stated housekeeping used a diluted bleach solution as the primary disinfectant for the facility. The HSKS stated the bleach solution had a dwell time of 10 minutes. The HSKS stated he did not evaluate the total contact time the disinfectant remained wet on surfaces. HSKS stated the disinfectant was effective if allowed to airdry. During review of the information for use (IFU) [Name of Product] bleach germicidal wipes, undated, the IFU indicated, . Directions . Remove gross soil if present or if disinfecting for C. difficile [Clostridioides difficile- a bacteria that c spores . Wipe the surface until completely wet . Wait for the contact time (3 minutes for C. diff, fungi, TB and select viruses; 30 second for bacteria; 1 minute for most viruses) . Discard the wipe . During a review of the IFU [Name of product] hydrogen peroxide disinfectant, dated 9/22/21, the IFU indicated, . When used as directed, this product is effective against (a broad spectrum of) pathogenic microorganisms . viruses, and fungi . To Use as a One- Step Cleaner/ Disinfectant . Pre- clean heavy soiled areas . Allow surface to remain wet for 1 minute. (For certain listed viruses, Allow treated surfaces to remain visibly wet for one-minute, additional towelettes if needed to ensure the correct visibly wet surface contact time . During a review of the CDC's document TOPIC 12: Environmental Cleaning & Disinfection: What is Contact Time?, undated, the document indicated, . Sometimes called dwell time, this is the amount of time a disinfectant needs to sit on a surface, without being wiped away or disturbed, to effectively kill germs . Wait until contact time is complete before using objects or surfaces or before a new patient comes into a room . Follow the instructions on the disinfectant label - especially instructions for contact time . 41816 50674 4. During a concurrent observation and interview on 3/3/25 at 3 p.m. with Resident 16 in Resident's room, Resident 16 was lying awake in bed and had an indwelling urinary catheter bag attached to the lower rail of the bed frame. Resident 16 stated she was currently using an indwelling urinary catheter, and staff was assisting with care by changing and emptying the bag as needed. There was no Enhanced Barrier Precautions (EBP) sign to indicate appropriate use of Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) was posted outside the Resident's room door. There was no isolation cart for PPE storage noted outside of Resident 16's room. During a concurrent observation and interview on 3/5/25 at 9:24 a.m. with Certified Nursing Aide (CNA) 3 outside of Resident 16's room, CNA 3 stated Resident 16 was dependent on staff and required help with bathing and toileting. CNA 3 stated that only gloves and masks were worn when giving direct care because the Resident was not on any isolation precautions. CNA 3 stated Resident 16 had no isolation sign posted or cart outside of the Resident's room, so the Resident was not on isolation. During a concurrent observation and interview on 3/5/25 at 9:30 a.m. with Licensed Vocational Nurse (LVN) 1 outside of Resident 16's room, LVN 1 stated there was no isolation cart or isolation precautions sign posted on the door to indicate Resident 16 was on isolation precautions. LVN 1 further stated if there was an isolation cart and sign posted outside the door, then the staff would wear what was posted every time the staff would go in the room to give care to Resident 16. During a concurrent interview and record review on 3/6/25 at 11:20 a.m. with Infection Control Preventionist (IP), the facility provided list of Residents with isolation precautions was reviewed. The list indicated Resident 16 was on Enhanced Barrier Precautions and the reason for precautions indicated, Indwelling Device-Catheter. The record also indicated, Potential Clearance Date for Resident 16 was Indefinite. IP stated the Residents who are on EBP have signs posted to their doors to notify staff and people of what to wear when they enter the room to prevent transmission of infection. During a record review of Resident 16's Minimum Data Set (MDS- A resident assessment tool), dated 1/24/25, the MDS indicated the Resident had an indwelling catheter and was dependent on staff for toileting hygiene and personal hygiene. During a record review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions (EBP), dated 6/25/24, the P&P indicated, EBP are essential infection control measures designed to minimize the transmission of multidrug-resistant organisms (MDROs) and protect both residents and staff in heathcare settings. The P&P indicated, Use EBP for residents with chronic wounds or indwelling medical devices, regardless of MDRO status. The P&P further indicated, Staff will . Display clear signs outside the resident's room indicating EBP and required PPE (gown and gloves). 5. During a concurrent observation and interview on 3/5/25 at 5 p.m. with RN 9 on [NAME] 2D while observing the start of Resident 64's tube feeding process. There was signage noted on the wall in front of Resident 64's room indicating EBP precautions were required during tube feedings. RN 9 stated she did not need to wear a gown for administration of the fluids. RN 9 stated, I use them when I do a dressing change and while suctioning, not with feeding. No cart was located near the resident room. RN 9 read the signage and confirmed it was required and donned the required protection. She stated staff have not been wearing gowns for this process. RN 9 stated, I was not aware it was required. During an interview on 3/5/25 at 5:10 p.m. with Resident 64, Resident 64 stated, The nursing staff have not been wearing gowns for this [delivering of formula through the tube]. Resident 64 stated, I know it is for my safety that they do. During a review of the facility Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 6/25/24, the policy indicated the use of EBP was mandated for residents identified as high risk for multidrug resistant organisms ([NAME]), including residents with indwelling devices [G-tube], during high contact resident activities. The policy indicated indwelling devices such as feeding tubes provide a direct pathway for pathogens to enter the body and cause infection. During a review of the signage in front of Resident 64's room titled, Enhanced Barrier Precautions, undated, the signage indicated, All providers and staff must wear at least a gown and gloves for these High Contact Resident Care Activities: [including] Indwelling Device Care or Use: [including] Feeding tube. 52357 5. During a review of Resident 35's Face Sheet (demographics), dated 12/18/24, the Face Sheet indicated Resident 35 was admitted on [DATE] with diagnoses which include tongue carcinoma (a type of cancer of the tongue), dysphagia (difficulty swallowing foods and liquids), and gastrostomy tube (G-tube - a small flexible tube that is inserted through the skin into the stomach to provide nutrition and fluids). During an observation on 3/3/25 at 9:34 a.m., in Resident 35's room, a sign was observed outside of the room alerting staff that Resident 35 required Enhanced Barrier Precautions (EBP - infection control practice that uses PPE-personal protective equipment including gloves and gowns to reduce the spread of infection). The EBP sign indicated that staff are required to wear a gown and gloves when performing High-Contact Activities including providing care for indwelling medical devices such as G-tubes. During a concurrent observation and interview on 3/6/25 at 12:02 p.m. with LVN (Licensed Vocational Nurse (LVN) 2 in Resident 35's room, LVN 2 was observed administering medications through Resident 35's G-tube; LVN 2 was not wearing a gown. LVN 2 confirmed she did not wear a gown while administering G-tube medications to Resident 35 and stated she was unaware a gown was required. During an interview on 3/6/25 at 2:02 p.m. with Nursing Supervisor (NS) 3, NS 3 stated staff must wear gloves and a gown when providing care for residents with a G-tube or other indwelling medical device. NS 3 stated it was important to use EBP to protect the resident from infection. During a review of the facility's Enhanced Barrier Precautions (EBP) Policy, approved on 6/25/24, the policy indicated, This policy mandates the use of EBP, including the donning of gowns and gloves during high-contact resident care activities, for residents identified as high-risk due to .indwelling medical devices. Examples provided of indwelling medical devices included G-tubes. 6. A review of Resident 71's Face Sheet (demographics), dated 01/21/25, indicated Resident 71 was admitted on [DATE] with diagnoses that included urinary tract infection (UTI - an infection of the bladder and or kidneys) and severe sepsis with septic shock (life threatening condition resulting from an infection). During a concurrent observation and interview on 3/6/25 at 11:00 a.m. with Registered Nurse (RN) 10 in Resident 71's room. RN 10 was observed preparing to flush Resident 71's nephrostomy tube (a long, thin, plastic tube inserted through the skin directly into the kidney which drains fluid). RN 10 donned clean gloves, opened a small sterile drape, (a sterile sheet used to create a sterile field during procedures with the purpose of preventing the spread of infection from non-sterile areas and protecting the resident from contamination) and placed the sterile drape under Resident 71's nephrostomy tubing. RN 10 removed a green cap from the port attached to the nephrostomy tubing and placed the green cap on the bedside table. RN 10 donned sterile gloves (gloves which have been sterilized to eliminate any bacteria to protect residents from infection during procedures. Once sterile gloves are donned, staff should not touch anything except other sterile supplies) and opened an alcohol wipe (non-sterile) and used it to clean the port of the nephrostomy tube. RN 10 then picked up a syringe filled with sodium chloride (solution to flush the nephrostomy tube) which was wrapped in plastic (non-sterile). RN 10 unwrapped the syringe with her sterile gloves and proceeded to use the port to inject sodium chloride into Resident 71's nephrostomy tube. RN 10 then placed the green cap (non-sterile) back on the port of the resident's nephrostomy tube. During an interview on 3/6/25 at 11:15 a.m. with RN 10, RN 10 confirmed she used sterile gloves to open the alcohol swab wrapper and to remove the plastic overlay from the sodium chloride syringe. RN 10 confirmed these supplies were not sterile and her sterile gloves were contaminated by handling the non-sterile supplies. RN 10 further stated the green cap she removed from the bedside table and placed back on Resident 71's nephrostomy tube port was not sterile. During an interview on 03/06/2025 at 2:02 p.m. with Nursing Supervisor (NS) 3, NS 3 stated it was important to use sterile technique when flushing Resident 71's nephrostomy tube because the nephrostomy tube was inserted through the skin directly into the resident's kidney. NS 3 stated failure to use sterile technique when flushing the nephrostomy tube could result in Resident 71 developing a serious infection. During a review of the facility's policy and procedure (P&P) titled Nephrostomy Tube, Management, dated 04/09/2024, the P&P indicated, Flushing of Nephrostomy . flushing of the nephrostomy tube is a sterile procedure.

Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 31) remained free from restraint when Resident 31's bed was placed against the wall with four bedrails in the upright position and the bedside table positioned over Resident 31's body. This failure had the potential to obstruct Resident 31's mobility and cause injury. Findings: During a review of Resident 31's Face Sheet [FS- a quick summary sheet that healthcare providers use to access key information, like name and medical history], the FS indicated Resident 31 had diagnoses of Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills) and Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain). During an observation on 3/3/25 at 9:04 a.m. in Resident 31's room, Resident 31 laid on his back awake in bed. The right side of the bed was pushed up against the wall with the bedside table placed between the bedrails, over Resident 31's body. All four bedrails were in the upright position. Resident 31 was pleasant but not interviewable. During an observation on 3/3/25 at 2:59 p.m. in Resident 31's room, Resident 31 laid on his back in bed with eyes closed. The bed was pushed up against the wall and three bedrails were in the upright position restricting Resident 31 from exiting the bed. The bedside table was positioned over Resident 31's body. During an interview on 3/4/25 at 10:30 a.m. with the designated person (DP) responsible for Resident 31's healthcare, the DP stated she observed all four bedrails in the upright position on several occasions but assumed they were facility measures implemented for Resident 31's safety. The DP stated she was not contacted by the facility about the bedrails. During concurrent observation and interview on 3/4/25 at 2:40 p.m. with Registered Nurse (RN) 3, in Resident 31's room, Resident 31 laid on his back awake in bed. The bed was pushed up against the wall, all four bedrails were in the upright position. The bedside table was positioned over Resident 31's body. RN 3 dropped the lower and upper bedrail and stated, This can't be like this. RN 3 stated bedrails were considered a restraint when left in the upright position to prevent the resident from exiting the bed. RN 3 stated she did not know Resident 31 was left like that. During an interview on 3/4/25 at 2:50 p.m. with the Nurse Supervisor (RNS) 1, RNS 1 stated the facility allowed two bedrails to remain in the upright position for certain residents to assist with bed mobility, however the use of four (upper and lower) bedrails were not permitted. RNS 1 stated bedrails or anything used to restrict the movement of a resident was considered a restraint and not allowed in the facility. RNS 1 stated Resident 31 was on 30-minute checks and the use for all four bedrails was not necessary. RNS 1 stated there was no restraint order in effect for Resident 31. During an interview on 3/4/25 at 3 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated he was assigned to the 30-minute checks for Resident 31. CNA 5 stated 30- minute checks were implemented on all residents to ensure their safety and prevent accidents. CNA 5 stated he did not notice Resident 31's bedrails were in the upright position during his safety rounds. CNA 5 stated he thought the bedrails were left in the upright position after Resident 31 was changed today, however CNA 5 could not explain why bedrails were used and in the upright position on 3/3/25 and why the bedside table was routinely positioned across Resident 31's body. During a review of Resident 31's Minimum Data Set (MDS- a tool for implementing standardized assessment and for facilitating care management in nursing homes), dated 12/18/24, indicated Resident 31's Brief Mental Interview for Mental Status (BIMs- a 15-point test indicating cognitive function) score was three (scores 13-15 suggest cognition is intact, 8-12 suggest mild impairment, and 0-7 suggest severe impairment). During a review of Resident 31's Safety Rounds [SR] monitoring log, dated 3/3/25 and 3/4/25, the SR log indicated safety rounds were performed every 30 minutes during the morning shifts and Resident 31 was in bed awake 7 a.m. and 2:30 p.m. The SR monitoring log included additional checks as follows: position, placement, function, & resident's comfort while in bed. There was no indication bedrails were in use. During a review of Resident 31's Behavior Monitoring Log, for March 2025, the log indicated Resident 31 did not exhibit agitation, aggressively hitting, or refusal of care behaviors. During a review of Resident 31's Care Plan, dated 12/20/24, the care plan indicated, . check side rail position, placement, function and residence comfort and resident in bed at least every shift . Staff to anticipate resident needs . continue 30 mins [minutes] safety rounds . offering toileting q [every] 2 hr. [hour] or while awake, snacks/ food . Environment, maintain hazard free . During a review of Resident 31's Physician's Orders, for March 2025, the orders indicated there was no physician order written for restraints. During a review of the facility's policy and procedure (P&P) Bedside Rails, Safety, dated 11/24/24, the P&P indicated, . To ensure safe use of bedside rails, especially for those residents considered high risk for entrapment . Nursing Staff will follow [Name of Facility] Bedside Rail, Restraint policy when considering the use of bedside rails . Residents at high risk for entrapment may include, but are not limited to, the following . Residents with altered mental status . Residents displaying general restlessness or agitation . Nursing staff will routinely evaluate and monitor the Resident for appropriateness of side rails . Check side rail position, placement, function, and residence comfort when in bed . During a review of the facility's P&P Physical Restraints, dated 4/8/24, the P&P indicated, . The facility will ensure that the resident is free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the Resident's medical symptoms . The following are physical restraint practices prohibited at the [Name of Facility], including, but not limited to . using bed rails that keep a Resident from voluntarily getting out of bed . Placing a chair or bed close enough to a wall that the Resident is prevented from rising out of the chair or voluntarily getting out of bed . Using devices in conjunction with a chair, such as trays, tables, cushions, bar or belts, that the Resident cannot remove and prevents the Resident from rising .

Based on interview and record review, the facility failed to ensure Resident 57's medication was documented when Registered Nurse (RN) 6 did not document medications were given. This failure had the potential to cause negative health-related outcomes to Resident 57. Findings: During a review of Resident 57's Minimum Data Set (MDS- a tool for implementing standardized assessment and for facilitating care management in nursing homes) Section I- Active Diagnoses dated 2/6/25, the MDS indicated Resident 57 had the following diagnoses: Anemia (body does not produce enough healthy red blood cells to carry oxygen), Hypertension (high blood pressure), Diabetes Mellitus (high blood sugar), and Hyperlipidemia (too much fat in the blood). During a review of Resident 57's Current Medication Orders, the orders indicated, . Isosorb Mono (isosorbide mononitrate) Tab (tablet) 30 milligram (mg- unit of measure) ER (extended release) Take one (1) tablet by mouth every evening for heartbeat abnl (abnormal) . Atorvastatin Tab 80 mg . Take one (1) tablet by mouth every evening for Hyperlipidemia . During a concurrent interview and record review on 3/5/25 at 11:55 a.m., with Registered Nurse Supervisor (RNS) 1 and RN 3, Resident 57's Medication Administration Record [MAR- a report detailing drugs administered] dated 3/1/25 to 3/31/25 was reviewed. Signature boxes on lines designated for Atorvastatin 80 mg and Isosorb Mono 30 mg medications and scheduled at 6 p.m. were left blank on 3/3/25. RN 3 stated she could not confirm the medications were refused by Resident 57 or administered because the signature boxes were left blank. RN 3 stated night shift RNs were responsible for auditing the MARs every 24 hours. RN 3 stated Resident 57's MAR did not indicate it was audited. During an interview on 3/5/25 at 3:15 p.m., with RN 6, RN 6 stated he reviewed Resident 57's MAR prior to the interview. RN 6 confirmed he worked the PM shift (2:30 p.m. to 11 p.m.) on 3/3/25 and stated he administered to Resident 57 Atorvastatin 80 mg and Isosorbide Mono 30 mg around 6 p.m. that evening. RN 6 stated he forgot to initial the MAR when he administered the medications. RN 6 stated facility policy required nurses to initial signature boxes at the time the medication was administered to residents or circle the boxes if residents refused. RN 6 stated, on 3/3/25, he did not follow facility policy and procedure for medication administration. RN 6 stated it was an omission that placed Resident 57 at risk for a medication dosing error if not identified by night shift. During a review of the facility's policy and procedure (P&P) titled, Medication, Administration Standards, last reviewed 11/21/24, the P&P indicated, . The licensed nurse is responsible to ensure the Six rights of medication administration are followed at all times . Right Documentation [the sixth right] . Medication name, administration time, route and dose of the drug or treatment administered to the Resident will be recorded in the MAR/ TAR by the licensed nurse who administers the drug or treatment .

Based on observation, interview, and facility document review, the facility failed to maintain a walk-in freezer when there was a large amount of ice build-up on the ceiling as well as ice build-up on boxes of food. The failure to maintain one freezer in one out of two kitchens had the potential to result in decreased quality and contamination of food. Findings: An observation in a walk-in freezer (referred to as the warehouse freezer) located in the Main Kitchen (where food was stored and prepared for the licensed care kitchen) on 3/4/25 at 10:25 a.m., showed ice build-up on the ceiling between wall mounted fans. The ice measured more than 24 inches long, 18 inches wide, and 2 inches thick. In addition, boxes of food stored below the fan had a layer of ice build-up on the top surface of the boxes. During a concurrent interview on 3/4/25 at 10:25 a.m., Food Manager (FM) 1 stated he did not know what the ice build-up was from. FM 1 confirmed there was ice build-up on boxes of food and stated he was unaware of the ice build-up. During an interview on 3/6/25 at 3:08 p.m., the Dietary Director (DD) stated freezers need to be free of ice-build-up. During an interview with the Direct Construction Supervisor (DCS) on 3/4/25 at 3:10 p.m., DCS stated his staff usually went into the warehouse freezer every other week but right now about every month because of a staff shortage. DCS stated he was not aware of ice build-up. During a review of the policy and procedure titled, Food & [and] Nutrition Services - Equipment (All Homes), dated 9/18/24, showed equipment will be maintained in good working order.

Based on observation, interview and record review, the facility failed to provide a safe environment by ensuring the safety of their residents for one of three sampled residents when Resident 1 was found dead outside the facility basement exit door. Findings: During a review of Resident 1's Interdisciplinary Note, dated [DATE] at 8:00 p.m., the note indicated Resident 1 was identified as missing at 6:00 p.m. on [DATE] when Resident 1 failed to return to the unit. A search for Resident 1 was initiated in the ward and throughout the building where the Skilled Nursing Facility (SNF) unit was located. A high-risk reportable incident was initiated. During a review of Resident 1's Patient Care Plan, dated [DATE], the plan indicated Resident 1 had the potential for Injury or Accident with his risk factors listed in Problem # 2 as a history of falls, chronic pain, neuropathy (a nerve condition that can lead to pain, numbness, weakness or tingling), weakness/unsteady gait, history of hypotensive (low blood pressure), history of ETOH [alcohol] consumption, poor safety awareness, forgets limitations, use of assistive device (4ww [four wheel walker], electric scooter) and Cognitive Impairment ( Problems with a person's ability to think, learn, remember, use judgement, and make decisions). Problem # 8 indicated an additional risk for injury to Resident 1 when leaving the ward unaccompanied. The care plan problem indicated Resident 1 could experience a serious accident and/or injury (i.e. falls, dehydration, heat stroke, hypothermia (low body temperature), assault, traffic danger, etc.) that may lead to death. Or the resident could potentially get lost and unable to return to the ward on time for their care such as medications and or other treatments. During a review of the facility document titled, Office of Public Safety - Patrol Division Officers Daily Log, dated [DATE], it indicated at 11:27 p.m., CHP found the missing person, Resident 1, in the west wing at the exterior the portion of the building. [State] Fire declared Resident 1 deceased at 11:27 p.m. During an interview on [DATE] at 10:45 a.m. with California Highway Patrol officer (CHP 1), CHP 1 stated he was called on [DATE] by the graveyard CHP officer who needed assistance with initiating a Silver Alert (a public announcement that a senior citizen is missing). At 8:30 p.m. the process was started for initiating the Silver Alert. CHP 1 stated, There was aircraft available to assist in the search. It was them who located someone outside of the building, they requested the CHP office go to check the location. During a concurrent observation and interview on [DATE] at 3:35 p.m., with Certified Nursing Assistant 1 (CNA 1) in the basement of the building where the facility's SNF was located, CNA 1 walked through the basement explaining the areas he searched for Resident 1 on [DATE] at approximately 7:00 p.m. He stated he did not open the exit door near the smoking area to check outside when he was searching. He stated that door was not being used. CNA 1 stated he knew the door was unlocked and accessible. CNA 1 stated, I skipped that area, I'm not sure why. It is not an access for residents. We did not talk anything about that door during our search. CNA 1 stated he should have looked there too. The area directly outside the door was observed. The area was coned off for safety and there was a cyclone fence barrier enclosing a construction zone atop a stairway several feet from the door. There was no direct access to the public sidewalk from the doorway except over a grassy incline. During an interview on [DATE] at 4:10 p.m. with Registered Nurse 1 (RN 1), the RN in charge of Resident 1's ward on [DATE], RN stated he did not consider the resident would exit the door where he was found dead. RN 1 stated, I believe it was open and residents did have access to that area. I felt OPS (Office of Public Safety) would be doing the search outside . I was not asked to search the perimeter of the building. During an interview on [DATE] at 6:18 p.m. with the Office of Public Safety officer (OPS 2) on duty on [DATE] from 6:00p.m. to 6:00 a.m., OPS 1 stated, I did not ask if they completed a perimeter search of the building . My assumption was we were two different entities working on this. I feel like us lacking a detailed SOP [standard operating procedure] is a crutch for everybody . We are using a nursing missing person policy. I have asked for policies a hundred times. I have been told to just wait. There should be a policy for every department for missing persons. I was told we work alongside with nurses to help find the person . I had not received any additional training other than the nursing policy for a missing person situation . Those doors he exited out of are to be secured usually between ,d+[DATE] p.m. by us [OPS]. With the priorities of what needed to be done, I was more focused on the missing person than locking the doors. During an interview on [DATE] at 4:15 p.m. with Supervising Registered Nurse (SRN 1), SRN 1 stated, I called the morning shift and asked them when they last saw him. I was told at 12:30 p.m. he [Resident 1] was going to his podiatry appointment then to [city]. I was the point person. The contact person for the whole incident . I did not ask if the perimeter was searched. It was not in my thought. I assumed OPS did that. I did not ask OPS if they did a perimeter search. We can't go outside long enough. We cannot leave the residents. We searched every floor in the building. I did not think about that area [outside the side door where Resident 1 was located]. I passed through that area three times that night. It was not in my thought to look there or to open the door. The door was unlocked. I think it should have been looked at. At that time, we were so focused on the search in [city] . No one goes in there, it is a construction area. It should have been searched. I should have pushed the door open. My concern was the building, not the perimeter. During an interview on [DATE] at 10:15 a.m. with OPS Chief (OPS 1), OPS 1 stated the OPS was primarily involved in the exterior and grounds search. They use the nursing policy on missing persons as their guide. During an interview on [DATE] at 4:03 p.m. with RN 2, RN 2 stated she saw the door where Resident 1 was located, but she did not check it. It was pitch black outside . I feared for my safety. During an interview on [DATE] at 5:00 p.m. with SRN 2, SRN 2 stated, I do not think the perimeter of the building was checked. There are stairs out that door, but no access in or out besides the door. If we were going to check the whole building, we should have checked the perimeter. SRN 2 stated the CNA said he drinks, he may have been confused. I'm thinking they might not have checked outside that door as it was nighttime already. During an interview on [DATE] at 8:46 a.m. with Chief Health and Safety Officer (HSO 1), HSO 1 stated the Emergency Only exit sign, caution tape and cones were placed after the incident. HSO 1 stated, That is something we should have considered prior to the event . It is not an area of high traffic. The signage now is to minimize even more traffic through there. HSO 1 stated the exit discharge does not meet the requirements of exit regulations as it was an old building and to meet the code it would cost too much money. HSO 1 stated she did not consider the exit area to be a risk. During a concurrent observation and interview on [DATE] at 10:30 a.m. with Administrative Staff 2 (AS 2) in the basement of the building through the hallway adjacent to the smoking area and outside the door where Resident 1 was located. AS 2 stated the door is always left unlocked for emergency exits due to the Health and Safety Code. AS 2 stated, The area was not observed by the staff that night after the CHP found Resident 1 as it was considered a crime scene. During a review of the facility policy and procedure titled, Missing Resident/Elopement - Code Purple, dated [DATE], the policy indicated Phase 1, the initial search and notification process shall be completed within the first 2 hours of a known or suspected missing Resident. The policy indicated, Licensed Nurse gathers available staff to implement a search of the environment as follow The staff searches the Residents room, the unit, the last known location, the immediate outside perimeter of the building, neighboring units, and finally the Supervising registered nurse or designee and Office of Public Safety (OPS) coordinate an expanded facility wide search.

F-580 Notification of Changes Based on interview and record review the facility failed to immediately notify the physician of a significant change of condition in Resident 1's breathing status with life threatening clinical complications warranting a transfer to the hospital. This failure resulted in a delay of care for Resident 1. Findings: During a review of Resident 1's hospital records titled, Emergency Department Provider Notes, dated [DATE] at 3:00 a.m., the note indicated around 6:30 p.m. [[DATE]] Resident 1 had a choking episode involving a hard-boiled egg at dinner. At around 1 a.m. [[DATE]] staff noted Resident 1 was in respiratory distress, with oxygen saturations (oxygen levels in the blood) in the 70's (normal range is ,d+[DATE]). EMS (Emergency Medical System) transferred Resident 1 to the emergency department. The provider note indicated Resident 1 was a DNR/DNI (do not resuscitate/do not intubate, no artificial breathing or chest compressions) with selective treatment. Resident 1 was given morphine (an opiate, a strong drug used to treat serious pain. Sometimes given to ease the feeling of shortness of breath) for air hunger and pain. Resident 1 died of a cardiac arrest on [DATE] at 2:16 a.m. in the hospital. During a review of the facility's policy and procedure (P&P) titled, Change of Condition and Notifications, dated [DATE], the P&P indicated, The licensed nurse will report in a timely manner through the appropriate channels this information to promote prompt and accurate reporting of a change of condition. The P&P indicated . In emergent situations 911 and ,d+[DATE] (Office of Public Safety on facility grounds) are activated with notification to the Supervising Registered Nurse (SRN) and the PCP (Primary Care Physician) or the DOC (Doctor On-Call). The policy indicated an emergent situation would include a significant change in VS (vital signs) with associated symptoms, SOB (shortness of breath) or other respiratory symptoms. The P&P indicated, The licensed nurse will gather appropriate data related to the resident's condition and/or information on situation/ event prior to contacting the provider . During a review of Resident 1's Interdisciplinary Progress Notes (IDN), dated [DATE] in error, the IDN reflected the nursing notes from [DATE] at 24:30 [12:30 a.m.], by Licensed Vocational Nurse (LVN) 1, the note indicated the patient had unstable vital signs after an episode of vomiting. The note indicated, Supv (sic) (supervisor) & family already aware. There was no indication in the IDN a physician was notified of the change of condition. During a review of Resident 1's Interdisciplinary Progress Notes dated [DATE] at 1:45 a.m. by LVN 1, the note indicated, Resident [1] was transported to (Emergency Department) at 1:34 a.m. via 911 to r/o (rule out) or confirm aspiration pneumonia (type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs). The IDN indicated another set of vital signs were unstable and Resident 1 was on 15 liters of oxygen delivered with a non-rebreather mask (a type of mask that delivers high concentrations of oxygen in emergency situations). The note indicated, a telephone call was made to the DOC, but was unsuccessful. The IDN did not indicate the time when the call was made or by who. During an interview on [DATE] at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she did not attempt to notify the DOC, or any other physician during the respiratory emergency with Resident 1. LVN 1 stated LVN 2 was not successful in reaching the DOC. LVN 1 stated the DOC phoned the unit near the end of the shift, several hours after the patient had been transferred to the hospital. This communication with the DOC was not documented in Resident 1's medical record. During an interview on [DATE] at 9:46 a.m. with LVN 2, LVN 2 stated, I was going to call the doctor. We needed an SBAR (an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication) report for that. I had to see what he [Resident 1] looked like to provide more information to the doctor when I called. I tried to call the MD but she did not answer, I called her twice, one call right after the first .I did not chart, I was just assisting the covering nurse. During an interview on [DATE] at 9:50 a.m. with DOC 1 who was on duty on [DATE] at 12:30 a.m. when Resident 1 had his change of condition. DOC 1 stated, I wanted to be notified if there was any change in Resident 1's condition. DOC 1 checked the call history on her phone and stated she received two calls from the facility that night, one at 1:02 a.m. and the other at 1:09 a.m. [34 minutes following the documented onset of distress by LVN 1]. Doc 1 stated, I inadvertently turned my ringer off instead of down, so it would not bother my husband. Both calls were missed. DOC 1 stated a heart rate of 119 and O2 saturation at 80% on 3 liters was unstable. DOC 1 stated if Resident 1's vital signs were unstable at 12:30 a.m., I would have expected them to call as soon as they could . I returned the call at 4:42 a.m. as soon as I realized I missed the call. He was already sent out to the hospital at that point. During an interview on [DATE] at 10:40 a.m. with Administrative Staff 1 (AS 1), AS 1 stated she called the fire department to get the record of the EMS report from the call on [DATE] for Resident 1. AS 1 stated she was told the 911 call came into the fire department on [DATE] at 1:14 a.m. The fire department arrived at 1:20 a.m. and EMS (emergency medical services -the ambulance) arrived at 1:22 a.m. During an interview on [DATE] at 11:05 a.m. with Resident 1's Primary Care Physician (PCP) 1, PCP 1 stated .a heart rate of 119 and oxygen saturation of 80% on 3 liters is unstable. 30 minutes is too long to wait to call 911 with those vital signs .

Based on interview and record review the facility failed to ensure the Doctor on Call (DOC 1) responded promptly to the notification of Resident 1's change of condition by nursing staff. This failure resulted in nursing staff not having the guidance of a physician to manage Resident 1's change of condition and transport to the emergency department. Findings: During an interview on 8/21/24 at 9:46 a.m. with LVN 2, LVN 2 stated, I tried to call the doctor, but she did not answer. I called two times, one after the other. I then notified the supervisor who advised me to call 911. LVN 2 could not recall the times. During an interview on 8/26/24 at 9:50 a.m. with the Doctor on Call 1 (DOC 1), DOC 1 stated on 8/2/24-8/3/24 NOC shift, I wanted to be notified if there was any change in condition. DOC 1 stated she received two calls from the facility that night, one at 1:02 a.m. and the other at 1:09 a.m. DOC 1 stated, I inadvertently turned my ringer off instead of down, so it would not bother my husband. Both calls were missed .I returned the call at 4:42 a.m., as soon as I realized I missed the call. Resident 1 was already sent out to the hospital at that point. During a review of the facility's policy and procedure (P&P) titled, Doctor on Call, dated 2/4/21, the P&P indicated the on-call hours are from 4:30 p.m. until 8:00 a.m. the following day. The P&P indicated the duties of the on-call doctor include providing in-person or phone consultation to the Long-Term Care SRN (Supervising Registered Nurse)/Nursing staff, and to make and receive calls to the local emergency department as appropriate when sending and receiving residents. The P&P indicated the doctor on call was expected to respond to phone calls within 10-15 minutes.

Based on interview and record review the facility failed to document complete and accurate records of assessments and interventions provided to Resident 1 during his change in medical condition. This failure resulted in Resident 1's medical records being incomplete and inaccurate. Findings: During a review of Resident 1's hospital records titled, Emergency Department Provider Notes, dated [DATE] at 3:00 a.m., the note indicated around 6:30 p.m. [[DATE]] Resident 1 had a choking episode involving a hard-boiled egg at dinner. At around 1 a.m. [[DATE]] staff noted Resident 1 was in respiratory distress, with oxygen saturations (oxygen levels in the blood) in the 70's (normal range is ,d+[DATE]). EMS (Emergency Medical System) transferred Resident 1 to the emergency department. The provider note indicated Resident 1 was a DNR/DNI (do not resuscitate/do not intubate, no artificial breathing or chest compressions) with selective treatment. Resident 1 was given morphine (an opiate, a strong drug used to treat serious pain. Sometimes given to ease the feeling of shortness of breath) for air hunger and pain. Resident 1 died of a cardiac arrest on [DATE] at 2:16 a.m. in the hospital. During an interview on [DATE] at 11:45 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated, I was told Resident 1 had a vomiting episode on the pm shift [prior shift], the MD (Medical Doctor) was notified, and the patient was to be monitored. LVN 1 indicated this meant to notify the physician if there was any change of condition. LVN 1 indicated during the initial rounds of her shift, Resident 1 was OK. LVN1 stated the CNA (certified nursing assistant) took the vital signs on identified patients and made their rounds as well. She stated she could not remember what the initial vital signs were, but either the CNA or the previous shift applied the oxygen. She stated she did not apply the oxygen. There was no documentation within the chart of the oxygen being started and what the oxygen levels were in the blood (O2 sats) when the oxygen was started. During an interview on [DATE] at 9:09 a.m. with LVN 3, LVN 3 stated he remembered he took a set of vital signs that night at the beginning of the shift, he was working as the CNA on the unit. LVN 3 stated he did not document the vital signs but gave them to LVN 1 on a piece of paper for her to review. LVN 3 stated he did not apply the oxygen to Resident 1, Resident 1 already had it on. LVN 1 stated, Possibly it was the PM shift that put the oxygen on him. During a review of Resident 1's Interdisciplinary Progress Note (IDN), dated [DATE] in error, the IDN reflected the nursing notes from [DATE] at 24:30, (12:30 a.m.) by LVN 1, the initial note indicated 2300 (11:00 p.m.) was written, then crossed off, then 2400 (12:00 a.m.) was written, then crossed off. Then finally written as [DATE] 24:30 (12:30 a.m.). The note indicated, Moderate amount of food substances, vomit. Unstable V/S (vital signs) 98XXX[DATE]-,d+[DATE]-,d+[DATE] 80% 3L -DX Stage IV Colon Cancer. MD, Supv (supervisor) & family already aware. There was no documentation the Doctor on Call (DOC) had been notified, and it was unclear at what time the Supervising Registered Nurse (SRN) was notified. During a review of Resident 1's Interdisciplinary Progress Notes, dated [DATE] at 1:45 a.m. by LVN 1, the IDN indicated, Resident [1] was transported to (Emergency Department) at 1:34 a.m. via 911 to r/o (rule out) or confirm aspiration pneumonia (type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs). The IDN indicated another set of vital signs were unstable and Resident 1 was on 15 liters of oxygen delivered with a non-rebreather mask (a type of mask that delivers high concentrations of oxygen in emergency situations). The note indicated, a telephone call was made to the DOC, but was unsuccessful. The IDN did not indicate time the DOC was called and who ordered and administered 15 liters of oxygen with a non-rebreather mask. During an interview on [DATE] at 11:45 a.m. with LVN 1, LVN 1 stated she called SRN 1 right away to inform her of Resident 1's unstable condition. LVN 1 stated SRN 1 sent over the float LVN (LVN 2) to help with assessing and transferring Resident 1 as LVN 2 was familiar with the Resident 1. LVN 1 stated LVN 2 had placed the patient on 15 liters of oxygen with a non-rebreather mask and took another set of vital signs. No time was documented on when the vital signs were taken. LVN 2 stated she then notified the SRN who then instructed her to call 911. LVN 1 stated she could not recall the time of the events. LVN 1 stated she did not assign the role of a scribe to anyone. During an interview with LVN 1 on [DATE] at 11:06 am, LVN 1 stated she could not remember if LVN 3 gave her the initial set of vital signs. She could not recall what they were. LVN 1 stated, I had all my papers with the critical vital signs, the bed hold, everything was gathered and placed under a rubber band on top of the chart, I must have put them there. LVN 1 stated she was unsure how the notes were going to be documented. During an interview on [DATE] at 9:46 a.m. with LVN 2, LVN 2 stated she was called by SRN 1 early in the shift, around midnight. LVN 2 stated she was notified by the SRN to go to Resident 1's unit to help with transferring a resident [to the emergency room ]. LVN 2 stated, When I got there Resident 1 was removing his oxygen, LVN 3 was assisting me while LVN 1 was talking to the daughter. I needed to gather additional information for the SBAR (Situation, Baseline, Assessment, Recommendations) report to better inform the doctor. I tried to call DOC 1, but she did not answer. I called two times, one right after the other. Then I notified the SRN who advised me to call 911 . I did not chart, I was just assisting the covering nurse. During an interview on [DATE] at 8:04 a.m. with SRN 1, SRN 1 stated at around 12:30 a.m. she received a call from LVN 1 with concerns of Resident 1's elevated heart rate, shortness of breath and another episode of vomiting. SRN 1 stated she told LVN 1 she was sending help over, and to notify the DOC. SRN 1 then stated LVN 2 called back and stated the DOC was unreachable, LVN 2 had phoned DOC 1 twice. SRN 1 stated, I told her to call 911. Then I called the dispatch operator to inform them the ambulance was coming. SRN 1 could not recall the timeline of events. She stated it was around 12:50 a.m. when she went to the unit to assist. During a review of a document titled, Office of Public Safety Communications Division Dispatchers Daily Log, dated [DATE] at ,d+[DATE] (11pm -7 am), the log indicated at 0111 (1:11 a.m) Received a call on the emergency line from the NOC (night shift) SRN reporting that staff on ward 1D had contacted 911 to respond to the unit, to transport Resident 1 to an outside medical facility . During an interview on [DATE] at 10:40 a.m. with Administrative Staff 1 (AS 1), AS 1 stated she called the fire department on [DATE] at 4:18 p.m. to get the record of the EMS report from the call on [DATE] for Resident 1. AS 1 stated she was told the 911 call came into fire department at 1:14 a.m. on [DATE]. The fire department arrived at 1:20 a.m. and EMS (Emergency Medical Services, the ambulance) arrived at 1:22 a.m. During a review of the policy and procedure (P&P) titled, Documentation, Transfers/Discharges (All Homes), dated [DATE], the P&P indicated, the documentation to include in an emergency/urgent transfer to a higher level of care was to include, Documentation of the event according to the protocols and policies set by the Home for resident changes of condition and emergencies. During a review of the policy and procedure (P&P) titled, Changes of Condition and Notifications, dated [DATE], the P&P indicated under the section for documentation, The Licensed Nurse will: a.) Record all attempts to notify and communicate with the DOC or PCP [Primary Care Physician] regarding resident change of condition or status whether verbally communicated or placed in a communication book requires a note by the nurse including the date, time, and method of communication in the Nurses Notes in the resident's health record. b.) Document date, time, condition and pertinent details of (the) sic incident and assessment in the Interdisciplinary Progress Notes.

Based on interview and record review, the facility failed to provide adequate supervision and follow their policy and procedure Missing resident and Elopement - Code Purple (SNF / ICF), for one of two sampled residents (Resident 1) when Resident 1 signed out of the unit and did not specify where he was going and gone for two days. The assigned nurse was aware that Resident 1 was out of the unit all night and didn't alert anyone. Unit staff initiated the policy for missing resident and elopement on the following day. These failures placed Resident 1's safety at risk for accidents, injuries, and resulted in Resident 1 going without scheduled and as needed medications for two days while he was at a motel in a nearby city. Findings: During a review of Resident 1's Face Sheet (FS-a document which contains patient medical history and contact details), undated, the FS indicated, Resident 1 had diagnoses of Schizoaffective Disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression), muscle weakness, Dysphagia (difficulty swallowing) and Post-Traumatic Stress Disorder (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event). During a review of Resident 1's Investigation Report dated 7/1/24, the Investigation Report indicated, On 07/1/24 at 1150, the Supervising Registered Nurse II reached Resident 1 through his cellphone. Resident 1 declined to disclose his location and reported he was with a 'girlfriend' whom he met in . [nearby city.] During an interview on 7/15/24 at 1:50 p.m. with Supervising Registered Nurse (SRN 2), SRN 2 stated on 6/30/24, at around 1:16 a.m., per nursing notes, Resident 1 went to the nursing station and asked if he could take his schedule morning medications. SRN 2 stated the night shift nurse informed Resident 1 she would not be able to give him his morning medications. SRN 2 stated the night shift nurse did not document and did not endorse to the incoming staff that Resident 1 had left the unit at 1:32 a.m. and had not returned all night. SRN 1 stated she was the morning nursing supervisor, and she was not aware Resident 1 had been missing, she was only informed about it on 7/2/24. SRN 2 stated the night shift nurse should have informed the night shift supervisor that Resident 1 had left the unit and should have begun searching for Resident 1's location. During an interview on 7/17/24 at 7:20 a.m., with SRN 3, SRN 3 stated the night shift staff Certified Nurse Assistant (CNAs) and nurses made hourly rounds to check on residents whereabouts. SRN 3 stated when a resident signs out, nurses expect the resident to return within 2 hours. SRN 3 stated per nursing notes on 6/30/24 at 1:16 a.m. while Resident 1 had requested his morning medications, the night shift nurse should have questioned, why the resident was asking for his medications that early in the morning. SRN 3 stated per documentation unit staff had initiated the policy for missing residents the next day 7/1/24 at 1:30 a.m. SRN 3 stated CNAs were responsible for making hourly rounds and documenting the whereabouts of the residents. During an interview on 7/17/24 at 9:20 p.m., with SRN 3, SRN 3 stated the 6/30/24 safety round sheet form indicated that from 12:30 a.m. to 6:45 a.m. resident was out of the unit. SRN 3 stated if the resident was still not in the unit after 2 hours, the CNA must report the resident missing to the charge nurse and start searching for the resident. SRN 3 stated because this wasn't done the resident was placed at risk for accidents and hypothermia since it was cold during the night. SRN 3 stated nurses and CNAs were responsible for making rounds during the shift and to ensure all residents were accounted for. During an interview on 7/17/24 at 9:55 a.m., with the Director of Nursing (DON), the DON stated the residents were monitored by staff during safety rounds. The DON stated per the facility policy if a resident did not indicate the estimated return time when signing out, the staff must start searching for the resident and call the family. The DON stated if they were not able to locate the resident after the search, the facility must implement the missing resident / elopement policy. During an interview on 7/17/24 at 3:45 p.m., with SRN 5, SRN 5 stated she was a night shift SRN on 6/30/24. SRN 5 stated it was not reported to her that Resident 1 had signed out and left the unit and had not returned all night. SRN 5 stated at around 1:15 a.m., the nurse called and informed her that Resident 1 was asking for his 8 a.m. medications. SRN 5 stated she told the nurse it was too early and the medications could not be given. SRN 5 stated per night nurse Resident 1 got agitated, therefore SRN 5 contacted the Office of Public Safety Officer (OPS ) to go check on Resident 1. SRN 5 stated 30 minutes later around 2 a.m., she called the nurse to check on Resident 1. SRN 5 stated the nurse informed her that OPS came, the resident had calm down and was back in his room. SRN 5 stated when she returned to work, after her day off, she was informed about the incident. SRN 5 stated on 6/30/24 at 2 a.m. when she called to nurse, Resident 1 was in the unit according to the nurse. SRN 5 stated nurses know they must call her and report resident concerns. SRN 5 stated before the end of the shift she asked the unit staff if there was anything she needed to know, but nothing was reported to her. SRN 5 stated she checked the MAR (medication administration records) on 6/30/24; the medication nurse had documented at 8:39 a.m. that Resident 1 was off the [NAME] (unit) during medication administration. SRN 5 stated the medication nurse should have informed the SRN and they should have started searching for the resident. During an interview on 7/18/24 at 10:05 a.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 1 was assigned to her on 6/30/24 the day he left the facility. CNA 1 stated on 6/30/24 around 12:30 a.m. in the morning, she noticed Resident 1 went outside for a smoke and returned to the unit. CNA 1 stated around 1 a.m. she had seen Resident 1 talking to the nurse and was asking to get his 8 a.m. morning medications. CNA 1 stated the nurse did not give the resident his medications. CNA 1 stated Resident 1 was nice and did not have any hostile behavior. CNA 1 stated around 1:30 a.m. she had seen the nurse having a conversation with OPS. CNA 1 stated she asked the nurse what the update for Resident 1 was, and the nurse told her that the OPS was going to be with Resident 1. CNA 1 stated she assumed that OPS was going to be with Resident 1 while he was out of the unit. CNA 1 stated most of the time when Resident 1 was agitated OPS would come to the unit and talk to him until he calmed down. CNA 1 stated in her mind Resident 1 was going to be ok, because he was going to be with OPS. CNA 1 stated she asked the nurse if Resident will be OK, and nurse told her, Resident 1 was going to be OK because he's going to be with OPS. CNA 1 stated she did not report anything anymore because she assumed OPS and the nurse were going to make a report. CNA 1 stated she did not start looking for the resident because she thought that the resident was with OPS. CNA 1 stated at around 5 a.m. she reported to the nurse that Resident 1 had not return, the nurse told her Resident 1 was going to be with OPS. CNA 1 stated she did not have any instructions from the nurse to look for Resident 1. CNA 1 stated in the morning during the shift change the nurse reported to a.m. shift that resident was with OPS all night. During an interview on 7/18/24 at 2:50 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated on 6/30/24 she was the night shift nurse and Resident 1 was assigned to her the day he left the facility. LVN 1 stated she was aware that Resident 1 was missing all night. LVN 1 stated she endorsed Resident 1 missing to the morning shift, but she did not remember/recall who the nurse was. LVN 1 stated she did not report that Resident 1 was missing all night to SRN. LVN 1 stated she was not aware that she had to report the Resident missing to the SRN. LVN 1 stated at 1:16 a.m. Resident 1 asked for his 8 a.m. medications. LVN 1 stated she did not question the reason why Resident 1 had asked for his scheduled 8 a.m. medications at 1:16 a.m. LVN 1 stated the OPS officer came to the unit, she explained Resident 1 had calmed down and Resident 1 was no longer aggressive. The OPS officer did not have to speak with Resident 1 and the OPS officer left. LVN 1 stated she told CNA 1 that she spoke with the OPS officer and told her that the resident was ok, and that the OPS officer did not have to speak with the resident. LVN 1 stated she did not tell CNA 1 that Resident 1 was with OPS. LVN 1 stated around 2 a.m. she received a follow up phone call from the SRN regarding Resident 1. LVN 1 stated she informed the SRN that Resident 1 was fine and the OPS officer came to the unit but did not speak with the resident because she had told the OPS that the resident was fine. LVN 1 stated she informed the SRN that Resident 1 went out for a smoke. LVN 1 state at 2 a.m. Resident 1 was not in his room. LVN 1 stated she did not know about the policy, and she did not alert anyone else. During a review of Resident 1's Interdisciplinary Progress Notes (IPN), dated 6/30/24 at 1:16 a.m., the IPN indicated, Resident came to nursing station and asked if he could take his morning meds at this time. I told the patient I'm not able to give you that A.M. meds. He then said, please I need them right now . I told him I would check it with supervisor, and he was Ok with that. Manager said to not give the A.M. meds and sent OPS officer to come . I told the patient again I'm not able to give you the A.M. meds and he said Ok thanks for trying. Officer came and I explained the situation and he left. During a review of the facility's policy and procedure (P&P) titled, Missing resident and Elopement - Code Purple (SNF / ICF), dated 1/24/23, the P&P indicated, Resident whereabouts are monitored according to established guidelines for licensed care: Skilled Nursing Facility (SNF) and Intermediate Care Facility (ICF) . 2. SNF / ICF: A Resident is considered missing in SNF / ICF when he / she fails to return to the unit at the expected time (based on the sign-out or other evidence) and / or cannot be readily located . SNF: Staff will conduct Resident rounds every hour. During rounds staff will have either observe the 4 P's [resident presence, position, pain, and Potty toileting needs] of each Resident and whereabouts; or will confirm Resident's authorized absence. Staff will use SNF Resident Sign-out Log to assist in monitoring Residents' whereabouts . Complete Phase 1 within first two (2) hours of known or suspect missing Resident. In Phase 1 of missing Resident situation, the OPS assume the Incident Command Lead at the time they are made aware of the incident. During Phase 1 staff will proceed as follows: 1. Notification: Licensed Nurse promptly notifies the SRN . During a review of the facility's document CNA Annual Skills Competency Checklist, dated 2/26/19, the document indicated . Demonstrates understanding of safety rounds, signing rounds log, checking for 4 P's - resident presence, position, pain, and toileting needs . During a review of the facility's document Licensed Vocational Nurse: Skills Competency, dated 3/7/19, the document indicated . K. Safety Rounds - signs Rounds Log. Checks for - Resident Presence, position, pain, and toileting needs . During a review of the facility's document Safety Round Sheet - 15 Minutes Rounds, dated 6/30/24, the document indicated Procedure: Observe residents hourly, checking for 4 P's (present, Positioning, Potty, Pain): please follow the legend at the bottom of the page to indicate the patient's location. Write your initials at the end of the table after your observation. If resident's whereabouts is Unknown (U), Immediately Initiate A Search, per policy: Missing Residents . The document indicated Resident 1 was out of the unit from 12:30 a.m. to 6:45 a.m. During a review of the facility's document Log Book, dated 6/30/24, the Log Book indicated, Resident 1 signed out of the unit at 1:32 a.m., the sign out did not specify where he was going and/or the estimated return time.

Based on interview and record review, the facility failed to keep one of three residents (Resident 1) free from neglect when the facility did not use the recommended Hoyer Lift (a transfer device) on 5/9/22 to transfer Resident 1 from the bed to his wheelchair. This failure resulted in Resident 1 sustaining a fracture to his right knee that required hospitalization . Findings: During a review of Residents 1's Interdisciplinary Progress Notes (IDN), dated 5/9/22, the IDN indicated Certified Nursing Assistant (CNA) 1 lifted Resident 1 and tried to transfer Resident 1 from his bed to his wheelchair with the help of CNA 2. Resident 1 informed the CNAs that his legs were going out. According to the IDN, Resident 1's legs got limp. Resident 1 let go of the support bar and was unable to support himself. He remained on the sling but was not able to assist the CNAs to transfer back to bed. Resident 1 was seen by the Nurse Practitioner (NP) and Resident 1 was transferred to the local emergency department. During a review of Resident 1's Transfer Physician's Order (TPO), dated 5/9/22, the TPO indicated an order was written for Resident 1 to transfer to an outside hospital due to acute pain and swelling of the right knee and right medial (towards middle) calf after a fall occurred during a transfer with an assistive device ([NAME] Flex). During a review of Resident 1's Investigation Report (IR), dated 5/13/22, the IR indicated Register Nurse (RN) 1 was interviewed by facility staff and had stated two CNAs were transferring Resident 1. RN 1 stated Resident 1's legs gave out and Resident 1 let go of the support bar. Resident 1 remained in the sling almost in a sitting position. The IR indicated RN 1 had stated Resident 1 had no unusual behavior or change of condition prior to the injury and staff had been using the Sara lift device with no incident. The IR indicated Resident 1's legs became weak, he let go of the support bars which caused his knees to bend against the rubber part of the transfer device. During a review of Resident 1's Interdisciplinary Resident Fall Investigation and Intervention, dated 5/10/22, the form indicated Resident 1 was bed bound and needed assistance all the time when transferring. The form indicated Resident 1 required a three person assist with transferring. During a review of Resident 1's Orders Suggested Non-Medication Admission Orders dated 5/10/22, the orders indicated Resident 1 returned to the facility from an acute hospital on 5/10/22 with a diagnosis of a mildly displaced right tibial tubercle fracture (knee fracture). During a review of Resident 1's List Patient Notes, dated 3/11/21, the form indicated the last Physical Therapy Assessment was completed on 3/11/21. The form indicated Resident 1 was dependent for all mobility needs and a Hoyer lift was recommended to be used to get Resident 1 out of bed and into his manual wheelchair. No documentation was found in Resident 1's medical record that a Physical Therapy Assessment for the use of a [NAME] Flex Lift was completed. During a review of Resident 1's Interdisciplinary Team Conference, dated 2/23/22, the form indicated Resident 1 was a total assist (the resident was unable to do any part of an activity of daily living (ADL) task, even with assistive devices, without the assistance of another person[s]) with the use of a Hoyer lift for transfers. The care plan was not updated. During a review of Resident 1's Care Plan: Custom Care Plan, run date 2/22/22, the care plan indicated Resident 1 was to be transferred by a one-person assist using the [NAME] Flex Lift. This intervention was initiated on 12/31/19. During an interview on 7/26/22 at 12:45 PM with Minimum Data Set (MDS- tool for implementing standardized assessment and for facilitating care management in nursing homes) Coordinator (MDS 1), MDS 1 stated Resident 1 was being transferred with a one-to-one person assist using the [NAME] Flex Lift prior to the fall. MDS 1 explained the different dates on the Care Plan: The run date was the day the care plan was printed. The init by was the date the intervention was initiated. Resident 1 had an (Interdisciplinary Team) IDT meeting on 2/23/22 and the care plan was printed 2/22/22. MDS 1 stated the IDT had a discussion with Resident 1's family regarding Resident 1's decline. MDS 1 stated it was determined in the IDT meeting that Resident 1 should be transferred using a Hoyer Lift. MDS 1 stated after each IDT meeting, MDS 1 notified the Supervising Registered Nurse (SRN) or the lead nurse on the new recommendations discussed in IDT. According to MDS 1, the best practice was to refer Resident 1 for a Physical Therapist (PT) and Occupational Therapy (OT) assessment to determine what transferring device should have been used. MDS 1 stated if her signature was on the IDT meeting notes it meant she notified the SRN or shift lead of the recommendation for Resident 1 to be transferred by a Hoyer Lift. MDS 1 verified her signature was on the IDT meeting notes. During an interview on 7/26/22 at 11:51 AM with Physical Therapist (PT) 1, PT 1 stated Physical Therapists were responsible for conducting the lift assessments. PT 1 confirmed an assessment dated [DATE] for Resident 1 was in the medical chart. PT 1 stated Resident 1 was assessed as an extensive assist for transfers. PT 1 stated according to the assessment, the recommendation was for a Hoyer lift to be used to transfer Resident 1. PT 1 stated Physical Therapy staff got involved when a referral was generated by a doctor or nursing staff. According to PT 1, a Physical Therapy assessment would be required for the use of a [NAME] Flex Lift because the lift required residents to assist in the transfer process. PT 1 stated the [NAME] Flex lift required the resident to have some trunk control (ability to control torso) and hand use to grasp and hold on to the handle. PT 1 was unable to locate an assessment for the use of a [NAME] Flex Lift in the medical record. During an interview on 7/19/22 at 1:02 PM with Registered Nurse (RN) 1, RN 1 stated the unit staff had been using the [NAME] Flex to transfer Resident 1. RN 1 stated that when a resident needed to use any type of lift, the Resident should be assessed by Occupational Therapy (OT). After the assessment, the OT recommended the type of lift that was the safest for the resident to use during transfers. During an interview on 7/19/22 at 1:45 PM with the Director of Nursing (DON), the DON indicated the IDT was responsible for determining the type of lift a resident should use. The care plan is then reprinted with the new interventions. The nursing staff was responsible to lead all communication regarding the new interventions.

Based on interviews and record review, the facility failed to update a care plan for one of three residents (Resident 1) for the use of a Hoyer Lift (a lift used for dependent residents requiring two caregivers to facilitate safe patient transfers) the recommended device by Physical Therapy (PT) and the Interdisciplinary Team (IDT). This failure resulted in a traumatic injury, of a right knee fracture for Resident 1. Findings: During a review of Resident 1's List Patient Notes, dated 3/11/21, the form indicated the last Physical Therapy Assessment was completed on 3/11/21. The form indicated Resident 1 was dependent for all mobility needs and a Hoyer lift was recommended to be used to get Resident 1 out of bed and into Resident's 1 manual wheelchair. No documentation was found in Resident 1's medical record that a Physical Therapy Assessment for the use of a [NAME] Flex Lift (a lift support aid which encourages residents to pull themselves up into a standing position) was completed. During a review of Resident 1's Interdisciplinary Team (team of health care professionals working together to treat a patient's injury or condition) Conference, dated 2/23/22, the form indicated Resident 1 was a total assist (the resident is unable to do any part of an activity of daily living (ADL) task, even with assistive devices, without the assistance of another person[s]) with the use of a Hoyer lift for transfers. The care plan was not updated. During a review of Resident 1's Care Plan: Custom Care Plan, run date 2/22/22, the care plan indicated Resident 1 was to be transferred by a one-person assist using the [NAME] Flex Lift. This intervention was initiated on 12/31/19. During an interview on 7/26/22 at 12:45 PM with Minimum Data Set (MDS- tool for implementing standardized assessment and for facilitating care management in nursing homes) Coordinator (MDS 1), MDS 1 stated Resident 1 was being transferred with a one-to-one person assist using the [NAME] Flex Lift prior to the fall. MDS 1 explained the different dates on the Care Plan: The run date was the day the care plan was printed. The init by was the date the intervention was initiated. Resident 1 had an Interdisciplinary Team (IDT) meeting on 2/23/22 and the care plan was printed 2/22/22. MDS 1 stated the IDT had a discussion with Resident 1's family regarding Resident 1's decline. MDS 1 stated it was determined in the IDT meeting that Resident 1 should be transferred using a Hoyer Lift. MDS 1 stated after each IDT meeting, MDS 1 notified the Supervising Registered Nurse (SRN) or the lead nurse on the new recommendations discussed in IDT. According to MDS 1, the best practice was to refer Resident 1 for a PT and Occupational Therapy (OT) assessment to determine what transferring device should have been used. MDS 1 stated if her signature was on the IDT meeting notes it meant she notified the SRN or shift lead of the recommendation for Resident 1 to be transferred by a Hoyer Lift. MDS 1 verified her signature was on the IDT meeting notes. During an interview on 7/26/22 at 11:51 AM with Physical Therapist (PT) 1, PT 1 stated PTs' were responsible for conducting the lift assessments. PT 1 confirmed an assessment dated [DATE] for Resident 1 was in the medical chart. PT 1 stated Resident 1 was assessed as an extensive assist for transfers. PT 1 stated according to the assessment, the recommendation was for a Hoyer lift to be used to transfer Resident 1. PT 1 stated Physical Therapy staff got involved when a referral was generated by a doctor or nursing staff. According to PT 1, a Physical Therapy assessment would be required for the use of a [NAME] Flex Lift because the lift required residents to assist in the transfer process. PT 1 stated the [NAME] Flex lift required the resident to have some trunk control and hand use to grasp and hold on to the handle. PT 1 was unable to locate an assessment for the use of a [NAME] Flex Lift in the medical record. During an interview on 7/19/22 at 1:45 PM with the Director of Nursing (DON), the DON indicated the IDT was responsible for determining the type of lift a resident should use. The care plan is then reprinted with the new interventions. The nursing staff was responsible to lead all communication regarding the new interventions. During a review of Residents 1's Interdisciplinary Progress Notes (IDN), dated 5/9/22, the IDN indicated Certified Nursing Assistant (CNA) 1 lifted Resident 1 and tried to transfer Resident 1 to his chair with the help of CNA 2. Resident 1 informed the CNAs that his legs were going out. According to the IDN, Resident 1's legs got limp. Resident 1 let go of the support bar and was unable to support himself. He remained on the sling but was not able to assist the CNAs to transfer back to bed. Resident 1 was seen by the Nurse Practitioner (NP) and transferred to the local emergency department. During a review of Resident 1's Transfer Physician's Order (TPO), dated 5/9/22, the TPO indicated an order was written for Resident 1 to transfer to an outside hospital due to acute pain and swelling of the right knee and right medial (towards the middle) calf after a fall occurred during a transfer with an assistive device ([NAME] Flex). During a review of Resident 1's Investigation Report (IR), dated 5/13/22, the IR indicated Register Nurse (RN) 1 was interviewed by facility staff and had stated two CNAs were transferring Resident 1. RN 1 stated Resident 1's legs gave out and Resident 1 let go of the support bar. Resident 1 remained in the sling almost in a sitting position. The IR indicated RN 1 had stated Resident 1 had no unusual behavior or change of condition prior to the injury and staff had been using the Sara lift device with no incident. The IR indicated Resident 1's legs became weak, he let go of the support bars which caused his knees to bend against the rubber part of the transfer device.

Based on interview and record review, the facility failed to keep one of three residents (Resident 1) free from accidents on 5/9/22 when facility staff attempted to transfer Resident 1 from his bed in a [NAME] Flex Lift (a lift support aid which encourages residents to pull themselves up into a standing position) to his wheelchair in place of the Hoyer Lift (a lift used for dependent residents requiring two caregivers to facilitate safe patient transfers). The recommended device by Physical Therapy (PT) and the Interdisciplinary Team (IDT) was the Hoyer Lift. This failure resulted in a traumatic injury, of a right knee fracture for Resident 1. Findings: During a review of Residents 1's Interdisciplinary Progress Notes (IDN), dated 5/9/22, the IDN indicated Certified Nursing Assistant (CNA) 1 lifted Resident 1 and tried to transfer Resident 1 to his wheelchair with the help of CNA 2. Resident 1 informed the CNAs that his legs were going out. According to the IDN, Resident 1's legs got limp. Resident 1 let go of the support bar and was unable to support himself. He remained on the sling but was not able to assist the CNAs to transfer back to bed. Resident 1 was seen by the Nurse Practitioner (NP) and transferred to the local emergency department. During a review of Resident 1's Transfer Physician's Order (TPO), dated 5/9/22, the TPO indicated an order was written for Resident 1 to transfer to an outside hospital due to acute pain and swelling of the right knee and right medial calf after a fall occurred during a transfer with an assistive device ([NAME] Flex). During a review of Resident 1's Investigation Report (IR), dated 5/13/22, the IR indicated Register Nurse (RN) 1 was interviewed by facility staff and had stated two CNAs were transferring Resident 1. RN 1 stated Resident 1's legs gave out and Resident 1 let go of the support bar. Resident 1 remained in the sling almost in a sitting position. The IR indicated RN 1 had stated Resident 1 had no unusual behavior or change of condition prior to the injury and staff had been using the Sara lift device with no incident. The IR indicated Resident 1's legs became weak, he let go of the support bars which caused his knees to bend against the rubber part of the transfer device. During a review of Resident 1's Interdisciplinary Resident Fall Investigation and Intervention, dated 5/10/22, the form indicated Resident 1 was bed bound and needed assistance all the time when transferring. The form indicated Resident 1 required a three person assist with transferring. During a review of Resident 1's Orders Suggested Non-Medication Admission Orders dated 5/10/22, the orders indicated Resident 1 returned to the facility from an acute hospital on 5/10/22 with a diagnosis of a mildly displaced right tibial tubercle fracture (break or crack of the bony bump on the upper part of the shin [knee fracture]). During a review of Resident 1's List Patient Notes, dated 3/11/21, the form indicated the last Physical Therapy Assessment was completed on 3/11/21. The form indicated Resident 1 was dependent for all mobility needs and a Hoyer lift was recommended to be used to get Resident 1 out of bed and into his manual wheelchair. During the medical record review no documentation was found in Resident 1's medical record that a Physical Therapy Assessment for the use of a [NAME] Flex Lift was completed. During a review of Resident 1's Interdisciplinary Team Conference, dated 2/23/22, the form indicated Resident 1 was a total assist (the resident was unable to do any part of an activity of daily living (ADL) task, even with assistive devices, without the assistance of another person[s]) with the use of a Hoyer lift for transfers. The care plan dated 2/23/22 was not updated. During a review of Resident 1's Care Plan: Custom Care Plan, run date 2/22/22, the care plan indicated Resident 1 was to be transferred by a one-person assist using the [NAME] Flex Lift. This intervention was initiated on 12/31/19. During an interview on 7/19/22 at 1:02 PM with Registered Nurse (RN) 1, RN 1 stated the unit staff had been using the [NAME] Flex to transfer Resident 1. RN 1 stated that when a resident needed to use any type of lift, the resident should be assessed by Occupational Therapy (OT). After the assessment, the OT recommended the type of lift that was the safest for the resident to use during transfers. During an interview on 7/19/22 at 1:45 PM with the Director of Nursing (DON), the DON indicated the IDT was responsible for determining the type of lift a resident should use. The care plan is then reprinted with the new interventions. The nursing staff was responsible to lead all communication regarding the new interventions. During an interview on 7/26/22 at 11:51 AM with Physical Therapist (PT) 1, PT 1 stated PTs' were responsible for conducting the lift assessments. PT 1 confirmed an assessment dated [DATE] for Resident 1 was in the medical chart. PT 1 stated Resident 1 was assessed as an extensive assist for transfers. PT 1 stated according to the assessment, the recommendation was for a Hoyer lift to be used to transfer Resident 1. PT 1 stated Physical Therapy staff got involved when a referral was generated by a doctor or nursing staff. According to PT 1, a Physical Therapy assessment would be required for the use of a [NAME] Flex Lift because the lift required residents to assist in the transfer process. PT 1 stated the [NAME] Flex lift required the resident to have some trunk control and hand use to grasp and hold on to the handle. PT 1 stated, PT was unable to locate an assessment for the use of a [NAME] Flex Lift in the medical record. During an interview on 7/26/22 at 12:45 PM with Minimum Data Set (MDS- tool for implementing standardized assessment and for facilitating care management in nursing homes) Coordinator 1, MDS 1 stated Resident 1 was being transferred with a one-to-one person assist using the [NAME] Flex Lift prior to the fall. MDS 1 explained the different dates on the Care Plan: The run date was the day the care plan was printed. The init by was the date the intervention was initiated. Resident 1 had an IDT meeting on 2/23/22 and the care plan was printed 2/22/22. MDS 1 stated the IDT had a discussion with Resident 1's family regarding Resident 1's decline. MDS 1 stated it was determined in the IDT meeting that Resident 1 should be transferred using a Hoyer Lift. MDS 1 stated after each IDT meeting, MDS 1 notified the Supervising Registered Nurse (SRN) or the lead nurse on the new recommendations discussed in IDT. According to MDS 1, the best practice was to refer Resident 1 for a PT and Occupational Therapy (OT) assessment to determine what transferring device should have been used. MDS 1 stated if her signature was on the IDT meeting notes it meant she notified the SRN or shift lead of the recommendation for Resident 1 to be transferred by a Hoyer Lift. MDS 1 verified her signature was on the IDT meeting notes.

Based on interview and record review, the facility failed to supervise Resident 1 adequately to protect from injury/accidents when Resident 1 fell , while walking off residence unsupervised. The resident had four falls in the six weeks prior to this reported fall. This resulted in Resident 1 falling on 7/16/16 off residence, and sustaining a nasal fracture, severe hematoma (bruising) over and around the right eye, and a laceration above the right eyebrow that required stitches. On 7/18/16, the facility reported that on 7/16/16 at 12:30 p.m., Resident 1 fell while walking on grounds in the area of the main dining room/bus stop. The resident was using a walker at the time he fell . The resident did not lose consciousness and was transported to a community hospital. Resident 1's history included: Major neuro-cognitive disorder, dementia, depressive disorder, chronic irritability, history of subdural hematoma and right frontal lobe hemorrhage (from a fall 12/3/14). The Minimum Data Set (MDS) assessment tool dated 6/16/16 identified the resident, as independent in all activities of daily living. He was assessed as very high risk for falls with a score of 80. (The legend indicated a score of 25-50 low risk, implement standard fall prevention interventions. A score of 51 and above, indicated high risk and to Implement high risk fall prevention interventions. The resident's plan of care dated 3/22/16 indicated: Injury/accident potential related to history of falls, lower back pain, [DIAGNOSES REDACTED], benign positional vertigo, impaired vision, and use of psychotropic medication, bilateral sensorineural hearing loss, and history of fall with small frontal lobe subarachnoid hemorrhage (12/4/14). Interventions included monitoring for environmental or physical conditions which may precipitate a fall, and fluctuating medical conditions, he was reminded to use a front wheel walker at all times, staff were to monitor medications for contributing factors, encourage fluid intake, monitor lighting and escort to all outside appointments. The record indicated that on 5/27/16, the resident fell in the parking lot at an off campus store. He fell backwards when he lifted his walker over the curb; hit his head on the ground. Left side forehead skin tear left elbow. Review of the post fall nursing note indicated that Resident 1 was brought back to Ward 4 by an off duty staff after a fall in the parking lot. Also the resident did not sign out today (usually he does) forgetful at times. The report indicated he sustained a skin tear on the left elbow, and bump on the left side of forehead. Immediate interventions included to sign out/in when leaving or returning to ward and to not use walker on the stairs or curb, but use the ramp for people with mobility impairment. During an interview on 8/25/16 at 1 p.m., RN 2 stated the resident took the bus and was brought back by a good Samaritan brought the resident back from the Walmart in downtown Napa. This staff was asked the difference between going off residence or off grounds without supervision and going to outside appointments with an escort as stated in the plan of care. RN 2 stated the escort for outside appointments was needed primarily due to the resident's memory lapses. A second fall occurred on 5/27/16 and a post fall nursing note at 6 p.m., indicated the staff heard a loud noise, and found Resident 1 lying on the floor in the shower room in which he fell /slipped, resulting in skin tears to right elbow and hand. This was the second fall for 5/27/16. A post fall document dated 7/6/16 indicated that Resident 1 while walking on the sidewalk, bent over to pick up an object, lost his balance and sustained a skin tear on his right elbow and right knee. Review of Resident 1's physician progress notes [REDACTED]. On 7/15/16 at 7:10 p.m., the resident's roommate reported to the nurse that Resident 1 fell . The nurse found the resident with his left knee touching the floor and right leg stretched out to the right. Resident 1's walker was next to him. Resident 1 was noted to be weak, with a cough and a temperature of 101.2° F. and his lung sounds were described as crackles (indicative of possible fluid). Resident 1 was transported to the community hospital for further evaluation. At the community hospital, Resident 1 was diagnosed with [REDACTED]. He returned to the facility at 4:50 a.m. On 7/16/16 at 8:30 a.m., the nursing note indicated the physician ordered antibiotics for the resident. At 9:30 a.m., documented vital signs were: temperature 98.5°F (Resident 1's normal temperature per his clinical record was 97.5°F) and his Oxygen saturation was 94% on room air. He was alert, forgetful, hard of hearing, but ambulating with front wheel walker. Resident 1's voice was husky and his needs were met. A late entry for 7/16/18, dated 7/18/16, indicated that Resident 1 had slept in; he was offered a sandwich since he had missed breakfast. Resident 1 went to the nursing station to get his pills and charge nurse noted his voice was hoarse. The charge nurse mentioned that he should stay in his room and rest since he just came back from the hospital. Resident 1 responded that he was okay and needed to go to the chapel since there was going to be a birthday celebration for the pastor. Resident 1 took his medications and signed himself out to go to the chapel. Review of Resident 1's Interdisciplinary Team Conference (IDT) notes dated 5/31/16, indicated that Resident 1 had fallen twice on 5/27/16. There were no team recommendations regarding strategies to assist Resident 1 in fall prevention. The IDT on 6/23/16 also documented the resident's fall risk and fall on 5/27/16 with no recommendations to assist Resident 1 with strategies to prevent falls. The 6/23/16 IDT note indicated that Resident 1 was not scheduled for physical therapy functional mobility program, and that Resident 1 structured his own physical activity. The IDT note dated 7/12/16, documented a fall when Resident 1 was trying to reach something on the ground. Occupational therapy provided Resident 1 with a Reacher. When Resident 1 fell on the sidewalk outside his residence the recommendation was to watch for uneven pavement. The Nursing Weekly Summary dated 7/13/16, noted that Resident 1 had a fall during that week, Resident 1's neurologic checks were within normal limits and he had a healing skin tear. Also noted was Resident 1 had poor safety awareness and needed staff to assist him when necessary. Resident 1 had mild cognitive impairment continued to need staff to orient him and he needed staff to anticipate his needs. It was noted that Resident 1 tended to get upset when needs were not anticipated. During an interview on 8/23/16 at 10 a.m., the Registered Nurse (RN 1) who assessed Resident 1 prior to his leaving the residence the day of the incident (7/16/16), stated that she recalled the resident as was written in her Interdisciplinary Note (IDN). RN 1 stated that although she thought the resident needed rest, his vital signs were stable and he could go out if he wanted since he was in the Intermediate Care area of the facility. RN 1 did not think she needed to call the physician in regards to further assessing the resident before he left. The staff also stated she did not know the resident well as she was part of a float pool and may only have worked on that residence once in 6 months. She was not aware of his recent falls in the weeks prior.

The facility must ensure that- (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The above regulation was violated when the facility failed to ensure that Resident 1 received adequate supervision and assistance devices to prevent accidents. This failure resulted in a fall on 12/11/14. The resident sustained [REDACTED]. Resident 1 was a [AGE] year old, admitted to the facility on [DATE]. The resident ' s medical problems included: Traumatic Brain Injury (after a fall in 2013), Kidney Disease necessitating ongoing dialysis, Diabetes, high blood pressure and progressive dementia. A facility reported incident, dated 12/16/14, indicated that on 12/11/14, Staff heard a noise and found the resident lying on her right side in the hallway outside of her room. On 12/12/14 the resident went to dialysis, was later taken to an acute community hospital by her family and diagnosed with [REDACTED]. On 12/15/14, the resident had a seizure just before dialysis, was taken to a community hospital and admitted for a head injury (subdural hematoma). The Interdisciplinary Team (IDT) conference, dated 8/27/14, indicated memory impairment, short-term memory loss related to dementia, impaired balance, unsteady gait, call light within reach. A quarterly Minimum Data Set (MDS assessment tool), dated 11/18/14, indicated the resident did not answer the questions for the mental status interview. The resident was identified with a short-term memory problem. A Post Fall Assessment, dated 11/20/14 at 1:45 a.m., indicated that Resident 1 was found seated on the floor next to her bed. The nurse assessed the resident as having no apparent injury and informed the physician. The assessment also indicated that the resident ' s fall risk score (legend: 51 and above indicated high risk for falls, implement High Risk Fall Prevention Interventions), worsened from 65 to 90. The plan of care interventions at this time included: encourage to use non-skid socks and will most likely get teaching to ask for help when needed. An Interdisciplinary Team Conference, dated 11/26/14 noted: Potential for injury/accident related to impaired balance and unsteady gait. The resident was encouraged to call for help if she went to the bathroom, resident refused non-skid footwear and stated she did not need help to go to the bathroom. Also indicated, the resident was non-compliant with calling for help and (sic) stubborn and impatient. Will consider (R.N. plus) bed alarm (sic) in the future for her safety. For now continue to anticipate needs. A post fall nursing note, dated 12/11/14 at 3:15 p.m., indicated staff heard a sound and found the resident lying on her right side in the hallway across from her room. The Registered Nurse assessed the resident as having no injury and that the resident denied that she struck her head. The physician was notified, per documentation, of this unwitnessed fall. The document titled, Post fall 24-hour Assessment Record, dated 12/11/14 at 3:15 p.m., indicated that there was no known or suspected head or neck injury per nursing assessment and patient history. No neurological assessments were initiated. The post fall plan of care interventions included: encourage to use 4WW (four wheel walker) which is available at bedside, use call light for staff assist, wait patiently for her requests . An Interdisciplinary Note (IDN), dated 12/11/14 at 5 p.m., indicated that the resident requested and received medication for right groin pain at 4 p.m. The note continued: Resident with steady slow movements when standing up. The walker was presented to resident to use for ambulation/support. There was no evidence of a physician assessment after the fall. On 2/11/15 at 9:30 a.m., during an interview, Physician A stated he just asked the nurse how she was and wasn ' t able to see her before she left for dialysis the following morning. During an interview, on 1/7/15 at 2:40 p.m., Staff A stated that she was down the hallway administering medications when she heard a loud sound and saw the resident on the ground. A concurrent interview with Staff B revealed that he had just left the resident to heat up her food. Both staff stated that the resident often failed to use her call light and would forget to use her walker and go to the bathroom unassisted. An Interdisciplinary Note (IDN), dated 12/12/14, indicated that the resident went to her dialysis appointment and would be with family afterwards. On 12/12/14 at 11 p.m., the IDN indicated the family took the resident to an acute community hospital for evaluation, as the resident was unable to bear weight and complained of right hip pain. A fracture of the pelvic bone was identified. An IDN at 3:30 a.m. on 12/13/14 indicated that the resident returned to the facility. On 12/15/14 the IDN indicated that two staff prepared the resident for dialysis. The staff notified the dialysis staff, that the resident now needed total assistance with mobility, especially transfer. At approximately 5:45 a.m., the resident left for dialysis. The IDN indicated that shortly thereafter, the facility staff received a call from the dialysis staff, that the resident had a seizure and could hardly respond. The resident was taken directly to the acute community hospital. Review of the community hospital discharge summary, dated 12/18/14, indicated that the resident ' s mental state on admission on 12/15/14 was altered and the resident was not responding well. The resident was placed on a ventilator. A brain scan revealed a subdural hematoma (an accumulation of blood beneath the brain ' s surface beneath the skull), and the resident was admitted to the intensive care unit. In summary, the facility failed to evaluate and analyze hazards and risks, implement effective and meaningful interventions and monitor and modify these interventions for Resident 1 whom the facility assessed as high risk for falls, with a decline in functional ability and poor short term memory and whom frequently failed to use the call light for assistance. The facility failed to: 1) assess Resident 1 (a cognitively impaired resident with poor memory), after an unwitnessed fall, with the potential for a head injury; 2) ensure the health and safety of Resident 1 when there was no physician assessment after an unwitnessed fall with potential head injury and groin pain; 3) implement meaningful and effective interventions for a resident at high risk for falls with a documented history of failing to use the call light. This failure had a direct or immediate relationship to resident health, safety and security.

Based on observation, interview, and record review, the facility failed to ensure that a system was in place to investigate, control and prevent infection related to the cleaning, sanitation and maintenance of ice machines in the licensed care wards of the facility. This had the potential to put all 319 residents who consumed contaminated ice from the 16 ice machines in the licensed care wards, at increased risk for foodborne illness from potential chemical, physical, or biological contaminant in the ice. This deficient practice is divided into three areas: 1)missing air gap (physical space required to prevent backflow of contaminated water), 2) visible debris buildup in ice chute (portion of ice machine that dispenses ice into collection receptacle (e.g. cup, bucket, etc.), and 3) visible debris buildup in ice machine floor drain. The survey team called an Immediate Jeopardy(IJ) situation on 3/12/14, at 7:00 p.m., and informed the facility Administrator and Standards Compliance Coordinator. The immediate jeopardy was called as a result of the facility's failure to have a system in place to ensure the cleanliness and sanitation of the ice machines in the licensed care wards, that provided ice to the residents of those wards. Absence of this system had the potential for allowing physical, chemical, and or biological contamination of the ice that the resident's consumed. The survey team accepted a written plan of action for the IJ situation on 3/14/14 at 2:15: p.m. Present were the facility Administrator, Director of Plant Operations, and Director of Sanitation and Housekeeping. The Immediate Jeopardy was abated. Findings: 1. On 3/12/14, at 11:15 a.m., an observation of the ice machine in the Holderman kitchen indicated no air gap between the drainage pipe and the floor drain. In a concurrent interview, the Plan Operations Director stated that he was aware of the air gap procedure, and that when the ice machine in the kitchen, and other ice machines in the facility had been originally installed, the was an air gap included. The 2013 Federal Food code section 5-202.13 titled "Backflow Prevention, Air Gap", states: "An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch)." On 3/12/14, at 10:00 a.m., observation of ice machines in the nourishment rooms of the facility's 14 licensed care wards revealed that 8 out of 13 ice machines did not have the necessary air gap backflow prevention. (Total sample is out of 13, because two wards in the Eisenhower Annex II share one ice machine.) 2. On 3/12/14, at 11:15 a.m., an observation of the Holderman kitchen ice machine revealed visible white debris buildup on the inside surfaces of ice chute. Subsequent observation of ice machines in the licensed care wards in Holderman, Eisenhower and Memory Care revealed 13 out of 13 had visible white debris buildup on the inside surfaces of the ice chute. In an interview on 3/12/14, at 11:10 a.m., the plan operations director also stated that the plan operations staff is responsible for the cleaning and sanitation of the interior of the ice machines, and that the sanitation and housekeeping staff was responsible for the exterior cleaning and sanitizing of the ice machines. In subsequent interview the Director of Sanitation and Housekeeping stated that his staff was responsible for the exterior cleaning of the ice machines, including the lower external ice chute where is is dispensed from the machine. He stated that this cleaning is completed on a daily basis, and that cleaning staff have green, abrasive pads for removing any hardened mineral deposits. The facility's policy titled "Cleaning Ice Machines on Resident Wards" indicated the following: "Environmental Services has the responsibility to clean outside of ice machines and sink area including under grate area with disinfectant solution daily. ...Remove water deposits/scales from under grates of ice machine; ...plant operations will clean inside of ice machines during routine maintenance." The 2013 Federal Food Code, section 4-602.11 (4) titled "Equipment Food Contact Surfaces and Utensils" states: In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers.....(a) at a frequency specified by the manufacturer, or, (b) absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold." 3. On 3/12/14, at 10:00 a.m. an observation of the floor drains on Holderman wards 1C, 2C, and 2D indicated significant debris accumulated in the drain. In a concurrent interview, supervising RN on Ward 2C stated that the sanitation department staff was responsible for the cleaning of the floor drains under the ice machines in the nourishment rooms. The facility's policy for Environmental and General Services, titled "Cleaning, Floor Drains", states: "All floor drains are to be cleaned daily with disinfectant solution." In an interview on 3/13/14 at 4:30 p.m., the Director of Sanitation and Housekeeping stated he had seen the floor drains on wards 1C, 2C, and 2D, and that they needed to be cleaned. There was no evidence that the infection control committee addressed the facility's ice machines as a potential source of infection or ruled out it out as a potential source, during outbreaks of infection. The survey team called an immediate jeopardy(IJ) situation on 3/12/14, at 7:00 p.m., as a result of the facility's failure to have a system in place to ensure the cleanliness and sanitation of the ice machines in the licensed care wards, that provided ice to the residents of those wards. Absence of this system had the potential for allowing physical, chemical, and or biological contamination of the ice that the resident's consumed. The Facility implemented a plan of action as follows: 1. The use of all ice machines in licensed care was discontinued on 3/12/14 at approximately 6:30 p.m.. Each ice machine was unplugged and posted with a "Do Not Use" sign. 2. All Yountville Veteran's Home facility staff were notified of the new emergency procedures for ice distribution on 3/12/14 at approximately 7:10 p.m.. 3. On 3/12/14 at approximately 8:00 p.m., the plant operations and sanitation staff began working on the following: a) air gap correction, b) internal cleaning, and c) external cleaning of the ice machines. 4. Ice and ice chests were procured from an outside source and delivered to each licensed care ward on 3/12/14 at approximately 9:00 p.m.. 5. Plant operations staff worked on 3/12, 3/13, and 3/14/14 to complete the cleaning, disinfecting and air gap corrections on all 16 ice machines used in licensed care, by 4:00 p.m. on 3/14/14. 6. On 3/13/14, at approximately 1:00 p.m., the facility created a Quality Assurance (QA) monitor to track compliance. 7. On 3/13/14, at approximately 3:00 p.m., the facility revised its policy titled "Ice Machine Sanitation, Cleaning and Maintenance." This policy directs Plant Operations responsibility for cleaning, sanitation and maintenance for all 16 ice machines throughout the licensed facility. 8. Plant Operations and sanitation/housekeeping staff were retrained on 3/14/14 regarding the procedure and process relating to cleaning and maintaining the ice machines. 9. On 3/14/14 the ice machines in licensed care were disinfected in two cycles, per manufacturer instructions. The survey team accepted a written plan of action for the IJ situation on 3/14/14 at 2:15: p.m. and the IJ was removed on 3/14/14, at approximately 2:15 p.m., based on implementation of the facility's plan. Present were the facility Administrator, Director of Plant Operations, and Director of Sanitation and Housekeeping.