Every finding on record at Villa Marin

Based on observation and interview, the facility failed to maintain a reliable and safe system for the storage and disposal of medications for a census of 16 residents when:1. Over the counter (OTC) medications stored in an active medication cart were not stored in its original packaging;2. Resident 17's expired medications remained in an active medication cart;3. Medications stored in the medication room were stored in a disorganized and unsafe manner, and;4. Expired medications for Resident 17 and Resident 31 were not disposed of properly.These failures increased the potential for medication misuse or diversion, administration of expired or compromised medications, and harm to residents due to unsafe and unreliable medication management practices.1. During a concurrent observation and interview on 8/03/26 at 10:19 a.m., Licensed Nurse 3 (LN 3) confirmed that a blister pack (a medication dispensing package) of Mucinex (a medication used for cough production) 1200 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount) that contained three pills and a blister pack of famotidine (a medication used to reduce stomach acid) 10 mg that contained eight pills were stored in an active medication cart with no resident label and were not stored in the original packaging. LN 3 stated, You have the lot number, the instructions, the expiration date all on the box. Without the original packaging you don't know if the medication expired. LN 3 verified that the Mucinex and famotidine should not be stored without the original packaging.2. A review of Resident 17's record of admission indicated he was admitted to the facility in July 2026 with medical diagnosis which included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and cardiac arrest (when the heart suddenly stops beating). During a concurrent observation and interview on 8/03/26 at 10:19 a.m., LN 3 confirmed a prescription bottle that contained medications labeled Aricept (donepezil- a medications used to treat symptoms of dementia [a progressive state of decline in mental abilities] related to Alzheimer's disease [a disease characterized by a progressive decline in mental abilities]) 5 mg with a discard date of 5/15/26 was stored in an active medication cart. LN 3 confirmed the medication belonged to Resident 17. LN 3 stated expired medications should not be stored in the medication cart. LN 3 further stated stored expired medications increased the risk for medication error and for residents to receive ineffective medication because they were expired.3. During a concurrent observation and interview on 8/06/26 at 8:49 a.m. in the medication room with the Director of Staff Development and Infection Preventionist (DSD/IP), a cabinet labeled extra medications was observed to contain sealed and unsealed, labeled resident prescription medications and OTC medications. The extra medications cabinet was disorderly, with labeled resident medications primarily on the bottom shelf in no specific order, and OTC medications stored on the middle shelf in no specific order. The DSD/IP stated medications that were delivered from the pharmacy or brought in by the resident's family were stored in this cabinet. The DSD/IP further stated the medications must be sealed. The DSD/IP confirmed there was no log to document the medications that have been ordered or brought in for the residents aside from the delivery pharmacy receipt. The DSD/IP confirmed that the extra medications cabinet was messy and not organized.During the same concurrent observation and interview, an unlocked cabinet located under the right side of the sink was found to contain a large black garbage bag that overflowed with multiple labeled medication blister packs that belonged to several residents. A yellow post-it note placed outside the bag was dated 3/14/26 and included the name of the Director of Nursing (DON). The DSD/IP stated he did not know why these medications were stored in this manner and not destroyed.4. A review of Resident 31's record of admission indicated she was admitted to the facility in June 2026 with medical diagnosis which included urinary tract infection (UTI, an infection in the bladder/urinary tract) and acute delirium (a sudden and serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking).A review of Resident 31's discharge summary indicated she was discharged on 7/08/26.During the same concurrent observation and interview on 8/06/26 at 8:49 a.m. in the medication room with the DSD/IP, an unopened latanoprost ophthalmic solution (a prescription eye drop used to lower high pressure in the eye) was stored in the extra medications cabinet. The eye drops were labeled for Resident 31 with instructions to store unopened product in the refrigerator. The DSD/IP stated that Resident 31 was discharged and that the eye drops should not be stored in the medication room and should have been disposed of after her discharge. Concurrently, an unlocked cabinet located under the left side of the sink was found to contain three labeled prescription medication bottles stored inside an open, unused red sharps container (a container used to dispose sharps [needles, razor blades, etc.] in). The medication bottles all contained pills and were labeled for Resident 17. The medications were:carvedilol (a medication to treat high blood pressure [the force of blood pushing against the walls of the arteries- muscular blood vessels] and heart failure) 6.25 mg with a discard date of 5/25/26;tamsulosin (a medication used to treat an enlarged prostate [a gland in the male reproductive system]) 0.4 mg with a discard date of 5/14/26, and;donepezil 5 mg with a discard date of 5/15/26 (this was the expired medication that was found originally stored in the active medication cart with LN 3).The DSD/IP confirmed that all three medications for Resident 17 were expired and were not stored or disposed of properly.A review of Resident 17's physician orders indicated an active order for carvedilol (Coreg) 6.25 mg 1 tablet by mouth daily.A review of Resident 17's medication records dated 7/01/26 - 7/31/26 and 8/01/26 - 8/31/26 indicated that he was administered carvedilol as ordered from 7/11/26 - 8/07/26.During an interview on 8/06/26 at 10:16 a.m., the DON stated the night shift LN or Registered Nurse (RN) were responsible for the destruction of non-controlled drugs. The DON stated the expectation was once a resident is discharged , or when the medication has been discontinued or expired, that medication was stored in the locked cabinet that was to the right of the extra medications cabinet for disposal. The DON further stated the medications were expected to be disposed every night shift.During a concurrent observation and interview on 8/06/26 at 10:39 a.m. in the medication room, the DON stated Resident 31's medication should not be stored in the extra medications cabinet. The DON further stated she expected the medication to be disposed once Resident 31 discharged . The DON confirmed the medication storage in the extra medications cabinet was messy and very unorganized. The DON stated if the cabinet was organized and the medications logged, it would prevent mistakes. The DON observed Resident 17's medications as they were stored under the sink and stated the medications should not be stored there. The DON confirmed all three of Resident 17's found medications were expired and she expected them to be disposed of properly. The DON stated expired medications should not be stored in the medication cart. The DON further stated expired medications should not be administered to residents because they could not be effective. Concurrently, the DON observed the black plastic bag of stored medications in an unlocked cabinet under the right side of the sink. The DON stated she was unaware of the bag of medications. The DON stated the unused, sealed medications are donated to a non-profit for redistribution. The DON further stated the facility had not been actively donating.During an interview on 8/06/26 at 4:19 p.m., the DON stated she expected OTC medications to be stored in the original package in the medication cart. The DON further stated the original packaging had medication instructions, expiration dates, the name and dosage of the medication.A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, revised 2023, indicated, Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Compartments [including but not limited to.cabinets] containing medications and biologicals are locked when not in use.Medications are stored in an orderly manner in cabinets.Medications requiring refrigeration are stored in a refrigerator located in the medication room.A review of the facility's P&P titled, Disposal of Medications, Syringes and Needles- Disposal of Medications, dated 1/23, indicated, Discontinued medication and/or medications left in the nursing care center after a resident's discharge are identified and removed from current medication supply in a timely manner for disposition.Outdated medications.and the contents of containers with no label shall be destroyed according to the above policy.

Based on observation, interview and record review, the facility failed to prepare and store food in a sanitary manner for a census of 16 residents when:Multiple refrigerated and frozen food items were kept ready-for-use past the use-by dates,Multiple refrigerated food items had no date labels or illegible labels,Unwrapped food was found open-to-air in refrigerator and freezer,Boxes of food items and produce were stored directly on cement floor,A large, dented food can was found in ready-for-use dry storage,Sanitizing test strips for three-compartment-sink process were expired, and;Multiple plastic cutting boards had deep scratches and were peeling.These failures had the potential to result in foodborne illnesses and spread of infections in a vulnerable resident population.1. During a concurrent observation and interview on 8/03/26 at 9:14 a.m. with COOK, the following was found in the kitchen refrigerators and freezers:A carton of dairy half-and-half with manufacturer expiration date of 8/02/26 (refrigerator),A metal bowl of aioli sauce with a label use-by date of 8/02/26 (refrigerator),A large plastic container of cranberry sauce with a label use-by date of 7/30/26 (refrigerator),A plastic container of blue cheese with a use-by date of 8/01/26 (refrigerator), and;A metal container of beef patties with a use-by date of 7/31/26 (freezer).As each item was found, the [NAME] (COOK) stated the items were expired, should not be stored in a ready-for-use area, and were discarded.2. During a concurrent observation and interview on 8/03/26 at 9:30 a.m. with COOK, the following was found in the kitchen refrigerators:Two unlabeled serving trays with uncovered, filled sauce cups, and;A plastic jar of applesauce with illegible/smeared date labeling.As each item was found, COOK stated the items should have been properly labeled and covered. 3. During a concurrent observation and interview on 8/03/26 at 9:50 a.m. with COOK, the following uncovered or unwrapped food items were found in the kitchen refrigerators and freezers:A metal bowl of leafy greens (refrigerator), and;Whole bread loaves (freezer)As each item was found, COOK stated these items should have been properly wrapped to ensure freshness.4. During a concurrent observation and interview on 8/03/26 at 10:10 a.m. with COOK, a box of dietary thickener and two boxes of whole melons were found in the dry storage area, placed directly on concrete floor. As this was discovered, COOK stated these should have been placed on shelves at least six (6) inches from floor and he immediately moved the boxes to shelves.5. During a concurrent observation and interview on 8/03/26 at 10:20 a.m. with COOK, a large dented can of clams was found in the ready-for-use dry storage area. The COOK stated this can should not be used and moved it to a separate shelf that contained items to return to food vendor.6. During a concurrent observation and interview on 8/05/26 at 11:30 a.m. with the Certified Dietary Manager (CDM) and the Sous Chef (SCHEF), the three-compartment-sink area was toured and the logs reviewed. The facility was found to be using testing strips for the sanitizer with an expiration date of June 2026. The CDM confirmed the expired strips were in current use, and immediately replaced them with new strips.7. During a concurrent observation and interview on 8/05/26 at 11:40 a.m. with the CDM, several brightly colored plastic cutting boards were seen in the clean ready-for-use kitchen equipment shelves. Upon inspection, five cutting boards were found to have deep scratches showing white material underneath, and the CDM mentioned that some boards had peeling particles. The CDM stated the cutting boards should be removed from use immediately and replaced with new cutting boards.During an interview on 8/06/26 at 10:40 AM with CDM, CDM stated facility policy is to properly label and throw away any expired foods to avoid foodborne illness in residents. The CDM further stated old, damaged cutting boards should have been discarded because scratched ones become hard to clean and can harbor bacteria, and plastic particles can transfer into the residents food causing gastro-intestinal issues. The CDM stated the facility should not use expired testing strips for sanitizing because they could give a false reading and dishes might remain dirty, leading to foodborne illness in residents. The CDM stated the risk of using food in dented cans could lead to contents growing botulism, which could harm or even kill residents. Lastly, the CDM stated the importance of properly wrapping and covering food to preserve freshness and to prevent cross-contamination.A review of the U.S. Food and Drug Administration (FDA, a federal agency of the United States) Food Code, 2022, 3-501.18 Disposition. Ready-to-Eat, Time/Temperature Control for Safety Food, indicated, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.A review of facility policy and procedure (P & P) titled, Refrigerated Storage, dated 2023, indicated, all refrigerated foods will be covered properly. All cooked food must be labeled and dated.unused portions of packaged foods should be covered, labeled and dated to assure they will be used first.A review of facility P & P titled, Food Receiving and Storage of Cold Foods, dated 2023, indicated, all open food items will have an open date and use-by date per manufacturers' guidelines.all refrigerated foods will be covered properly. All cooked food must be labeled and dated.A review of facility P & P titled, Freezer Storage, dated 2023, indicated, all foods should be stored in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn.A review of facility P & P titled, Canned Food and Dry Goods Storage, dated 2023, indicated, food will be stored above the floor, on shelves, racks or other surfaces that facilitated thorough cleaning.canned food items should be routinely inspected for damage such as dented, bulging or leaking cans.A review of the FDA Food Code, 2022, section, 48. Warewashing [the commercial process of cleaning and sanitizing kitchenware, tableware, and equipment] Facilities, Installed, Maintained, Used, Test Strips, indicated, Adequate warewashing facilities must be available and used for the cleaning and sanitization of food contact surfaces, including the availability of means to monitor its use and the effectiveness of sanitization.A review of facility P & P titled, Food Preparation, dated 2023, indicated, cutting boards may be nonporous acrylic and in good condition without deep cuts. Discard any boards with deep cuts immediately.foods which are prepared and not served on the day of preparation are to be stored appropriately, covered, clearly identified, dated with the date of preparation and served within 24 hours.

Based on observation, interview, and record review, the facility failed to follow CDC (Centers for Disease Control, the national public health agency of the United States) recognized recommendations for infection prevention and facility policy when:Respiratory care supplies were not properly stored and labeled for two residents (Resident 1 and Resident 17);Enhanced Barrier Precautions (EBP, infection control measures used in nursing homes to stop the spread of drug-resistant germs) were not initiated for two residents (Resident 1 and Resident 25) with indwelling medical devices (refers to a medical device left inside the body), and;A glucometer (a small, portable medical device used to measure the amount of sugar (glucose) in the blood) was found soiled in the medication storage room.These failures increased the potential for cross contamination and the spread of infection within the facility. 1. A review of Resident 1's record of admission (facility demographic) indicated he was admitted to the facility in May 2026 with medical diagnosis which included chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and atrial fibrillation (A-fib- an irregular rapid heart rhythm that raises the risk of stroke [when blood flow to part of the brain stops]). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/25/26, indicated that his cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. A review of Resident 1's physician orders indicated the following active orders as of 8/05/26, .Apply oxygen 2 L (liters) via nasal cannula (a thin, flexible plastic device used to deliver supplemental oxygen directly into a person's nostrils via two small prongs). During an observation on 8/04/26 at 10:16 a.m., Resident 1 was observed with a nasal cannula on his face with the oxygen on and set at 2 L. The nasal cannula was without a label that indicated the date and time the nasal cannula was last replaced. During a concurrent observation and interview on 8/05/26 at 12:40 p.m., Licensed Nurse 2 (LN 2) confirmed that Resident 1's nasal cannula was not labeled. During an interview on 8/05/26 at 4:03 p.m., LN 2 stated the expectation was that the nasal cannula was changed every week and labeled. A review of Resident 17's record of admission, indicated Resident 17 was admitted to the facility on [DATE]. A review of Resident 17's MDS dated [DATE], indicated Resident 17 had an active diagnosis of pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus). A review of Resident 17's medication record, dated 8/01/26, indicated, 07/10/26-Oxygen @ 1-2L per minute via nasal cannula as needed. During an observation on 8/04/26 at 10:06 a.m. in Resident 17's unoccupied bedroom, an oxygen concentrator machine (a medical device that pulls in room air, removes nitrogen, and delivers 90% to 95% pure oxygen to people who have trouble breathing) was observed on the right side of the bed. The cannula tubing was draped loosely over the top and sides of machine and was not bagged or otherwise labeled with last-changed-date information. During a concurrent observation and interview on 8/06/26 at 12:30 p.m. with the Director of Staff Development/Infection Preventionist (DSD/IP), Resident 17's oxygen equipment was again viewed in his unoccupied bedroom. The cannula tubing was still unbagged and unlabeled, laying over the top and sides of the concentrator. The IP stated this was against facility policy and the tubing should have been properly bagged and labeled. A review of an undated facility policy and procedure (P & P) titled, Oxygen & Nebulizer Tubing, indicated, it is the policy of [Facility] to maintain clean oxygen and nebulizer tubing.all oxygen tubing & nebulizer tubing shall be kept in a plastic storage bag when not in use.the storage bags will be changed once a month on the first Sunday of the month, and each bag will be dated and initialed. 2. A review of Resident 1's MDS, dated [DATE], indicated an additional active diagnosis of encounter for attention to gastrostomy (a medical procedure to create an opening in the stomach for the placement of a feeding tube (g-tube) to deliver nutrition, fluids, and medication). A review of Resident 1's physician orders indicated the following active orders as of 8/05/26: Isosource (nutrition given via tube feeding) between 6 p.m. – 9 a.m. daily; Free water flush (when water is given through the feeding tube) 160 ml (milliliter- a unit of measure) every six hours; 30-60 ml flush before and after feeding; G-tube site dressing change.daily; All medications via g-tube crushed; 14 out of 20 ordered medications administered via tube feeding, and; mupirocin antibiotic cream (a cream used to treat skin infections)- apply to area around g-tube for redness three times a day A review of Resident 1's medication record, dated 8/01/26 – 8/31/26, indicated the physician orders were completed 8/01/26 – 8/05/26, which further indicated repeated access to Resident 1's g-tube site. A review of Resident 1's skin condition record, dated 7/24/26, indicated 1 cm (centimeter- a unit of length) redness from g-tube site with gray drainage. A review of Resident 1's [name of diagnostic (a test, tool, or procedure used to identify a disease or condition) company] report, dated 7/30/26, indicated, Specimen Source [where the sample was taken from]: Drainage from g-tube.Result: Heavy growth of Staphylococcus aureus [a bacteria that commonly lives on the skin that can cause life-threatening infections if it enters the body]. During an observation on 8/04/26 at 10:16 a.m. outside Resident 1's room, there was no evidence that signage was posted that indicated Resident 1 was on enhanced barrier precautions (EBP, infection control guidelines used in nursing homes to stop the spread of dangerous germs). Two certified nurse assistants (CNA) entered Resident 1's room with a Hoyer lift (a mechanical device used to lift and/or transfer a person) and one CNA stated that they were going to change the resident and closed the door for privacy. The CNAs were not wearing gowns. Concurrently, outside Resident 25's room, there was no evidence that signage was posted that indicated that Resident 25 was on EBP. During a medication pass observation on 8/05/26 at 10:56 a.m. – 12:40 p.m., LN 2 was observed administering Resident 1's medications through his g-tube. LN 2 was not wearing a gown. There was no evidence inside Resident 1's room that indicated that EBP was required. During an interview on 8/06/26 at 12:25 p.m., the DSD/IP stated, Typically, we would not have staff wear a gown when administering medications via g-tube. The DSD/IP confirmed there was potential for splashes when medications were administered via g-tube and further stated he did not expect the nurse to wear a gown. The DSD/IP stated that signage that indicated EBP was not posted outside of residents' room. The DSD/IP further stated that a cart with appropriate personal protective equipment (PPE- gear designed to create a physical barrier between healthcare workers and hazardous biological agents, infectious fluids, or contaminants) was not placed outside of residents' room that required EBP. The DSD/IP stated PPE was available at the end of the hall near the entrance of the unit. The DSD/IP stated placing a cart of PPE or EBP signage that informed staff and visitors of precautions was not placed outside of resident rooms because, It could lead to a misinterpretation of what is going on with the resident. The DSD/IP further stated when a resident was on EBP he communicated that information to staff. The DSD/IP stated he was not under the impression that a gown or a mask was required when staff provided direct care to a resident with an indwelling device. During an interview on 8/06/26 at 12:40 p.m., CNA 2 stated she was not aware that any of the residents were on EBP. CNA 2 further stated she was not instructed to wear a gown when she provided direct care to Resident 1 and Resident 25. CNA 2 confirmed that Resident 1 had a g-tube, and Resident 25 had a foley catheter. CNA 2 stated she did not wear a gown when she emptied Resident 25's Foley catheter bag. During an interview on 8/06/26 at 12:43 p.m., CNA 3 stated that no residents were on infection control precautions. CNA 3 further stated that she was not informed that Resident 1 and Resident 25 were on EBP. CNA 3 confirmed that she provided direct care to Resident 1 and Resident 25 and further stated that she did not wear a gown when she bathed Resident 1. During an interview on 8/06/26 at 12:47 p.m., CNA 4 stated the facility currently did not have any residents that were on infection control precautions. CNA 4 further stated there were no residents that required more than gloves to be worn when direct care was provided. 2. During a concurrent observation and interview on 8/06/26 at 8:49 a.m. in the medication room, a glucometer (a portable device that measures blood glucose [sugar] levels using a test strip and a drop of blood) was observed stored on top of a paper cup inside a blue plastic carrier basket that stored glucometer test strips (a chemical strip inserted into a glucometer that is used to test blood sugar), syringes, and alcohol swabs. The blue plastic carrier basket was stored on the countertop. The glucometer was observed with two red drops of an unknown substance on the top left corner and a red smear on the bottom left side of the device. The DSD/IP stated, It [the glucometer device] is soiled, and described the substance as, It's red in color. The DSD/IP confirmed the observation of two drops on the top left and a smear on the left side of the device. The DSD/IP stated, It [the glucometer] should not be stored in that condition. It should be cleaned, and further stated the condition of the glucometer was an infection control concern. During an interview on 8/06/26 at 4:19 p.m., the Director of Nursing (DON) stated she expected the glucometer to be cleaned before and after each use for infection control purposes. The DON further stated that while the blood sugar was checked, blood from the strip could transfer onto the device. A review of the facility's policy & procedure (P & P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 2022, indicated, Resident-care equipment.will be cleaned and disinfected according to current CDC recommendations for disinfection.reusable items are cleaned and disinfected or sterilized between residents.Single resident-use items are cleaned/disinfected between uses by a single resident. A review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, revised 2019, indicated, Spills of blood or other potentially infections materials will promptly be cleaned and decontaminated. A review of a facility provided document titled, Position Description- Title: Infection Control/Licensed RN [Registered Nurse] or LVN [Licensed Vocational Nurse], dated 2020, indicated, The Infection Preventionist is responsible for the facility Infection Prevention and Control Program [IPCP], which is designed to provide a safe, sanitary.environment and to help prevent the development and transmission of communicable diseases and infections. Responsible for decreasing the incidence and transmission of infectious diseases between patients, staff, visitors and the community.Authority and responsibility for ensuring appropriate intervention and education occurs with staff.Understands and complies with infection control. A review of CDC guidelines on website www.cdc.gov, accessed on 8/13/26, indicated, Injection safety.Clean and disinfect blood glucose meters after every use. 3. A review of Resident 25's record of admission, indicated Resident 25 was admitted to the facility on [DATE]. A review of Resident 25's MDS, dated [DATE], indicated Resident 25 had the following active diagnoses: urinary tract infection (a bacterial infection in any part of the urinary system, including the bladder, urethra, or kidneys) within the last 30 days, chronic kidney disease stage 3 (moderate kidney damage; kidneys are working at half or less than normal capacity), and enterococcus infection (normal gut bacteria that can turn into urinary tract and bloodstream infections; resilient and often resistant to many standard antibiotics). A review of Resident 25's medication record, dated 7/01/26, indicated the following treatment order, 03/27/26-Changed foley catheter [a flexible plastic tube passed through the urethra into the bladder to drain urine continuously] . During an interview on 8/04/26 at 12:20 p.m., DSD/IP stated he was not aware EBP was required for routine Foley-catheter care. In addition, the IP stated it was not necessary to place precautionary signage or PPE [gear designed to create a physical barrier between healthcare workers and hazardous biological agents, infectious fluids, or contaminants] directly outside residents' room to remind staff and visitors to wear gowns, gloves, etc. A record review of facility P & P, titled, Enhanced Barrier Precautions, dated 8/2022, indicated (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents.employ target gown and glove use during high contact resident care activities.examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing b. bathing/showering c. transferring d. providing hygiene e. changing linens f. changing briefs or assisting with toileting g. device care or use (central line, urinary catheter, feeding tube.); and wound care.EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices.EBPs remain in place for the duration of the residents stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at risk.signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE.PPE is available outside of resident rooms.

Based on interview and record review, the facility failed to accurately document the controlled drug inventory count for a census of 16 residents when the inventory count was not signed off every ongoing and outgoing shift by nurse staff (Licensed Nurse [LN] or Registered Nurse [RN]).This failure increased the facility's potential for diversions (the unlawful removal or misuse of prescription or controlled substances from their intended path, from manufacturer to patient) and led to a lack of accountability for inaccurately documented controlled drugs. During a concurrent interview and record review on 8/06/26 at 1:18 p.m., Licensed Nurse 1 (LN 1) stated narcotic (a controlled drug used to treat pain) reconciliation was expected to be completed with the ongoing nurse every shift and was documented on the drug control release form by the off going nurse and ongoing nurse. LN 1 further stated the signature of the second nurse indicated that the counts were correct and completed by two nurses. LN 1 reviewed the drug control release form dated August 2026 and confirmed the ongoing nurse on the morning shift and the off going nurse on the evening shift on 8/03/26 were not signed. LN 1 further confirmed the ongoing nurse on the morning shift and the off going nurse on the evening shift on 8/04/26 were not signed. LN 1 stated it was important to correctly document and to sign off on the form to confirm the narcotic counts were reviewed and accounted for. LN 1 stated if the count were not correct it indicated that medications were missing; there were errors; or diversion. LN 1 further stated if the count were not signed, it could indicate that it was not completed.During a concurrent interview and record review on 8/06/26 at 4:19 p.m., the Director of Nursing (DON) stated she expected the off going and the ongoing shift to sign off on the drug control release form at the beginning and end of every shift. The DON confirmed narcotic counts were checked because they were controlled substances and it was the facility's responsibility that they were accounted for and not diverted. The DON reviewed the drug control release form dated August 2026 and confirmed the ongoing nurse on the morning shift and the off going nurse on the evening shift on 8/03/26 were not signed. The DON further confirmed the ongoing nurse on the morning shift and the off going nurse on the evening shift on 8/04/26 were not signed.A review of the facility's policy and procedure titled, Controlled Substances, revised 2022, indicated, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimized the time between loss/diversion and detention/follow up. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document.

Based on interview and record review, the facility failed to ensure residents' rights to provisions set forth in their Advanced Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions), when this document was not readily available in six (6) of 12 sampled residents' medical charts (Resident 4, Resident 5, Resident 6, Resident 19, Resident 28, and Resident 30) .This failure had the potential to result in residents' life-sustaining treatment wishes not being honored should they become unable to make end-of-life care decisions. A review of Resident 19's record of admission (facility demographic) indicated she was admitted to the facility in July 2026. A review of Resident 19's Minimum Data Set (MDS, a standardized, federally mandated clinical assessment tool used in nursing homes and skilled nursing facilities) dated 7/29/26, indicated that her cognition (the mental processes involved in acquiring knowledge and understanding through thought, experience, and the senses) was intact. A review of Resident 19's [Facility] Advance Directive Acknowledgement (a facility document that indicates whether a resident has, or does not have an AD), signed 7/23/26, indicated Resident 19 had an AD, however this document was not found in the medical chart. A review of Resident 30's record of admission indicated he was admitted to the facility in August 2026. A review of Resident 30's MDS, dated [DATE], indicated his cognition was intact. A review of Resident 30's Advance Directive Acknowledgement, signed 8/03/26, indicated Resident 30 had an AD, however this document was not found in the medical chart A review of Resident 4's record of admission indicated he was admitted to the facility on [DATE]. A review of Resident 4's MDS dated [DATE] indicated Resident 4's cognition was intact. A review of Resident 4's Advance Directive Acknowledgement, signed 5/06/25, indicated Resident 4 had an AD, however this document was not found in the medical chart. A review of Resident 5's record of admission indicated he was admitted to the facility on [DATE]. A review of Resident 5's MDS, dated [DATE], indicated Resident 5's cognition was moderately impaired. A review of Resident 5's Advance Directive Acknowledgement, signed 4/11/25, indicated Resident 5 had an AD, however this document was not found in the medical chart. A review of Resident 6's record of admission indicated she was admitted to the facility on [DATE]. A review of Resident 6's MDS indicated Resident 6 had severe cognitive impairment. A review of Resident 6's Advance Directive Acknowledgement, signed 7/09/26, indicated Resident 6 had an AD, however this document was not found in the medical chart. A review of Resident 28's record of admission indicated he was admitted to the facility on [DATE]. A review of Resident 28's MDS, dated [DATE], indicated Resident 28's cognition was intact. A review of Resident 28's Advance Directive Acknowledgement, signed 7/30/26, indicated Resident 28 had an AD, however this document was not found in the medical chart. During an interview on 8/04/26 at 2:04 p.m. with the Social Services Director (SSD), he indicated the facility did not have copies of AD's for Resident 4, Resident 5, Resident 6, or Resident 28. He further stated the facility neglected to follow-up on obtaining these documents so resident wishes might not be honored in case of incapacitation. The SSD acknowledged if the AD was not in the residents' chart, it might be hard or impossible to find it when needed later. A review of facility policy and procedure titled, Advance Directives, dated 9/2022, indicated if the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.the residents wishes are communicated to the residents direct care staff and physician by placing advance directive documents in a prominent, accessible location in the medical record and discussing the resident wishes in care planning meetings.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of five sampled residents, were free from significant medication errors when the following medications were not administered in accordance with the physician's order or medication label:1. Medications that managed the heart rate (the number of times the heart beats per minute) and blood pressure (the force of blood pushing against the walls of the arteries [muscular blood vessels]) were administered late, and;2. The Surveyor had to intervene to prevent Licensed Nurse 2 (LN 2) from making a medication error, when antibiotics (a medication used to treat and prevent bacterial infections) were going to be administered with iron.These failures decreased the facility's potential to safely administer medications and increased the potential for Resident 1 to experience an unmanaged heart rate and blood pressure, as well as ineffective antibiotic treatment. Cross reference F658 and F759.A review of Resident 1's record of admission indicated he was admitted to the facility in May 2026 with medical diagnosis which included chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and atrial fibrillation (A-fib- an irregular rapid heart rhythm that raises the risk of stroke [when blood flow to part of the brain stops]).A review of Resident 1's physician orders indicated the following active orders as of 8/05/26:doxycycline monohydrate (an antibiotic used to treat bacterial infections) 100 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount) by mouth twice daily. for peg tube (a medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids and medications) redness. Order clarified: doxycycline monohydrate 100 mg one tablet via peg tube.ok to crush medication;Lanoxin (digoxin- a medication to treat heart failure) 0.25 mg one tablet via peg tube daily.for A-fib;Lasix (furosemide- a water pill used to reduce extra fluid in the body) 20 mg 1 tablet via peg tube daily.for high blood pressure (HTN);Lopressor (metoprolol tartrate- a medication to treat HTN) 25 mg 1 tablet via peg tube twice daily.for HTN;Aldactone (spironolactone- a medication to treat HTN, heart failure and fluid swelling in the body) 25 mg 0.5 tablet via peg tube daily.for HTN, and;Ferrous Sulfate (iron) 325 mg 1 tablet via peg tube daily.for anemia (a condition where the body does not have enough healthy red blood cells).A review of Resident 1's paper medication record dated 8/01/26 - 8/31/26 indicated the medications were scheduled for administration at 9 a.m. on 8/05/26, with the exception that the iron was scheduled for 8 a.m.A review of the medication label adhered to Resident 1's doxycycline monohydrate blister pack (a medication dispensing package) indicated, Do not take antacids, calcium, iron or zinc within two (2) hours.During a concurrent medication pass observation and interview on 8/05/26 at 10:56 a.m. - 12:40 p.m., LN 2 administered to Resident 1 his doxycycline monohydrate, digoxin, furosemide, metoprolol tartrate, and spironolactone.During this medication pass observation, LN 2 prepared Resident 1's doxycycline monohydrate and iron for administration. Because Resident 1 was visiting with family and a private caregiver, LN 2 was asked to review the label on the doxycycline blister pack before entering the room. LN 2 unlocked the doxycycline from the medication cart and confirmed that the label read, Do not take antacids, calcium, iron or zinc within two (2) hours. Again, LN 2 stated that she intended to administer the tablets as prepared on the medication tray and confirmed that included the doxycycline and the iron. LN 2 confirmed that she did not read the label instructions for the doxycycline before preparing the medication for administration and she then excluded the iron from the medication pass. LN 2 acknowledged that giving doxycycline and iron within two hours of one another would interfere with the antibiotic's effectiveness. LN 2 confirmed all the medications on the medication tray were for Resident 1's 9 a.m. medication administration time.During an interview on 8/05/26 at 4:03 p.m., LN 2 confirmed that Resident 1's 9 a.m. medications were administered late on 8/05/26.During a concurrent interview and record review on 8/06/26 at 4:19 p.m., the Director of Nursing (DON) stated a medication could be given one hour before and one hour after the designated medication administration time. The DON verified that the facility's paper medication record did not accurately reflect the time a medication was administered. The DON was informed that LN 2's medication pass was observed on 8/05/26 from 7:53 a.m. - 10:15 a.m., and Resident 1's medication pass was observed from 10:56 a.m. - 12:40 p.m. The DON confirmed that medications scheduled for 9 a.m. but were administered after 10 a.m. were late. The DON further stated that timely administration was necessary to maintain therapeutic drug levels. The DON explained that doxycycline should not be administered with iron because iron binded to and reduced the effectiveness of the antibiotic. The DON stated she expected doxycycline and iron to be administered at least two hours apart. The DON confirmed that medications prescribed for heart conditions and blood pressure management should be administered consistently at the same time each day to ensure safe and effective regulation of heart rate and blood pressure. Concurrently, the DON reviewed Resident 1's paper medication record dated 8/01/26 - 8/31/26 and stated on 8/05/26 she expected LN 2 to circle her initials under the date and time the medications were administered late and document the reason the medications were late on the nurse's medication notes. The DON further stated this was a way of communicating between staff, especially the on-coming nurse, to ensure medications were given as ordered and safely. After a review of Resident 1's paper medication record, the DON confirmed LN 2's initials were not circled to account for the late administration of doxycycline, digoxin, furosemide, spironolactone, and metoprolol. The DON further confirmed that one medication was an antibiotic and the others were prescribed to control the heart rate and blood pressure. The DON stated these were important medications that required additional monitoring and a steady concentration in the body to maintain efficacy.A review of the facility's policy and procedure titled, Administering Medications, revised 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.Medication administration times are determined by resident need and benefit.Factors that are considered include: enhancing optimal therapeutic effect of the medication; preventing potential medication.interactions.Medications are administered within one [1] hour of their prescribed time.A review of a facility provided document titled, Job Description: Registered Nurse [RN], revised 2026, indicated, Administers prescribed medications and treatments in accordance with physician orders, facility policies, and pharmacy procedures.A review of a facility provided document titled, Position Title: Licensed Vocational Nurse [LVN].Position Summary, revised 2026, indicated, Administers medications according to physician orders and facility policies and procedures.

Based on observation, interview, and record review, the facility failed to provide medically necessary accommodations to one of nine sampled residents (Resident 19) when an accompanying staff member was not provided for transportation services when she was unable to independently attend the medical appointment.This failure had the potential to result in Resident 19 missing critical medical care or experiencing delays in treatment, which could have negatively impacted her health and well-being by preventing timely interventions or follow-up and possibly leading to further complications or deterioration of her medical condition.A review of Resident 19's admission record indicated she was admitted to the facility in July 2026 with medical diagnosis which included comminuted displaced fracture of the distal right ulnar (when the lower end of the right forearm bone is broken into multiple pieces), non-displaced medial right malleolus (a crack in the inner bone of the right ankle) and nondisplaced fracture of right distal fibula (a break in the lower outer calf bone near the ankle).A review of Resident 19's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 7/29/26, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 13 which indicated her cognition was intact (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact).A review of Resident 19's physician orders indicated the following active orders as of 8/07/26:Non-weight bearing [NWB- no body weight or pressure on the injured leg, foot or ankle] right lower extremity, and;PT (physical therapy) five times a week. NWB right upper and lower extremities.A review of Resident 19's physical therapy treatment encounter notes dated 8/04/26, indicated, Comments:.Pt [patient] agitated due to confusion re [regarding]: upcoming ortho [orthopedic] appointments, transportation and who will accompany her.During an observation on 8/04/26 at 9:45 a.m. in the unit hallway, Resident 19 was overheard discussing her appointment arrangements with the Minimum Data Set Coordinator (MDSC). Resident 19 asked what time her appointment was scheduled for so she could arrange to have a friend or family member accompany her. Resident 19 stated to the MDSC that she had exhausted her contacts and may require assistance with an escort to her appointment. The MDSC conveyed to Resident 19 that escort services were not covered by Medicare.During an interview on 8/04/26 at 9:47 a.m., the MDSC stated the social service director (SSD) could make arrangements for a certified nurse assistant (CNA) to accompany Resident 19 to the appointment, but it would cost Resident 19 out of pocket. The MDSC further stated the facility did not have enough staff to pull someone off the floor [to relieve them of their duties while physically at the facility] to accompany residents.During an observation and concurrent interview on 8/05/26 2:15 p.m. in the unit hallway, Resident 19 was observed maneuvering herself in a wheelchair with the use of her left hand and arm. Resident 19 was observed with a cast (a hard shell wrapped around a broken bone to aid in healing) on her right arm wrapped around her hand up to her elbow, and a cast on her right leg wrapped around her foot up her lower leg. Resident 19 stated she was informed that she had to provide an escort for her appointments because it was a service the facility did not provide. Resident 13 further stated she was quoted $30 - $40 an hour for the service because she would have to pay out of pocket. Resident 19 stated the facility told her, I need someone to be with me, during transportation to assist with wheeling her from the vehicle to the office, and back. Resident 19 stated she was NWB on the right foot and she could only wheel herself in the wheelchair with her left hand. Resident 19 stated she had been relying on friends to help her. Resident 19 further stated her friends list was getting low [meaning she is exhausting her resources]. Resident 19 stated it was a hassle [inconvenience] to make the arrangements for an escort to accompany her to her appointments.During an interview on 8/06/26 at 1:30 p.m., the Physical Therapist 1 (PT 1) stated physical therapy had been working with Resident 19 to improve her wheelchair use. PT 1 stated Resident 19 required assistance to leave the facility because she was NWB on her right foot and cannot put very much weight on her right wrist. PT 1 confirmed it was safe for Resident 19 to be unaccompanied because she required assistance to maneuver the wheelchair.During an interview on 8/06/26 at 2:57 p.m., the SSD stated the facility did not provide an escort to assist when a resident required assistance into another facility. The SSD stated the facility had never provided an escort and further stated, It's a capacity problem, which meant that the facility van service assisted with other residents of the facility. The SSD stated the facility could not take staff off the floor to accompany residents. The SSD stated when a resident could not secure someone to escort, he provided the resources to an agency that would provide a caregiver to escort the resident at an out of pocket cost of the resident. The SSD confirmed it was medically necessary to have someone accompany Resident 19. The SSD further stated, Considering she can't do it herself [propel herself in a wheelchair], for safety reasons she would need someone with her.A review of the undated facility policy and procedure titled, Transportation for Outside Medical Appointments, indicated, This facility will ensure that all residents are provided with safe, appropriate, and dignified transportation and accompaniment [escort] to all necessary outside medical appointments.When a resident is.physically vulnerable.and no family member or legal representative is available, the facility will assign a qualified staff member or authorized contracted escort to accompany the resident.Consolidated [NAME] Verification: The facility will be responsible for the cost of the escort if the appointment is determined by the physician to be clinically required as related to the admission diagnosis for Part A stay.Internal Assignment: If no family is available, notify the Director of Nursing [DON] or Director of Social Services to provide an agency caregiver, internal staff member or other staff member.

Based on observation, interview, and record review, the facility failed to provide services in accordance with professional standards of practice for one resident (Resident 1) of nine sampled residents when:1. The physician was not notified of significant medication errors, and;2. Resident 1's medications were not documented as administered late.These failures increased the potential for Resident 1 to experience delayed medical monitoring and intervention, inconsistent medication management, and adverse health concerns. Cross reference F759 and F760.A review of Resident 1's record of admission (facility demographic) indicated he was admitted to the facility in May 2026 with medical diagnosis which included chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and atrial fibrillation (A-fib- an irregular rapid heart rhythm that raises the risk of stroke [when blood flow to part of the brain stops]).A review of Resident 1's physician orders indicated the following active orders as of 8/05/26:doxycycline monohydrate (an antibiotic used to treat bacterial infections) 100 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount) by mouth twice daily. for peg tube (a medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids and medications) redness. Order clarified: doxycycline monohydrate 100 mg one tablet via peg tube.ok to crush medication;Lanoxin (digoxin- a medication to treat heart failure) 0.25 mg one tablet via peg tube daily.for A-fib;Lasix (furosemide- a water pill used to reduce extra fluid in the body) 20 mg 1 tablet via peg tube daily.for high blood pressure (HTN);Lopressor (metoprolol tartrate- a medication to treat HTN) 25 mg 1 tablet via peg tube twice daily.for HTN, and;Aldactone (spironolactone- a medication to treat HTN, heart failure and fluid swelling in the body) 25 mg 0.5 tablet via peg tube daily.for HTN.A review of Resident 1's paper medication record dated 8/01/26 - 8/31/26 indicated the medications were scheduled for administration at 9 a.m. on 8/05/26.During a concurrent medication pass observation and interview on 8/05/26 at 10:56 a.m. - 12:40 p.m., Licensed Nurse 2 (LN 2) administered to Resident 1 his doxycycline monohydrate, digoxin, furosemide, metoprolol tartrate, and spironolactone.During an interview on 8/05/26 at 4:03 p.m., LN 2 confirmed Resident 1's 9 a.m. medications were administered late on 8/05/26. LN 2 stated that she did not notify Resident 1's physician in regard to the late medication administration. LN 2 further stated Resident 1's physician should have been notified in case an emergency related to the late medication administration occurred. LN 2 stated Resident 1's blood pressure could have been affected by the delayed medication administration, and that his antibiotic should be administered 12 hours apart which required following doses to be rescheduled. LN 2 further stated the physician should have been notified so they were aware and if Resident 1 required further monitoring for issues.During a concurrent interview and record review on 8/06/26 at 4:19 p.m., the Director of Nursing (DON) stated a medication could be given one hour before and one hour after the designated medication administration time. The DON verified that the facility's paper medication record did not accurately reflect the time a medication was administered. The DON was informed that Resident 1's medication pass was observed on 8/05/26 from 10:56 a.m. - 12:40 p.m. on 8/5/26. The DON confirmed that medications scheduled for 9 a.m. that were administered after 10 a.m. were late. The DON further stated that timely administration was necessary to maintain therapeutic drug levels. The DON confirmed that medications prescribed for heart conditions and blood pressure management should be administered consistently at the same time each day to ensure safe and effective regulation of heart rate and blood pressure. The DON confirmed she expected the physician to be notified of Resident 1's late medication administration. Concurrently, the DON reviewed Resident 1's paper medication record dated 8/01/26 - 8/31/26 and stated she expected LN 2 to circle her initials under the date and time the medications were administered late and document the reason the medications were late on the nursing medication notes. The DON further stated this was a way of communicating between staff, especially the on-coming nurse, to ensure medications were given as ordered and safely. After a review of Resident 1's paper medication record, the DON confirmed LN 2's initials were not circled to account for the late administration of doxycycline, digoxin, furosemide, spironolactone, and metoprolol. The DON further confirmed that one medication was an antibiotic and the others were prescribed to control the heart rate and blood pressure. The DON stated these were important medications that required additional monitoring and a steady concentration in the body to maintain efficacy.A review of the facility's policy and procedure titled, Administering Medications, revised 2019, indicated, Medication errors are documented, reported.If a dosage.or a medication has been identified as having potential adverse consequences for the resident.the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.If a drug is. given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR [medication administration record] space provided for that drug and dose.A review of a facility provided document titled, Job Description: Registered Nurse [RN], revised 2026, indicated, Reviews and maintains accurate nursing documentation to ensure resident records reflect the care provided.A review of a facility provided document titled, Position Title: Licensed Vocational Nurse [LVN].Position Summary, revised 2026, indicated, Maintains accurate nursing documentation, including nurses' notes, summaries, records, charts, and other required documentation.

Based on interview, and record review, the facility failed to accurately assess one (1) of 16 sampled residents (Resident 25), when five (5) past Minimum Data Set (MDS, an assessment tool) submissions indicated an incorrect clinical condition.This failure resulted in reported inaccuracies of Resident 25's clinical condition and placed him at risk for non-receipt of care appropriate to his needs.A review of Resident 25's record of admission (facility demographic) indicated Resident 25 was admitted to the facility on [DATE].A review of Resident 25's MDS, dated [DATE], indicated Resident 25 had moderate difficulty in daily decision making. The MDS also indicated Resident 25 had the following active diagnoses: urinary tract infection (a bacterial infection in any part of your urinary system, including the bladder, urethra, or kidneys) within the last 30 days, chronic kidney disease stage 3 (moderate kidney damage; kidneys are working at half or less than normal capacity), and enterococcus infection (normal gut bacteria that can turn into urinary tract and bloodstream infections; resilient and often resistant to many standard antibiotics).A review of Resident 25's Medication Record, dated 7/01/26, indicated the following treatment order, 03/27/26-foley catheter [a flexible plastic tube passed through the urethra into the bladder to drain urine continuously] . Resident 25's Medical Record did not indicate he had an external urinary catheter (a non-invasive device worn over the penis like a condom to collect urine). During a concurrent interview and record review on 8/06/26 at 2:47 p.m., the most recent MDS assessment (dated 7/28/26) was reviewed. Section I of the MDS, which pertains to bladder and bowel evaluation, indicated Resident 25 had an external urinary catheter rather than a Foley catheter (which was documented in his physician orders above). The MDSC acknowledged that the assessment was inaccurate, as it documented an external urinary catheter instead of a Foley catheter for Resident 25. The MDSC added, but there is still time to change it.A record review of the last five (5) MDS reports was conducted. These included the reports for 7/28/26 (nursing home discharge), 7/28/26 (comprehensive), 5/28/26 (quarterly), 2/13/26 (quarterly), and 11/07/25 (quarterly). These assessments indicated Resident 25 had an external urinary catheter and not a Foley catheter.During an interview on 8/06/26 at 4:47 p.m., the MDSC stated she physically assessed residents prior to completing each MDS but could not explain why Resident 25's bowel and bladder assessments had been repeatedly incorrect over the past eight (8) months.A review of the facility policy and procedure titled, Resident Assessments, dated 3/2022, indicated, all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.the results of the assessments are used to develop, review and revise the resident's comprehensive care plan.

Based on observation, interview, and record review, the facility failed to ensure that a licensed nurse maintained a medication error rate below the five-percent threshold when eight errors were identified during 33 medication administration opportunities, which resulted in a 24.24% medication error rate, for a census of 16 residents.This failure limited the facility's ability to ensure medications were administered as prescribed, reduced the expected therapeutic effectiveness of ordered medications, and placed Resident 1 at risk for compromised clinical outcomes. Cross reference F658 and F760.A review of Resident 1's record of admission (facility demographic) indicated he was admitted to the facility in May 2026 with medical diagnosis which included chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and atrial fibrillation (A-fib- an irregular rapid heart rhythm that raises the risk of stroke [when blood flow to part of the brain stops]).During a concurrent medication pass observation and interview on 8/05/26 at 10:56 a.m. - 12:40 p.m., Licensed Nurse 2 (LN 2) prepared and administered the following medications for Resident 1:doxycycline monohydrate (an antibiotic used to treat bacterial infections) 100 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount) tablet- Give one tablet by mouth twice daily for seven (7) days. The label read, Do not take antacids, calcium, iron or zinc within two (2) hours. LN 2 confirmed one tablet for administration;vitamin C (a nutrient used in the body to protect cells from damage, aids in iron absorption and supports immune function) 500 mg- LN 2 confirmed one tablet for administration;digoxin (a medication to treat heart failure) 250 mcg (microgram- a metric unit of mass or weight)- Give one tablet via g-tube (gastrostomy tube- a medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids and medications) daily.for A-fib. LN 2 confirmed one tablet for administration;furosemide (a water pill used to reduce extra fluid in the body) 20 mg- Give one tablet via peg tube (g-tube) daily for hypertension (high blood pressure [HTN]- the force of blood pushing against the walls of the arteries [muscular blood vessels]). LN 2 confirmed one tablet for administration;vitamin E (a nutrient used in the body to protect cells from damage and supports immune function) 1000 Units (one individual, ready to administer portion)- LN 2 stated Resident 1's vitamin E was not available and needed to be ordered. LN 2 confirmed Resident 1's vitamin E is omitted from administration because it is not available;metoprolol tartrate (a medication to treat HTN) 25 mg tablet- LN 2 confirmed one tablet for administration;spironolactone (a medication to treat HTN, heart failure and fluid swelling in the body) 25 mg tablet- Give a half tablet via peg tube daily for HTN. LN 2 confirmed a half tablet for administration, and;iron 325 mg tablet- LN 2 confirmed one tablet for administration.During this medication pass observation, LN 2 verified the number of tablets prepared prior to entering Resident 1's room. LN 2 placed each medication tablet into individual cups on a medication tray and explained that she would educate Resident 1 about the medications before they were crushed for administration through his g tube. LN 2 further stated that all medications prepared on the tray, including doxycycline and iron, would be crushed and administered via the g tube during this medication pass. Because Resident 1 was visiting with family and a private caregiver, LN 2 was asked to review the label on the doxycycline blister pack before entering the room. LN 2 unlocked the doxycycline from the medication cart and confirmed that the label read, Do not take antacids, calcium, iron or zinc within two (2) hours. Again, LN 2 stated that she intended to administer the tablets as prepared on the medication tray and confirmed that included the doxycycline and the iron. LN 2 confirmed that she did not read the label instructions for the doxycycline before preparing the medication for administration and she then excluded the iron from the medication pass. LN 2 acknowledged that giving doxycycline and iron within two hours of one another would interfere with the antibiotic's effectiveness. LN 2 confirmed all the medications on the medication tray were for the 9 a.m. medication administration time.A review of Resident 1's physician orders indicated the following active orders as of 8/5/26:doxycycline monohydrate 100 mg by mouth twice daily. Order clarified: doxycycline monohydrate 100 mg one tablet via peg tube.ok to crush med medication;Ascorbic Acid (vitamin C) 1,000 mg one tablet via peg tube every morning;Lanoxin (digoxin) 0.25 mg [converts to 250 mcg] one tablet via peg tube daily;Lasix (furosemide) 20 mg 1 tablet via peg tube daily;D-alpha Topopherol (vitamin E) 1,000 Units 1 capsule via peg tube;Lopressor (metoprolol tartrate) 25 mg 1 tablet via peg tube twice daily;Aldactone (spironolactone) 25 mg 0.5 [12.5 mg] tablet via peg tube daily, and;Ferrous Sulfate (iron) 325 mg 1 tablet via peg tube daily.A review of Resident 1's paper medication record dated 8/01/26 - 8/31/26 indicated on 8/05/26, within the 9 a.m. [indicated the hour the medication was scheduled for administration] row, doxycycline monohydrate, vitamin C 1,000 mg, digoxin, furosemide, metoprolol tartrate, and spironolactone were documented as administered by LN 2. This same record indicated that vitamin E was initialed in the 9 a.m. row with LN 2's initials circled, and iron was initialed in the 8 a.m. row with LN 2's initials circled, which indicated the following on Resident 1's paper nurse's medication notes: Date: 8/5/26.Hour: 1130 [11:30 a.m.]. Initials: LN 2's.Describe: vitamin E.Reason: order in progress.; and; Date: 8/5/26.Hour: 1300 [1 p.m.].Initials: LN 2's.Describe: iron held.Reason: too close to time of doxycycline.During an interview on 8/05/26 at 4:03 p.m., LN 2 confirmed that Resident 1's 9 a.m. medications were administered late on 8/05/26.During an interview on 8/05/26 at 5:11 p.m., the Director of Staff Development and Infection Preventionist (DSD/IP) stated medications could be given one hour before and one hour after the schedule administration time. The DSD/IP stated a medication that was intended to be administered at 9 a.m. but was not administered until 12 p.m. was considered late.During an interview on 8/06/26 at 4:19 p.m., the Director of Nursing (DON) stated a medication could be given one hour before and one hour after the designated medication administration time. The DON verified that the facility's paper medication record did not accurately reflect the time a medication was administered. The DON was informed that LN 2's medication pass was observed on 8/05/26 from 7:53 a.m. - 10:15 a.m., and Resident 1's medication pass was observed from 10:56 a.m. - 12:40 p.m. The DON confirmed that medications scheduled for 9 a.m. but were administered after 10 a.m. were late. The DON further stated late medication administration constituted a medication error and emphasized that timely administration was necessary to maintain therapeutic drug levels. The DON explained that doxycycline should not be administered with iron because iron binded to and reduced the effectiveness of the antibiotic. The DON stated she expected doxycycline and iron to be administered at least two hours apart. The DON confirmed that medications prescribed for heart conditions and blood pressure management should be administered consistently at the same time each day to ensure safe and effective regulation of heart rate and blood pressure.A review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.Medications are administered within one [1] hour of their prescribed time.A review of the facility's P&P titled, Medication and Treatment Orders, revised 2016, indicated, Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three [3] days prior to the last dosage being administered to ensure that refills are readily available.A review of a facility provided document titled, Job Description: Registered Nurse [RN], revised 2026, indicated, Administers prescribed medications and treatments in accordance with physician orders, facility policies, and pharmacy procedures.A review of a facility provided document titled, Position Title: Licensed Vocational Nurse [LVN].Position Summary, revised 2026, indicated, Administers medications according to physician orders and facility policies and procedures.

Based on interviews and record review, the facility failed to ensure sufficient staff to fulfill the responsibilities of a full-time supervisor of the Skilled Nursing Facility food and nutrition service.This failure had the potential to place residents at risk for impaired nutritional status.Findings:During an interview on 9/24/25 at 2:42 p.m. with Registered Dietician (RD), RD stated she worked at the facility a minimum of eight hours a week, and that the dietary lead (DL) oversaw tray line, menus, snacks, supplements, and meal preferences for skilled nursing residents. RD stated that the DL reported to the General Kitchen Manager (GKM).During an interview on 9/24/25 at 3:28 p.m. with GKM, GKM stated he oversaw assisted living and skilled nursing units. GKM stated that the DL was responsible for skilled nursing and assisted living units and that the DL did work full-time but that time is split between the two different units. GKM stated they do not have a designated full-time staff for just the skilled nursing unit. During an interview on 9/25/25 at 8:31 a.m. with Health Services Administrator (HSA), HSA stated no dietary staff are designated as full-time for skilled nursing. Confirmed the DL oversaw skilled nursing and assisted living and that the GKM oversaw the entire facility. HSA also confirmed that the RD was only part-time. During a review of the facility's Position Description for Dietary Lead [DL], dated with a last revised date of October 1999, the record indicated, . Responsible for monitoring regulatory compliance related to dietary needs for SNF residents.During a review of California Code of Regulations, Title 22, Chapter 3. The regulation 72351(b) stated If a dietician is not employed full-time, a full-time dietetic services supervisor shall be employed to be responsible for the operations of the food service.

Based on observation, interview, and record review, the facility failed to store food in a safe and sanitary manner when:1. Multiple food items were not discarded after their use-by-date.2. Opened food items were not properly labeled with open and use-by-date.These failures had the potential to cause food-borne illnesses in an already medically fragile population.Findings:1. During a concurrent observation and interview on 9/22/25 at 3:25 p.m. in the main kitchen with the General Kitchen Manager (GKM), kitchen refrigerator 5 was observed with the following items past their use by date: Tuna Salad - use by 9/12/25Pepper Dressing - use by 9/12/25Bag of Turkey - use by 9/14/25Bag of Ham - use by 9/22/25 at 11:53 a.m.The GKM confirmed the items were past their use by date and stated they should have been discarded. During a concurrent observation and interview on 9/22/25 at 3:41p.m. in the main kitchen with the GKM, walk-in freezer 2 was observed with the following items past their use by date:3 bags of vegetable dumplings - use by 9/20/251 bag of bagels - use by 8/31/25The GKM confirmed that the items were past their use by date and stated staff should have disposed of them.During a concurrent observation and interview on 9/22/25 at 3:46 p.m. in the main kitchen with the GKM, walk in fridge 3 was observed with the following item past its use by date: 1 lb. (pound - unit of measurement) container of [NAME] Hummus - use by 8/15/25 GKM stated that expiration dates are supposed to be monitored daily and expired products should have been disposed of. During a concurrent observation and interview on 9/22/25 at 4:42 p.m. in the resident snack room with Certified Nursing Assistant (CNA) 1, resident snack refrigerator was observed with the following item past its expiration date: 1 carton of fat free milk - exp 9/21/25. CNA 1confirmed the date on the carton of milk and stated, it should have been thrown out. During a review of the facility's policy and procedure (P&P) titled, Labeling & Dating, dated 5/2023, the P&P indicated, Policy: All foods will be appropriately . labeled, and dated. Procedure: All foods are labeled, dated, . and use-by dates are monitored and followed.2. During a concurrent observation and interview on 9/22/25 at 3:25 p.m. in the main kitchen with the General Kitchen Manager (GKM), kitchen refrigerator 5 was observed with the following undated items: Container of bushberries - undated The GKM stated they should have had a best by date label on them. During a concurrent observation and interview on 9/22/25 at 3:41p.m. in the main kitchen with the GKM, walk-in freezer 2 was observed with the following undated items: 3 bags of hamburger buns - undated The GKM stated that the hamburger buns should have been labeled with a best by date. During a review of the facility's policy and procedure (P&P) titled, Labeling & Dating, dated 5/2023, the P&P indicated, Policy: All foods will be appropriately . labeled, and dated. Procedure: All foods are labeled, dated,. and use-by dates are monitored and followed.

Based on interview and record review, the facility failed to ensure housekeeping staff donned personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when handling 14 out of 15 resident's soiled laundry. This failure had the potential to negatively impact the residents.Findings:During an interview on 9/24/25 at 8:03 a.m. with the Housekeeper, the Housekeeper stated the resident's soiled laundry was transported in a clear plastic bag to the laundry room and was removed from the clear plastic bag and placed in the washer machine. The Housekeeper stated she does not don a gown during handling of the resident's soiled laundry. During an interview on 9/24/25 at 3:06 p.m. with the Infection Preventionist (IP), the IP stated housekeeping staff should don proper PPE which includes a mask, gloves and a gown during the handling of resident soiled laundry for infection prevention and control practices. During an interview on 09/25/2025 at 8:21 a.m. with the Housekeeper Director (HSD), the HSD stated the housekeeping staff should don proper PPE when handling the resident's soiled laundry to prevent cross contamination. During a review of the facility's policy and procedure titled, Laundry and Bedding, Soiled, dated September 2022, indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control . Handling 1. All used laundry is handled as potentially contaminated using standard precautions .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than five percent when six identified medication errors out of 27 opportunities were observed for three of five sampled residents (Resident 2, Resident 16 and Resident 21).These failures resulted in an overall facility medication error rate of 22.22% and had the potential to result in negative health outcomes for Resident 2, Resident 16 and Resident 27. Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than five percent when six identified medication errors out of 27 opportunities were observed for three of five sampled residents (Resident 2, Resident 16 and Resident 21).These failures resulted in an overall facility medication error rate of 22.22% and had the potential to result in negative health outcomes for Resident 2, Resident 16 and Resident 27.Findings:1. During a review of the Record of Admission, the Record of Admission indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (nerve disorder of the brain which causes tremors, abnormal movement, and loss of balance).During an observation on 9/24/25 at 8:13 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed preparing and administering Resident 21's morning medications. LVN 4 administered one tablet of Losartan (medication to treat high blood pressure) 25 mg (milligrams- unit of measurement) which Resident 21swallowed with sips of water.During a record review on 9/24/25 at 12:06 p.m. the physician's order dated 9/17/25 indicated Losartan 50 mg with Hydrochlorothiazide 12.5 mg (combination high blood pressure medication with a diuretic medication to increase urine output) every morning.During an interview and review of Resident 21's medications on 9/24/25 at 12:21 p.m. with LVN 4, LVN 4 confirmed she did not administer Losartan 50 mg with Hydrochlorothiazide and instead administered the wrong medication.During an interview on 9/25/25 at10:28 a.m. with the pharmacist, (Pharm) 1 stated it was important for Resident 21 to receive the diuretic portion of the mediation in the morning so that Resident 21's blood pressure was managed, and his urine output was increased during the daytime. Pharm 1 confirmed, LVN 4 administered the wrong medication during the morning medication pass.During a review of the facility's Policy and Procedure titled, Administering Medications (P&P) dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed.the individual administering the medication checks the label to verify the right. medication, right dosage. prior to giving the medication.2. During a review of the Record of Admission, the Record of Admission indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (nerve disorder of the brain which causes tremors, abnormal movement, and loss of balance).During an observation on 9/24/25 at 8:13 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed preparing and administering Resident 21's morning medications. LVN did not administer Aspirin (medication to prevent blood clotting) to Resident 21 during the observation.During a record review on 9/24/25 at 12:06 p.m., the physician's order dated 9/13/25 indicated, Aspirin 81 mg chewable tablet every morning for blood clot prevention.During an interview with LVN 4 on 9/24/25 at 12:21 p.m., LVN 4 confirmed she did not administer Aspirin to Resident 21.During an interview with the Director of Staff Development (DSD) on 9/24/25 at 4:12 p.m., DSD stated, LVN 4 did not follow physician's orders and should have administered Resident 21's Aspirin to prevent blood clotting.During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. medications are administered in accordance with prescriber's orders 3. During a review of the Record of Admission, the Record of Admission indicated, Resident 16 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and fracture of the humerus (arm).During an observation on 9/24/25 at 8:35 a.m. with Licensed Vocational Nurse (LVN) 4 was observed preparing and administering Resident 16's morning medications. LVN 4 administered one tablet of Lisinopril (medication to reduce blood pressure) which Resident 16 swallowed with sips of water.During a record review on 9/24/25 at 12:46 p.m., the physician's order dated 9/17/25 indicated, Hold Lisinopril . if SBP (systolic blood pressure- the top number in a blood pressure reading which measures the pressure the blood is pumping in the blood vessels) is less than 110.During a record review on 9/24/25 at 12:52 p.m., Resident 16's Medication Administration Record indicated Resident 16's SBP was 107 prior to the resident receiving Lisinopril during the morning medication administration observation on 9/24/25.During an interview on 9/24/25 at 4:12 p.m. with the Director of Staff Development (DSD), the DSD stated LVN 4 should have checked Resident 16's blood pressure to ensure it was within parameters prior to administering the resident's blood pressure medications. DSD stated he would expect LVN 4 to hold Resident 16's blood pressure medications when her SBP was 107 as the physician instructed.During an interview on 9/25/25 at 10:28 a.m. with the pharmacist (Pharm) 1, Pharm 1 stated LVN 4 should have followed the physician's order and held Lisinopril when Resident 16's SBP was 107. Pharm 1 stated, Resident 16 was at risk for symptoms of low blood pressure from receiving blood pressure medications which were not indicated.During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. the following information is checked/verified for each resident prior to administering medications: vital signs if necessary. 4. During a review of the Record of Admission, the Record of admission indicated, Resident 16 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and fracture of the humerus (arm).During an observation on 9/24/25 at 8:35 a.m. with Licensed Vocational Nurse (LVN) 4 was observed preparing and administering Resident 16's morning medications. LVN 4 administered one tablet of Norvasc (medication to reduce blood pressure) which Resident 16 swallowed with sips of water.During a record review on 9/24/25 at 12:46 p.m., the physician's order dated 9/17/25 indicated, Hold . Norvasc if SBP (systolic blood pressure- the top number in a blood pressure reading which measures the pressure the blood is pumping in the blood vessels) is less than 110.During a record review on 9/24/25 at 12:52 p.m., Resident 16's Medication Administration Record indicated Resident 16's SBP was 107 prior to the resident receiving Norvasc during the morning medication administration observation on 9/24/25.During an interview on 9/24/25 at 4:12 p.m. with the Director of Staff Development (DSD), the DSD stated LVN 4 should have checked Resident 16's blood pressure to ensure it was within parameters prior to administering the resident's blood pressure medications. DSD stated he would expect LVN 4 to hold Resident 16's blood pressure medications when her SBP was 107.During an interview on 9/25/25 at 10:28 a.m. with the pharmacist (Pharm) 1, Pharm 1 stated LVN 4 should have followed the physician's order and held Norvasc when Resident 16's SBP was 107. Pharm 1 stated, Resident 16 was at risk for symptoms of low blood pressure from receiving blood pressure medications which were not indicated.During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. the following information is checked/verified for each resident prior to administering medications: vital signs if necessary. 5. During a review of the Record of Admission, the Record of Admission indicated, Resident 16 was admitted was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and fracture of the humerus (arm).During an observation on 9/24/25 at 8:35 a.m. with Licensed Vocational Nurse (LVN) 4 was observed preparing and administering Resident 16's morning medications. LVN 4 did not administer Duloxetine (medication used to reduce pain) during the observation.During a record review on 9/24/25 at 12:46 p.m., the physician's order dated 9/11/25 indicated, Duloxetine 60 mg 1 capsule daily for neuropathic pain (nerve pain associated with abnormal sensations).During an interview on 9/24/25 at 4:12 p.m. with the Director of Staff Development (DSD), the DSD stated LVN 4 should have administered Resident 16's Duloxetine with the morning medications as ordered by the physician.During an interview on 9/25/25 at 10:28 a.m. with the pharmacist (Pharm) 1, Pharm 1 stated Resident 16 was at risk for unrelieved pain as a result of not receiving Duloxetine with her morning medications on 9/24/25.During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. medications are administered in accordance with prescriber's orders 6. During a review of the Record of Admission, the Record of Admission indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and osteoporosis (decrease in bone mass with age).During an observation on 9/24/25 at 8:23 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed preparing and administering Resident 2's morning medications. LVN 4 prepared Vitamin B 12 (medication to treat vitamin B12 deficiency) in a pill cup with eight other medications. The instructions on the Vitamin B 12 bottle indicated, Place one tablet under the tongue for 30 seconds before swallowing. LVN 4 did not instruct Resident 2 to allow the tablet to dissolve under her tongue. LVN 4 handed Resident 2 the pill cup and the resident swallowed the Vitamin B 12 tablet whole with a sip of water.During a record review on 9/24/25 at 12:27 p.m., the physician's order dated 9/19/25 indicated, Vitamin B 12 dissolve 1 tablet under tongue every day for B 12 deficiency.During an interview with LVN 4 on 9/24/25 at 12:36 p.m., the instructions on the bottle of Vitamin B were reviewed. LVN 4 confirmed she did not instruct Resident 2 to dissolve the Vitamin B tablet under her tongue as the instructions indicated.During an interview on 9/25/25 at 10:28 a.m. with the pharmacist (Pharm) 1, Pharm 1 stated LVN 4 should have instructed the resident to dissolve Vitamin B 12 under her tongue for better absorption of the medication.During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. The individual administering the medication checks the label to [NAME] the. right method (route) of administration before giving the medication.

Based on interview and record reviews, the facility failed to transmit the Minimum Data Set (MDS - an assessment care - planning tool) to the Centers for Medicare and Medicaid Services (CMS) within 14 days after the completion for two of 15 sampled residents (Resident 1 and Resident 6).This failure resulted in the delay of information to CMS for payment and quality measure purposes and for potential changes in Resident 1 and Resident 6's condition to be missed or go unaddressed.1 Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included pneumonia. During a record review on 9/24/25 at 3:47p.m. Resident 1's quarterly MDS assessment was reviewed. The quarterly MDS was initiated on 8/6/25 and completed (signed by the Director of Nurses (DON) ) on 8/24/25. The MDS was not transmitted to CMS until 9/23/25 (29 days after it was completed). During a concurrent interview and record review of Resident 1's quarterly MDS with the Director of Staff Development (DSD) on 9/24/25 at 4:41p.m., the DSD confirmed Resident 1's MDS was not transmitted until 9/23/25 and should have been transmitted within 14 days. During a review of the facility's policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, dated July 2017, the P&P indicated, .2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. During a review of the MDS Manual, Centers of Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual - Chapter 5, dated October 2024, indicated, .Transmitting Data. Assessment Transmission. MDS Assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). 2. During a review of Resident 6's Record Of Admission, the record indicated that Resident 6 was admitted to the facility on [DATE] with a history of diagnoses that included: essential (primary) hypertension (a chronic condition of persistently high blood pressure), Hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone), and a need for assistance. During a concurrent interview and record review on 9/23/25 at 1:32 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 6's MDS 3.0 Nursing Home Quarterly, dated 8/20/25 was reviewed. The record indicated that Resident 6's Quarterly MDS was completed on 8/12/25 and section Z0500B was signed off by the Director of Nursing (DON) on 8/20/25. LVN1 stated that they had 30 days to submit the completed MDS to CMS after the DON signed it off. During a concurrent interview and record review on 9/24/25 at 8:16 a.m. with Director of Staff Development (DSD), Resident 6's MDS 3.0 NH [Nursing Home] Final Validation Report, dated 9/19/25 was reviewed. The record indicated that Resident 6's MDS was submitted on 9/19/25 at 7:10 p.m. DSD confirmed the MDS section Z0500B was signed off on 8/20/25 and stated that the MDS should have been submitted before 9/19/25. DSD stated it should have been submitted within 14 days. During a review of the facility's policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, dated July 2017, the P&P indicated, .2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. During a review of the MDS Manual, Centers of Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual - Chapter 5, dated October 2024, indicated, .Transmitting Data. Assessment Transmission. MDS Assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

Based on interviews and records review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) in accordance with Federal requirements for one of two sampled residents (Resident 1). This failure resulted in a delayed investigation of the alleged abuse by CDPH and had the potential for other residents to be at risk of abuse. Findings: On 4/02/24 at 1:42 p.m., CDPH received a Facility Reported Incident regarding a facility staff member being physically aggressive to Resident 1. A review of the Minimum Data Set (MDS - health status screening and assessment tool used for all residents) dated 1/16/24 indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including but not limited to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Left eye blindness and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). The MDS indicated Resident 1 had a BIMS score of 3 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive (relating to the mental process involved in knowing, learning, and understanding things) screening measure that evaluates memory and orientation. A score of 00 to 07 is severe cognitive impairment). A review of the facility document titled Nurse's Notes dated 3/30/24 at 11:00 p.m., indicated Unlicensed Staff A reported to Licensed Nurse B that she witnessed Unlicensed Staff C slapping Resident 1's left hand and pushed Resident 1 to bed. The Nurse's Notes indicated the Director of Nursing (DON), Social Service, and Administrator were notified of the incident. The Nurse's Notes indicated the facility had twenty four (24) hours from 11:00 p.m. to call and fax the incident to the ombudsman (an official who investigates complaints against businesses, public entities, or officials) and authorities. During a telephone interview with Unlicensed Staff A on 4/11/24 at 8:52 a.m., when Unlicensed Staff A was asked about the incident with Resident 1 on 3/30/24, Unlicensed Staff A stated she saw Unlicensed Staff C slapped Resident 1's hands twice during transfer when Unlicensed Staff C had Resident 1 hold on to the transfer lift (used for a patient who is unable to assist with transferring in and out of a bed or wheelchair). Unlicensed Staff A stated she reported the incident to Licensed Nurse B. During an interview with Licensed Nurse D on 4/10/24 at 3:05 p.m., when Licensed Nurse D was asked what she would do if she received a report of an abuse allegation, Licensed Nurse D stated she would report to the supervisor and ombudsman. She stated she would call the police immediately if the abuse resulted in an injury. When Licensed Nurse D was asked who was responsible for reporting when incident happened after hours, she stated the charge nurse could report to CDPH by leaving a message. When Licensed Nurse D was asked about the time frame of reporting an allegation of abuse, she stated immediately within 24 hours. During an interview with Licensed Nurse E on 4/10/24 at 3:10 p.m., when Licensed Nurse E was asked what she would do when she received a report of staff being rude or rough to residents, she stated she would step in, she would ask what happened and make sure to separate the staff from the resident. Licensed Nurse E stated she would report the incident to the police and ombudsman immediately. When Licensed Nurse E was asked if she would report the incident to CDPH, she stated yes. She stated the nurse was responsible for reporting to CDPH, the ombudsman, and police when an allegation or incident of abuse happened after hours or on the weekend. Licensed Nurse E stated they have a book at the nurses' station with a step by step instructions on who, and how to report abuse. When Licensed Nurse E was asked about the time frame for reporting an allegation of abuse, she stated immediately, within 24 hours. After review of the policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised on September 2022 with Licensed Nurse E, Licensed Nurse E verified the policy indicated to report an allegation involving abuse within two hours. During an interview with the DON on 4/10/24 at 3:29 p.m., when the DON was asked about her expectations from the nurses for reports of abuse. The DON stated the nurses were expected to report the incident to CDPH immediately. She stated they have a binder at the nurses' station with an algorithm (a process or set of rules to be followed in calculations or other problem-solving operations) for the nurses to follow. The DON stated the incident with Resident 1 happened on p.m. shift on 3/30/24. She stated Licensed Nurse B started the report and was completed on 3/31/24 with the help of the Director of Staff Development (DSD). The DON concurred the facility's policy for reporting an allegation of abuse was not followed. A review of the Facility policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised on September 2022 indicated, all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management.

Based on interview and record review, the facility failed to provide adequate supervision to one of two residents at risk for falls (Resident 117) when Resident 117 was left unsupervised on her wheelchair after lunch. This failure resulted in Resident 117 getting up from the wheelchair unassisted, falling, injuring her head, right knee, elbow, and being sent to the hospital for evaluation and treatment of her injuries. Findings: A review of Resident 117's Admission Record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness or inability to move) following cerebral infarction (stroke ) affecting the left side of the body. A review of Resident 117's Fall Risk Evaluation (a standardized tool that assesses the resident's risk for falls based on different parameters), dated 7/10/23, indicated Resident 117 was at HIGH RISK for falls. The Fall Risk Evaluation indicated Resident 117 had the following fall risk factors: a history of falls, was confused, had gait and balance problems, and had predisposing diseases and took medications that increased the risk for falls. A review of Resident 117's Fall Risk Care Plan (a document indicating the care and services to be provided to the resident), dated 7/10/23, indicated Resident 117 was at risk for fall/injury due to: impaired/limited mobility, poor balance, limited ROM [range of motion - the ability to extend and flex limbs], deconditioning [weakness], and aging process [old age]. The Fall Risk Care Plan indicated fall prevention interventions including, anticipate and meet resident's needs, transfer safely with the assistance of one or more staff, visual checks every shift when up, and place resident in areas where staff can monitor resident's activities and whereabouts. A review of Resident 117's Care Plan Conference Summary dated 7/13/23, indicated, under Safety Issues Identified, that Res[ident] stands on own. A review of Resident 117's Minimum Data Set (MDS - a comprehensive, standardized, federally mandated resident assessment) dated 7/17/23, indicated Resident 117 had a BIMS (Brief Interview for Mental Status - the cognitive assessment tool of the MDS) score of 6 (scores of 0-7 indicate severe cognitive impairment), needed extensive assistance of at least two persons for transfers between surfaces such as bed, wheelchair and toilet, and was not steady, only able to stabilize with staff assistance with regards to balance during transitions and walking. A review of Resident 117's Progress Notes indicated Progress Note dated 7/21/23, at 2:50 p.m., indicating: Resident [117] was found on the floor by CNA [Certified Nursing Assistant], skin tear approx[imately] 1 inch to . head, X2[two] skin tears to R[ight] knee and X1[one] skin tear to R[ight] elbow . New orders to transport to [Hospital] for further evaluation. A review of Resident 117's Post Fall Assessment, dated 7/21/23, at 3 p.m., indicated: Per AM [day shift] nurse, Resident [117] was found on the floor by her wheelchair. Resident [117] told AM nurse and CNA she wanted to go back to bed. Resident sustained multiple skin tears on her head, right knee, and right forearm. The Post Fall Assessment indicated the following as contributing factors to the fall: Resident has intermittent confusion and lacks safety awareness. She is also impulsive and will get up w/o [without] assist from staff d/t [due to] confusion. The Post Fall Assessment indicated as recommendations to prevent further falls: Staff will . supervise resident at nursing station. Do not leave [Resident 117] alone in room. During an interview on 8/15/23, at 2 p.m., the Director of Nursing (DON) stated Resident 117 was admitted to the facility on [DATE] for rehabilitation following a stroke and was at high risk for falls. The DON stated that Resident 117 was extremely restless and impulsive and frequently tried to get out of bed. The DON stated on 7/21/23 Resident 117 had a late lunch in her room in her wheelchair assisted by CNA A. The DON stated Resident 117 finished her lunch and while CNA A was out of the room Resident 117 attempted to get up from the wheelchair unassisted and fell to the floor. The DON stated she heard CNA B shout she [Resident 117] is on the floor. The DON stated she went to Resident 117's room and found she had been assisted back to her wheelchair by staff. The DON stated Resident 117 had injuries to her forehead, right elbow, and right knee. The DON stated Resident 117 was sent to the hospital the same day for evaluation and treatment after her fall. During an interview on 8/16/23, at 9:10 a.m., CNA B stated she was assigned to care for Resident 117 when Resident 117 fell on [DATE]. CNA B stated Resident 117 was really restless that day and trying to crawl out of bed. CNA B stated on 7/21/23 Resident 117 had lunch in her room, in her wheelchair, assisted by CNA A, and finished eating at around 2:30 p.m. CNA B stated after Resident 117 finished her meal, CNA A left Resident 117's room to take Resident 117's lunch tray to the cart on the hallway, and at this time CNA B heard Resident 117's wheelchair alarm go off (a type of alarm combined with a chair sensor or chair pad that operates, or sounds the alarm, by detecting a reduction of pressure, for example when the resident gets out of the wheelchair), ran towards her room, and found Resident 117 on the floor. CNA B stated Resident 117 had a cut on her forehead and was bleeding from it. A review of Resident 117's Hospital record titled History and Physical (H&P), dated 7/21/23, indicated, The patient was brought in as a limited trauma [some injuries] after an unwitnessed fall from her wheelchair at her care facility. The H&P's Physical Exam indicated She has a small laceration [cuts] on her forehead . She has several areas of skin abrasions [scratches] on both lower extremities. She also has some mild bruising on her upper extremities. During an interview on 8/17/23, at 11:22 a.m., the family of Resident 117 stated Resident 117 fell because she was left unsupervised in her wheelchair after lunch. The family stated Resident 117 had a routine of eating lunch, going to the commode (a portable toilet place next to the bed for residents with mobility difficulties), and then going to bed. The family stated Resident 117 should not have been left alone or unsupervised in her wheelchair because she had a history of trying to get up unassisted. The family stated she had discussed this fall risk factor with staff during the care plan conference after Resident 117's admission on 7/10/23. During an interview and record review on 8/18/23, at 8:54 a.m., the MDS Coordinator provided the admission care plan conference for Resident 117's titled Care Plan Conference Summary dated 7/13/23. Resident 117's Care Conference Summary indicated, under Safety Issues Identified, that Res[ident] stands on own. The MDS Coordinator was asked what this meant. The MDS Coordinator stated it meant Resident 117 was at risk of falls because she attempted to get up on her own (from the bed or wheelchair). A review of facility policy and procedure titled Falls and Fall Risk, Managing, Revised March 2018, indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.

Based on observation, interview and record review, the facility failed to provide a program supporting the residents choice of activities with activities supporting the residents physical, mental, and psychosocial well-being, and encouraging interaction with the community, for one of eight sampled residents (Resident 2), when the activities provided by the facility to Resident 2 were limited to having the TV turned on in her room, despite activity assessments which indicated Resident 2 enjoyed reading, listening to music, being around pets, and spending time outdoors. This failure resulted in Resident 2 not having her activities needs met. Findings: A review of Resident 2's Admission Record indicated she was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hemiplegia (paralysis on one side of the body), hemiparesis (weakness in one side of the body), aphasia (loss of ability to understand or express speech due to brain damage), difficulty in walking, muscle weakness, osteoarthritis (joint disease) and need for assistance with personal care. A review of Resident 2's Activities Assessment, dated 12/20/22, indicated Resident 2 enjoyed group activities, pet visits, intellectual activities, music, spiritual activities, television, and radio. A review of Resident 2's Comprehensive Care Plan indicated an Activities Care Plan, created on 12/20/22, which indicated Resident 2's current interests and preferences for activities and daily routine included, family involvement/visits, reading/keeping up with the news, listening to music, being around animals such as pets, and spending time outdoors. A review of Resident 2's Minimum Data Set (MDS - a comprehensive, standardized and federally mandated resident assessment), dated 12/21/22, indicated, under Preferences for Customary Routine and Activities, that Resident 2 preferred family involvement, reading books, newspapers, or magazines, listening to music, being around animals such as pets, keeping up with the news, spending time outdoors and participating in religious activities or practices. During an observation on 8/14/23, at 2 p.m., Resident 2 was in her room. Resident 2 was lying in her bed, supine (face upward). The TV was turned on. During an attempted interview, Resident 2 opened her eyes but did not answer questions. During an observation on 8/14/23, at 4:10 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/15/23, at 10:07 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/15/23, at 11:50 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/15/23, at 3:30 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/15/23, at 4:10 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/16/23, at 10:10 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/16/23, at 11:20 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/16/23, at 1:50 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/16/23, at 3:15 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/17/23, at 10 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/17/23, at 12:04 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an interview and record review on 08/17/23, at 2:06 p.m., the Life Enrichment Director (LED), responsible for resident activities, stated the facility provided group activities daily for residents in the activities room at 11 a.m. and 4 p.m. For bed-bound residents, the LED stated activities were provided according to the resident's activity preferences, as indicated in the activities assessment and activities care plan. The LED provided Resident 2's activities assessment and activities care plan dated 12/20/22 which indicated Resident 2's preferences for activities including group activities, pet visits, intellectual activities, music, spiritual activities, television, and radio. The LED was asked for documentation of the activities offered to Resident 2. The LED stated she documented resident activities in their Activity Participation Record (APR). A review of Resident 2's APR for August 2023 indicated Resident 2 did not participate in any group activities, did not attend social dining, did not leave her room, and did not participate in physical activities for the period August 1-16, 2023. The APR indicated Resident 2 received Sensory Enrichment daily, which the LED stated meant hygiene/personal care provided by nursing staff. The APR indicated Resident 2 received daily room visits which the LED stated were family/friends visits on 8/2, 8/3, 8/6, 8/9 and 8/10, LED visits on 8/3 and 8/15, and nursing staff visits the other days. The only recreational activity provided by the facility to Resident 2 documented on the APR was TV. A review of the facility's Life Enrichment Calendar for August 2023, indicated at least 10 music activities for the period August 1-16 offered to residents in the activities room. The LED stated Resident 2 refused activities. The LED stated an RNA [Restorative Nursing Assistant - a type of CNA] recently reported to her that she tried to play music to Resident 2 but she cried. A review of facility document titled Facility assessment dated [DATE], indicated the facility provides Opportunities for social activities/life enrichment (individual, small group, community) .

Based on interview and record review, the facility failed to ensure timely documentation of resident assessments for the risk of entrapment from bed rails and obtaining informed consent prior to installation of bed rails for 15 of 15 residents. This failure placed residents at risk of entrapment. Findings: During an interview and concurrent record review on 8/18/23 at 8:05 a.m., the DON (Director of Nursing) stated all 31 resident beds had bilateral quarter-size bedrails. The DON provided a copy of form titled Interdisciplinary Assessment and Progress Notes which had a field for evaluation of bed rails for entrapment risks and space to document informed consent completed for all residents upon admission. The DON reviewed the charts of all 15 facility residents and stated the entrapment risk assessment fields had not been completed. During an interview on 8/18/23, at 11:45 a.m., the DON stated assessment of bed rails for risk of entrapment had been completed and documented and informed consent obtained for all but two residents, and no residents were at risk for entrapment. A review of facility policy and procedure titled Bed Safety and Bed Rails, dated August 2022, indicated: Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted . If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails .The resident assessment to determine risk of entrapment includes .A resident or part of his/her body could be caught between rails, the opening of the rails, or between the bed rails and mattress . Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent .

Based on observation, interview and record review, the facility failed to ensure Agency/Registry (staffing agencies that hire and train staff and place nursing professionals in a variety of nursing positions) Licensed Nurses and Certified Nursing Assistants (CNAs) had the competencies and skills necessary to care for its residents' needs when: 1) the facility did not verify that Agency/Registry Licensed Nurses and CNAs had valid and complete competency/skills checks to meet resident needs prior to working at the facility; 2) an Agency/Registry Licensed Nurse (Licensed Nurse E) did not perform hand hygiene per facility policies prior to medication administration to five residents (cross-reference to Tag F880 - Infection Control); 3) an Agency/Registry Licensed Nurse (Licensed Nurse E) attempted to perform a medical procedure involving blood draw using needles on a resident who did not have orders for and did not need the procedure, and was only stopped by the resident who refused the procedure; and 4) the facility did not have a policy and procedure governing its use of Agency/Registry Licensed Nurses and CNAs. These failures placed residents at risk of incompetent care and not having their care needs met. Findings: 1) During a resident group interview on 8/15/23, at 11:00 a.m., residents reported dissatisfaction with the services provided by Agency/Registry Licensed Nurses and CNAs. The residents reported the Agency/Registry staff were not familiar or knowledgeable about the residents and their needs. During an interview and record review on 8/16/23, at 10:13 a.m., the Director of Staff Development (DSD) stated the facility used a mix of directly hired and Agency/Registry Licensed Nurses and CNAs. The DSD stated directly hired Licensed Nurses and CNAs had to pass a skills/competency check demonstrating the skills to meet resident needs. The DSD provided the checklists he used to assess their skills/competency. A review of the Licensed Nurse skills/competency checklist indicated five pages with about 70 different skills/competencies. A review of the CNA skills/competency checklist indicated one page with about 72 different skills/competencies. The DSD stated their directly hired Licensed Nurses and CNAs must successfully complete these checklists upon hire and annually thereafter. For Agency/Registry Licensed Nurses and CNAs, the DSD stated the facility relied on skills/competency checks performed by the agencies that employed them, but he checked them online before the staff were allowed to work with residents. The DSD provided a ledger indicating the use of Agency/Registry Licensed Nurses and CNAs for the week of 8/9/23 to 8/15/23. The ledger indicated that Agency/Registry Licensed Nurses and CNAs worked on six of the seven days, as follows: 8/9/23: one CNA during two shifts (each shift consisting of eight hours); 8/11/23: one CNA during one shift; 8/12/23: one Licensed Nurse during one shift and four CNAs during six shifts; 8/13/23: one Licensed Nurse during one shift and four CNAs during four shifts; 8/14/23: one CNA for one shift; and 8/15/23: two CNAs during two shifts. The DSD was asked to provide the skills/competency checks for three agency staff that worked at the facility during the week of 8/9/23 to 8/15/23: CNAs G and H and Licensed Nurse I. The DSD accessed the website of Agency A that employed CNAs G and H and opened the staff profiles of CNAs G and H. The DSD stated the skills/competency checks were found under the Annual Competencies tab, which he opened. The Annual Competencies tab contained the following statement: I have read and been informed of facility mandated annual competencies related to my profession as a healthcare provider. and listed 29 topics including hand hygiene, patient rights, restraints, and sexual harassment and others. The list had an Expiration Date of 7/15/24. This was the only document related to skills/competencies found in their file. The DSD was asked what the statement in the Annual Competencies tab meant, if Agency A had verified the skills/competencies listed or it was merely an affirmation by the CNAs they had those skills/competencies, and what the Expiration Date meant. The DSD stated he did not know. The DSD then accessed the website of Agency B, which employed Licensed Nurse I. There were no skills/competency checklists for Licensed Nurse I available for verification there. 2) During five observations on 8/17/23, from 5:45 a.m. to 6:35 a.m., Licensed Nurse E, an Agency/Registry Licensed Nurse, prepared and administered medications to five residents without observing the facility's hand hygiene policies and procedures. (Cross-reference to Tag F-880). 3) During an observation and interview on 8/17/23, at 6:45 a.m., Licensed Nurse E stated she was going to check the blood sugar level of Resident 5, who received insulin (a medication to control blood sugar), and had orders to have his blood sugar level checked daily. (Blood sugar levels are checked by pricking the tip of the resident's finger with a small needle called a lancet to produce a blood drop which is placed on a test strip. The test strip is then inserted into a portable device called glucometer which analyses the blood and indicates the blood sugar level). Licensed Nurse E collected a plastic basked with Resident 5's name containing a glucometer, lancets, test strips, alcohol swabs, gloves, and other supplies, and entered Resident 9's room. Licensed Nurse E did not ask Resident 9's name or checked her wrist band (containing the resident's name and date of birth) or identify Resident 9 by other means. Licensed Nurse E informed Resident 9 she was going to check her blood sugar level. Resident 9 asked what she was doing. Licensed Nurse E repeated she was going to check her blood sugar level, and asked if she could prick her right middle index finger. Resident 9 once more asked what she was doing. Licensed Nurse E again informed Resident 9 she was going to check her blood sugar level and proceeded to wipe Resident 9's right index finger with an alcohol swab. Licensed Nurse E then took a lancet and placed it against Resident 9's finger. Resident 9 recoiled her right hand and stated she did not have blood sugar checks done. Licensed Nurse E checked Resident 9's wrist band, stated she was the wrong resident, and left the room. A review of Resident 9's physician orders indicated no order for blood sugar checks. During an interview on 8/17/23, at 4 p.m., the MDS Coordinator/Case Manager stated only two residents at the facility had orders for blood sugar checks: Residents 5 and 6. 4) During an interview on 08/18/23, at 10:33 a.m., the DSD stated there was no policy and procedure on the use of Agency/Registry Licensed Nurses and CNAs. A review of facility policy and procedure titled Staffing, Sufficient and Competent Nursing, Revised August 2022, indicated: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.

Based on observation, interview and record review the facility failed to maintain sanitary conditions as evidenced by: 1) Dietary Staff put used paper towels on a food prep area. 2) Dietary Staff touched the lid of a dirty garbage can with clean hands and did not wash their hands. 3) Dietary Staff did not have a garbage can to discard dirty paper towels. 4) Dishes were not properly sanitized. 5) Potatoes were stored uncovered under meat prep area. 6) Cooking appliances were not cleaned. 7) Dietary Staff were not wearing proper hair and facial covering. The cumulative effects of the systemic failures resulted in an Immediate Jeopardy was declared on 2/1/18 at 2:30 p.m., and reported to Administrator and CEO due to unsanitary conditions and cross-contamination in the kitchen that had the potential for food borne illness that could cause serious illness and death. Findings: During the initial tour of the kitchen on 1/29/18 at 08:20 a.m., The hand washing sink did not have a garbage can available to discard paper towels after washing hands. Past Executive Chef found a garbage can for another area and placed it by the hand washing sink. During an observation on 1/31/18 at 12:20 p.m., kitchen staff were seen washing hands at the hand washing sink and walking over to the garbage can past the dishwasher area. They were seen using a clean hand to push open a dirty trash can lid to dispose the used paper towels. During an observation on 1/31/18 at 12:25 p.m., Food Service H used hand washing sink to wash hands, walked towards the garbage can and decided not to use it. She went to the food prep counter and put down the used paper towel. Food Service H then went to get knife and cutting board, came back to food prep counter, wiped the area off with the used paper towel, then put down the cutting board, and started to cut the vegetables. Food Service H paused, washed hands, and the used paper towels from that hand washing ended up on the cutting board, contaminating the food prep surface. During an interview on 1/31/18 at 2:40 p.m., Food Service H stated she did not want to use the garbage can with the lid that had to be pushed by hand because she knew it would contaminate her hands. Food Service H stated there had been a garbage can by the hand washing sink until it was broken and her supervisors had not gotten a replacement. During an observation on 1/31/18 at 9:00 a.m., the cooking appliances were dirty. The 'Hot Hold' warming oven had burnt residue at bottom of compartment. The Warming Oven next to the Hot Hold oven had baked on dirt on bottom shelf of oven, baked on food on racks, and the glass doors had a brown substance clinging to the glass. The large stand alone burner for huge pots and pans had food residue on the pan rack over the burner and the top of the appliance had fresh and burnt on food residue. The grill section of the main range had food residue on the rack and grease and black crumbs of food particles under the grill and on the supporting edges of the grill. The rack on top of the range to support the pans had food particles on it and under the rack there was aluminum foil covered with grease and burnt food residue. The 2 main ovens had burnt on food residual on the bottom and on the oven racks. The plate warmer has brown staining along the back of the compartment. During an interview on 1/31/18 at 9:10 a.m., Food Service H stated that she did not clean the appliances but a person comes in at night to do all the cleaning. During an observation and concurrent interview on 2/1/18 at 11:10 a.m., Food Service E acknowledged that the appliances were dirty and explained that it was from cooking that morning such as the pan on the large stand alone burner had boiled over. Food Server E stated that the facility had a company to come in and clean the kitchen during the night. Prep cooks were responsible to clean their work areas and place used cooking items to the dishwashing areas. During an observation on 1/31/18 at 9:15 a.m., clean cooking utensils and clean plastic mugs for the meal trays were stored in open bins, right next to the dishwasher. The cooking utensils were jumbled in the bins and heaped up above the rim of the bins. During an observation on 2/1/18 at 11:40 a.m., the clean mugs stored by the dishwasher, had visible food particles. The clean cooking utensils stored in the open bins next to the dishwasher had traces of food on the inside surface of the bin, water collected on the bottom of the bin and a candy wrapper mixed in with the utensils. During an observation of the ice maker on 1/31/18 at 9:30 a.m., the outside of the ice bin was visibly dirty. The ice bin was full of ice. Near the top of the bin was an area of brown substance, and when wiped with a dry white cloth a gray unknown substance was found. A log about the cleaning of the ice maker was not located with the appliance. During an interview on 2/1/18 at 12:30 p.m., Engineer stated that maintenance of the kitchen equipment was contracted out and the ice maker in the basement was maintained by a separate company. During an interview on 1/31/18 at 2:35 p.m., Food Service F stated that he thought the dishwasher used heat to sanitize the dishes. He stated the testing of the dishwasher with test strips was three times a week. During an interview on 2/1/18 at 11:00 a.m., Food Service E stated the dishwasher sanitizes the dishes by heat and the water temperature was checked three times a day when washing the dishes from the last meal served. During an observation on 2/1/18 at 11:50 a.m., the food service person washing the dishes ran the temperature test strip through the dishwasher. The test strip failed to react to the heat. A second test was ran because it was thought the test plate was removed before the cycle completed. Two more temperature tests were done and still the strip failed to react to the heat. New RD stated she would find a thermometer to run through the dishwasher to test the temperature again. During an interview on 2/1/18 at 9:00 a.m., Food Service F stated that they check the dishwasher temperature with the EcoLab strips. They do not have a thermometer. The temperature they had documented on the daily temperature log were based on readings from the temperature gauges attached to the dishwasher machine, not from test strips. Food Service F stated the EcoLab strips stopped turning black about a week ago. The turning of the strips from white to black would indicate that the temperature is appropriate for disinfecting the dishes. During an interview on 2/1/18 at 9:15 a.m., Food Service G stated that the EcoLab strips stopped working about five to six days ago, but he did not alert management about this issue. Food Service G stated he did not inform management because he figured somebody else would do it. During the initial tour of the kitchen on 1/29/18 at 08:20 a.m., Past Executive Chef had a baseball cap on to cover his hair and did not have a beard cover over his facial hair. Two food service staff had on hair nets but did not covering all of their hair. During an interview on 1/31/18 at 2:35 p.m., Food Service F sported a mustache and when asked if he needed to wear a beard cover he stated he did not need to wear one. During an observation on 2/2/18, Food Service E was wearing a hair net but it was not covering all of her hair. When asked if she knew that some of the staff did not have their hair completely covered, she stated OK I will go get a net for my hair. During an observation on 1/31/18 at 12:00 p.m., Food Service F put on an cloth oven mitt to place the the warmed metal plate holders onto the food trays and moved the food trays down the line wearing the oven mitt. The oven mitt was visibly soiled from prior uses. During on interview on 1/31/18 at 2:35 p.m., Food Service F stated that his duties included helping at tray line and he uses the oven mitt on the hot metal plates. Food Service F stated that the oven mitts are not washed and thrown away when worn out. During on observation on 1/31/18 at 9:15 a.m., the steam table pans, stored on shelving between the 3 compartment sink and the food prep tables, were found stacked together and wet. During an observation on 2/1/18 at 11:30 a.m., the food service staff was seen washing steam table pans at the 3 compartment sink and adding them to a stack of pans on the storage shelf, instead of onto a surface where they could air dry. During an observation on 2/2/18 at 8:30 a.m., steam pans on the shelving by the 3 compartment sink were stored wet. During an observation on 1/31/18 at 9:15 a.m., the food preparation table had 3 plastic bins with red onions, white onions and potatoes and the lids were loose. The lid over the potatoes only covered about half of the potatoes. During on observation on 2/1/18 at 1130 a.m., the food preparation table with the bins of onion and potatoes was being used to prepare meat. The meat was on a cutting board with no sides and meat juice was being released from the meat. The plastic bin holding the potatoes was under this food prep table and the lid on the potato bin left the potatoes uncovered. The cumulative effects of the systemic failures resulted in an Immediate Jeopardy was declared on 2/1/18 at 2:30 p.m., and reported to Administrator and CEO due to unsanitary conditions and cross-contamination in the kitchen that had the potential for food borne illness that could cause serious illness and death. During an observation and concurrent interview on 2/2/18 at 9:00 a.m., pans had been placed under the meat prep table. New Executive Chef stated thought if something dripped onto the bottom surface of the pan it would not matter, as the pans could be rewashed. Pans were sent to the dishwasher. The Immediate Jeopardy was abated on 2/2/18 at 3:20 p.m. Dietary Staff followed their plan of action, dated 2/2/18 at 11:20 a.m , as follows: 1) The facility bought a garbage can for the kitchen, 2) In-service and education to dietary staff on maintaining infection control practices, 3) Ice machine was cleaned and logs for cleaning and maintenance revised, 4) Silicon oven mitts were purchased, 5) Identified that dietary staff needed to use correct temperature test strips to verify sanitation by the dishwasher, 6) Throw out all contaminated vegetables and relocated the vegetables, 7) In-serviced on not stacking wet pans and ensuring steam pans were placed on drying rack, 8) In-service dietary staff on hair and facial covering. Dietary Manager will monitor use of hair/facial covering daily. The facilities Sanitation and Infection Prevention/Control policy dated 1/2016 instructed that All associates associated with the handling of food shall wash hands, Use sinks designated for hand washing For the kitchen it is indicated that the food contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. Nonfood contact surfaces of equipment . shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. The dishwasher temperatures procedure instructed that once a day, run a test strip through the dishwasher to verify the surface temperature of a dish. The test strip must verify that the surface temperature of the plate reached 160 degrees, and in the event of inappropriate temperature the director must investigate. Other parts of the policy include: Hair restraints are worn by all when in the kitchen, and the storage of pots, dishes and flatware section instructed the following: air dry food contact surfaces including pots, dishes, flatware and utensils before storage . Do not stack or store when wet. The ice machine's manufacture guidelines documented the storage bin must be cleaned and sanitized regularly to maintain a sanitary environment, and frequency of cleaning man need to be adjusted to local conditions and environment.

Based on observation, interview and record review the facility failed to have a trash receptacle located at the hand washing sink which led to the inability of staff to dispose of the used paper towels causing cross-contaminated. This failure resulted in an Immediate Jeopardy called on 2/1/18 at 2:30 p.m., due to unsanitary conditions and cross-contamination that could affect the health and safety of residents causing serous illness and death. This was reported to Administrator and CEO at above date and time. (see F 812) Findings: During the initial tour of the kitchen on 1/29/18 at 08:20 a.m., The hand washing sink did not have a garbage can available to discard paper towels after washing hands. Past Executive Chef found a garbage can for another area and placed it by the hand washing sink. During an observation of the kitchen on 1/31/18 at 8:30 a.m., the hand washing sink did not have a garbage can nearby. Staff had to walk past the dishwasher area of the kitchen to a trash can with a lid that had to be pushed inwards by hand to place garbage inside. During an observation on 1/31/18 at 12:20 p.m., kitchen staff were seen washing hands at the hand washing sink and walking over to the garbage can past the dishwasher area. They were seen using a clean hand to push open a dirty trash can lid to dispose the used paper towels. During an observation on 1/31/18 at 12:25 p.m., Food Service H used hand washing sink to wash hands, walked towards the garbage can and decided not to use it. She went to the food prep counter and put down the used paper towel. Food Service H then went to get knife and cutting board, came back to food prep counter, wiped the area off with the used paper towel, then put down the cutting board, and started to cut the vegetables. Food Service H paused, washed hands, and the used paper towels from that hand washing ended up on the cutting board, contaminating the food prep surface. During an interview on 1/31/18 at 12:30 p.m., Past RD stated she had requested the hand washing sink to have a new garbage can about a week ago. During an interview on 1/31/18 at 2:35 p.m., Food Service G stated that the garbage can broke about a week ago and they asked their bosses for a replacement. During an interview on 1/31/18 at 2:40 p.m., Food Service H stated she did not want to use the garbage can with the lid that had to be pushed by hand because she knew it would contaminate her hands. Food Service H stated there had been a garbage can by the hand washing sink until it was broken and her supervisors had not gotten a replacement. Durning an observation on 2/1/18 at 11:00 a.m., the kitchen's hand washing sink lacked a garbage can for the used paper towels. Durning an interview on 2/1/18 at 11:00 a.m., Food Service E stated that a replacement garbage can had been ordered and would be there in a few days. Durning an interview on 2/1/18 at 12:30 p.m., requested a copy of work orders or requisitions and invoices for repairs for the kitchen. Food Service E stated that she did not have any work orders, that requests were made verbally or by telephone. During an interview on 2/1/18 at 12:50 p.m., Engineer stated that the kitchen maintenance was contracted out. The facilities maintenance department filled requests for the kitchen like changing light bulbs, adding bulletin boards or fixing clogged drains. Requests were made by phone and the maintenance department did not keep a log of repairs they did in the kitchen. This failure resulted in an Immediate Jeopardy called on 2/1/18 at 2:30 p.m., due to unsanitary conditions and cross-contamination that could affect the health and safety of residents causing serious illness and death. This was reported to Administrator and CEO at above date and time. (see F 812) During an interview on 2/2/18 at 9:00 a.m., Food Service E stated that she communicated with the past food service's General Manager by leaving notes and complained that they were not responsive to her requests. Food Service E stated that she rarely communicated with the facilities administration, she reported to the General Manager. The Immediate Jeopardy was abated on 2/2/18 at 3:20 p.m. The facility bought a new garbage can and Dietary Staff were in-serviced in how to maintain infection control practices. The facilities policy on Hand Hygiene, dated 1/2016, specified All hand wash sinks should be easily accessible with nothing blocking their access in food production, food service and dishwashing areas. Hand wash sinks . should be clean and stocked with soap, paper towels, a covered waste receptacle and a Hand Wash sign. Food safety code documents that a trash receptacle must be located at the hand washing sinks to discard disposable towels.