Every finding on record at Vista Pacifica Center

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident, for one of seven residents reviewed for abuse (Resident 1), when Resident 2 struck Resident 1 a second time following an earlier physical altercation. The facility failed to ensure Resident 2 was adequately separated from Resident 1 following the initial incident to prevent further incidents. This failure resulted in Resident 1 being subjected to second physical assault and had the potential to negatively affect the resident's physical, emotional, and psychosocial well-being. Findings: On June 2, 2026, at 11:41 a.m., an interview was conducted with Resident 1. Resident 1 stated, on May 25, 2026, Resident 2 struck him in the back of the head while they were in the TV room. Resident 1 stated he ran away to avoid further confrontation and staff intervened. Resident 1 stated that approximately 30 minutes later, Resident 2 struck him again on the side of the head while he was walking in the hallway. Resident 1 stated he had no prior disagreements with Resident 2 and did not retaliate. On June 2, 2026, at 1:25 a.m., an interview was conducted with Mental Health Worker (MHW 2). MW 2 stated after the initial altercation, Resident 2 was placed on 1:1 supervision and escorted to the smoking patio by two staff members. MHW 2 stated after the smoke break, staff escorted Resident 2 back through the hallway and Resident 2 struck Resident 1 near the nursing station. MHW 2 stated she failed to ensure the hallway was clear and that established protocols to prevent further altercations were not followed. On June 2, 2026, at 2:13 p.m., an interview was conducted with the Mental Health Counselor MHC. MHC stated 1:1 supervision was implemented to prevent further incidents and that staff should have ensured Resident 1 was not in the area before escorting Resident 2 through the hallway. MHC stated a 1:1 protocol meant staff should ensure a minimized activity while monitoring behaviors to ensure further incidents would not occur during a 'cool down' process, which was a process of attempting to calm the resident after an altercation. MHC stated the purpose of having 1:1 intervention in place were to prevent retaliation. MHC stated staff should have made sure the hallways were clear of all residents, including Resident 1, and should not have escorted Resident 2 within a close proximity of Resident 1 after the smoke break. On June 2, 2026, at 3:19 p.m., an interview was conducted with Licensed Vocational Nurse (LVN 1). LVN 1 stated the protocol for escorting a resident on 1:1 supervision requires clearing the hallway by announcing the need for clearance and ensuring safety before escorting a resident into the area. LVN 1 stated staff assigned to the 1:1 supervision should have ensured the hallway was clear and avoided bringing Resident 2 into close proximity to Resident 1 following the earlier altercation. LVN 1 stressed the importance of all staff maintaining vigilance during 1:1 supervision and monitoring nearby residents to prevent similar incidents, which was not done in this case. On June 2, 2026, Resident 1 and Resident 2's records were reviewed. Resident 1 was admitted to the facility on [DATE], with diagnosis which included, schizoaffective disorder bipolar type (mental health condition that combines hallucinations or delusions with severe mood swings). The Minimum Data Set (MDS - an assessment tool, dated February 27, 2026, indicated, .Brief Interview for Mental Status (BIMS - screening test used for mental and cognitive status) score of 15 (intact cognitive status). A review of Resident 1's progress notes dated May 26, 2026, at 12:08 p.m., indicated, .program note. PC met with resident to discuss the incident noted regarding this resident being the victim in two resident to resident altercations. A review of the care plan dated May 25, 2026, indicated, .resident to resident altercation as non-aggressor.resident will have no complications through the review date.interventions.give resident space to express fears and apprehension. Resident 2 was admitted to the facility on [DATE], with diagnosis which included Schizophrenia (mental health condition that combines hallucination or delusions with severe mood swings). The Minimum Data Set (MDS - an assessment tool, dated May 6, 2026, indicated, .Brief Interview for Mental Status (BIMS - screening test used for mental and cognitive status) score of 15 (intact cognitive status). A review of Resident 2's progress notes indicated the following:-Dated May 25, 2026, at 11:33 a.m., .at approximately 11 am on 5/25 the residents were sitting in the TV room with this resident seated in the back row and his peer in the row in front of him, without provocation this resident stuck his peer one time with a closed fist on the right side of his head. The resident attempted to strike his peer again; however his peer got out of his seat and ran. This resident began chasing his peer when staff intervened. Code amber (all staff response) was called and the resident was escorted to his room using proper NCI (nonviolent crisis intervention). Resident was placed on 1:1 supervision. When asked about the incident the resident stated, I don't know want to talk about it. No injuries were reported for either resident. -Dated May 25, 2026, at 3:48 p.m. indicated, .At approximately 12 p.m., resident was being escorted to room from smoke break. Peer was turning away from nursing station after receiving medication. Resident broke away from escort and struck peer on left lower jaw x1.Resident immediate separated from peer and escorted to room using proper NCI. Resident and per assessed for injury none. The care plan, revised on May 28, 2026, indicated, .resident to resident aggressor.will have no further behavior through the review date.will monitor and assist to identify the causative factor or trigger effect.will monitor and supervise resident for every shift. On June 2, 2026, at 3:58 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated staff failed to effectively communicate and assess the risk when escorting Resident 2 after the smoke break, resulting in Resident 2 being brought near Resident 1 and creating the opportunity for a second physical altercation. The DON stated staff were required to maintain a safe environment by clearing the area and escorting residents carefully to prevent additional altercations. A review of the facility policy and procedure titled, Resident to Resident Abuse undated, indicated, .should the resident be observed/accused of seriously abusing another resident, our facility will.remove the aggressor from the situation if the aggressor is still in the area in which the incident occurred.temporarily separate the resident from other residents as a therapeutic intervention to help lower the agitation.prevent recurrence of such incident.

Based on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Two Dietary staff were unable to demonstrate the correct concentration for the red bucket sanitizer solution. 2. One Dietary staff did not wear gloves while sanitizing the food preparation table. 3. Four Dietary Staff could not demonstrate the proper procedure for testing dish sanitization. These failures had the potential to cause food borne illness (stomach illness acquired from ingesting contaminated food) to the residents in the facility. Findings: 1. On April 29, 2025, at 1:12 p.m., a concurrent observation and interview were conducted with the [NAME] (CK). The CK was observed demonstrating how to prepare the bleach sanitizer solution for the red bucket. The CK placed water in the red bucket, and stated the ratio was approximately two quarts of water to one tablespoon of bleach. The CK pointed inside the red bucket and stated it contained two quarts. The red bucket was observed halfway filled with water, and it did not contain the required one gallon of water. On May 1, 2025, at 9:25 a.m., a concurrent observation and interview were conducted with Dietary Aide 4 (DA 4). DA 4 was observed demonstrating how to prepare the bleach sanitizer solution in the red bucket. DA 4 poured water into the red bucket and stated the correct ratio is one gallon of water to one tablespoon of bleach. DA 4 pointed to the inside of the bucket, indicating that it contained one gallon of water. The red bucket was observed filled to approximately three-quarters full and did not contain the required one gallon. On May 5, 2025, at 1:21 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated, the proper concentration for the red bucket sanitizer is one gallon of water to one tablespoon of bleach. The RD further stated, if the sanitizing solution was not prepared at the correct concentration, it could result in foodborne illness among residents. A review of the Red Sanitizer Bucket Log Checklist, indicated, .check concentration every 3 hours per shift .acceptable PPM (parts per million) range: 200 PPM .1T to 1 gallon of water . A review of U.S. FDA (Food and Drug Administration) Food Code 2022, Section 4-501.114 Manual and Mechanical Ware washing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness, indicated, .The effectiveness of chemical sanitizers can be directly affected by the temperature, pH, concentration of the sanitizer solution used, and hardness of the water . 2. On May 1, 2025, at 3:41 p.m., during a concurrent observation and interview with [NAME] Aide 1 (CA 1), CA 1 was observed demonstrating how to sanitize the preparation table using the green and red bucket solutions without wearing gloves. CA 1 stated he had forgotten to wear gloves and that he should have worn them for safety and to avoid contaminating the preparation table. On May 5, 2025, at 2:01 PM, during an interview with the Director of Dietary Services (DDS), the DDS stated that it is best practice for the staff to wear gloves when wiping down the preparation table with the bleach solution. He further stated this was for safety reasons as bleach can be absorbed through the skin and enter the bloodstream. 3. On April 29, 2025, at 8:50 a.m., a concurrent observation and interview regarding the dish machine were conducted with DA 1 and DDS. DA 1 and DDS dipped a test strip into the water compartment to test the chlorine sanitization level. Both stated this was the correct location to check the concentration of the sanitizer in the dish machine. On May 1, 2025, at 9:10 a.m., a concurrent observation and interview regarding the dish machine were conducted with DA 2. DA 2 dipped a test strip into the water compartment to test the chlorine sanitization level and stated this was the proper procedure to check for dish sanitization. On May 1, 2025, at 11:05 a.m., a concurrent observation and interview regarding the dish machine were conducted with DA 3. DA 3 dipped a test strip into the water compartment to test the chlorine sanitization level and stated this was the correct procedure to check for dish sanitization. On May 5, 2025, at 2:01 p.m., an interview was conducted with the DDS. The DDS stated the proper procedure for checking dish sanitization involved dipping the test strip both into the water compartment and onto the surface of a glass that had just been cleaned. The DDS further stated that he could not provide a written policy indicating that testing in the water compartment alone was acceptable. A review of the facility owner manual titled, CMA Dish machine Owner's manual, undated, indicated, .Low Temperatures chemical sanitizing dish machines must not exceed 6% sodium hypochlorite solution (beach) as the sanitizing agent .Follow the direction precisely that are on the litmus paper vial and test the water on the surface of the bottom of the glasses .

Based on observation, interview, and record reviews, the facility failed to maintain a sanitary environment, prepare, and serve food in accordance with professional standards for food service safety when three cutting boards with deep indentations were found in the kitchen. This failure had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) among the residents in the facility. Findings: On May 5, 2025, at 2:01 p.m., a concurrent observation and interview was conducted with the Director of Dietary Services (DDS) in the kitchen. Three cutting boards (brown, green and red color measuring at 24 inches [(a unit measurement of length)] in width and 18 inches in length) were observed with deep indentations and rough surfaces. The DDS stated, the cutting boards had indentations and should have had smooth surfaces to prevent microorganisms (germs) from growing in the grooves, which could lead to foodborne ilness among residents. A review of the U.S FDA Food Code 2022, Section 4-501.12 Cutting Surfaces, indicated, .Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces .

Based on observation, interview, and record review, the facility failed to provide a safe accident-free environment when the facility did not offer a smoking apron during smoking break for one of two residents (Resident 10). This failure had increased the potential for the resident to experience accidents and injury while smoking. Findings: A review of Resident 10's Admission Record indicated, Resident 10 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (a mental disorder), legal blindness, acquired absence of upper limb below elbow. A review of Resident 10's Minimum Data Set (an assessment tool), dated April 9, 2025, indicated a Brief Interview of Mental Status (a short, structured test used to assess cognitive status) score of 4 (cognitively impaired). A review of Resident 10's SMOKING ASSESSMENT, dated April 28, 2025, indicated, .SAFETY .RESIDENT NEED FOR ADAPTIVE EQUIPMENT .Smoking apron .Team Decision .Safe to smoke with supervision .Uses smoking apron . A review of Resident 10's Care Plan, revised dated August 19, 2021, indicated, .Risk for injury r/t (related to) smoking .Intervention .Offer smoking apron during smoking breaks . On April 30, 2025, at 8:30 a.m., during a smoking observation on the North smoking patio, Mental Health Counselor (MHC) 1 lit a cigarette for Resident 10. Resident 10 was not wearing a smoking apron and not offered one. On April 30, 2025, at 8:45 a.m., during an interview with MHC 1, MHC 1 stated, Resident 10 had not been offered a smoking apron. MHC 1 stated an apron should have been offered and further stated, the use of a smoking apron can help prevent accidental burns or injuries while smoking. A review of the facility policy and procedure titled, Resident Smoking, dated April 2024, indicated, To provide the safest means known for residents who smoke .Smoking Aprons .when appropriate .

Based on observation, interview, and record review, the facility failed to ensure medications were administered as prescribed and used appropriately to meet the needs of the resident when: 1. One injectable antipsychotic medication (used to manage schizophrenia symptoms such as delusions, hallucinations, paranoia, and/or altered sense of reality) was not administered every 28 days as prescribed by the physician and per manufacturer's prescribing information. 2. One Oral Emergency Ekit did not have an accurate expiration date on the outside of the kit. These failures had the potential for residents to receive ineffective or excessive medication therapy. Findings: 1. On May 1, 2025, Resident 46's medical record was reviewed, and the following was noted: Resident 46 was a [AGE] year-old, who was admitted to the facility on [DATE], with diagnoses that included schizophrenia (thought disorder that includes hallucination, delusion, paranoia, and altered sense of reality). There were physician orders for Invega Sustenna (long-acting injectable antipsychotic medication to manage symptoms of schizophrenia), and Haldol Decanoate (long-acting injectable antipsychotic medication to manage symptoms of schizophrenia) as follows: Invega Sustenna Prefilled Syringe 234 mg/1.5 ml (milligram per milliliter - unit of measurement) with the direction to inject intramuscularly (into muscle tissue) once on the 23rd day of every month for delusions/hallucinations related to schizophrenia, ordered on September 23, 2024, and discontinued on February 25, 2025; Invega Sustenna Prefilled Syringe 234 mg/1.5 ml with the direction to inject intramuscularly once every 28 days for delusions/hallucinations related to schizophrenia, ordered March 16, 2025, and discontinued on March 18, 2025; Invega Sustenna Prefilled Syringe 234 mg/1.5 ml with the direction to inject intramuscularly once every 28 days for delusions/hallucinations related to schizophrenia, ordered on April 7, 2025, and currently active; Haldol Decanoate 150 mg/ml with the direction to inject intramuscularly once every 28 days for delusions/hallucinations related to schizophrenia, ordered on September 9, 2024, and currently active; and Resident 46's medication administration record (MAR) indicated one dose of Invega Sustenna was given on February 23, 2025, March 16, 2025, and April 7, 2025. The March dose of Invega Sustenna was given 21 days after the February dose (7 days earlier than prescribed by the physician). The April dose of Invega Sustenna was given 22 days after the March dose (6 days earlier than prescribed by the physician). On May 5, 2025, at 10:40 a.m., during an interview, the pharmacist from the dispensing pharmacy (RPH 1) stated, after reviewing Resident 46's record, agreed the medication was administered earlier than prescribed. RPH 1 stated the Invega Sustenna doses were administered sooner than recommended by the manufacturer. On May 5, 2025, at 11:30 a.m., during an interview, the Director of Nursing (DON) stated Resident 46 was on two long-acting injectable antipsychotics ([NAME] APs) and the physician wanted to stagger the [NAME] APs two weeks apart over the period of few doses. On May 5, 2025, at 1 p.m., during an interview, the Medical Director (MD) stated the reason for two [NAME] APs to be spaced two weeks apart could be to potentially prevent wearing off of the [NAME] APs to towards the last few days of the dosing interval if given together and by staggering one [NAME] AP would still provide steady dosing effect even if the effect from the other [NAME] AP wore off. However, the MD stated the staggering of two [NAME] APs two weeks apart did not make a significant difference. The MD stated it would not be okay to extend and/or shorten the dosing interval of two [NAME] APs over a period in the attempt to stagger the two drugs two week apart. On May 5, 2025, review of Resident 46's medical record indicated there was a physician order to administer two [NAME] APs two weeks apart. On May 5, 2025, at 1:30 p.m., during an interview, the Consultant Pharmacist (CP) stated there was no published data which supported the use of two [NAME] APs in such a way that they were administered two weeks apart from each other. The prescribing information for Invega Sustenna, provided by the facility, indicated: .After the recommended initiation regimen of Invega Sustenna, the third and subsequent injections are recommended to be given monthly. To avoid a missed monthly dose, patients may be given the injection upto 7 days before or after the monthly time point. However, this does not imply that the dosing interval can be changed to 3 or 5-week cycle There are no data from clinical trials to support the routine administration of Invega Sustenna maintenance doses at intervals shorter or longer than 4 weeks . The facility's policy and procedure titled, Administration of Medications and Treatments, last revised, April 18, 2024, was reviewed, and it indicated: .Medications and treatments shall be administered as prescribed . 2. On April 29, 2025, at 9:30 a.m., during an inspection of Emergency Kits (a sealed container of various medications for use in emergencies) located in the Northside Nursing Station, it was noted the expiration written on the outside of the Oral Emergency Kit was July 2025. The inspection of the content of the Oral Emergency Kit indicated there were four tablets of doxycycline (antibiotic for infection) 100 mg with the expiration date of June 2025. During a concurrent interview, LVN 10 confirmed the expiration date of doxycycline 100 mg tablets and agreed the expiration date on the outside of the Oral Emergency Kit was not correct. The facility's policy and procedure titled, Emergency Pharmacy and Emergency Kits, undated, was reviewed, and it indicated: .The [Emergency] Kits are inventoried by the provider pharmacy at monthly for completeness and expiration dating of the contents. The date of earliest expiring medication is noted on the outside of the kit .

Based on observation, interview, and document review, the facility failed to ensure proper storage of one medication in accordance with manufacturer's specifications by not protecting it from light. This failure had the potential for one resident to receive ineffective medication therapy. Findings: On April 30, 2025, at 10:25 a.m., during an inspection of the Medication Cart A located in Southside Nursing Station, it was noted there were four ipratropium/albuterol (medication used to open airways in lungs to help breathing) 0.5/3 mg (milligram - unit of measurement) unit dose inhalation solution vials, which belonged to Resident 47, stored outside the original manufacturer's foil pouch. During a concurrent interview and review of the manufacturer's storage instruction, LVN 11 acknowledged the unit dose vials should have remained in the foil pouch to protect from light. The manufacturer of ipratropium/albuterol 0.5/3 mg indicated, Protect from light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week . The facility's policy and procedure titled, Storage of Medications, last revised, January 2018, was reviewed, and it indicated: .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations .

Based on interview and record review, the facility failed to ensure the resident's food preference was honored for one of three residents reviewed for nutrition (Resident 22). This failure had the potential to result in the resident refusing meals and experiencing decreased nutritional intake. Findings: During an interview on April 29, 2025, at 9:55 a.m., with Resident 22, Resident 22 stated, she had informed the dietitian of her food preference for cottage cheese but had only been receiving fruit cups. A review of Resident 22's Admission Record, dated May 5, 2025, indicated Resident 22 was admitted on [DATE]. A review of Resident 22's History and Physical, dated March 23, 2025, the indicated Resident 22 was admitted with a diagnoses which included unspecified severe protein-calorie malnutrition (a form of undernutrition caused by a deficiency in both protein and total caloric intake) and type 2 diabetes mellitus (a condition in which the body has trouble controlling blood sugar) without complications. A review of Resident 22's Minimum Data Set (an assessment tool), dated March 24, 2025, indicated Resident 22 had a Brief Interview of Mental Status (a tool to assess cognitive function of an individual) score of 15 (intact cognitive response). A review of Resident 22's Nutritional assessment dated [DATE], indicated, .FOOD PREFERENCE DATE .Food requests .lowfat cottage cheese for HS (bedtime) snack . A review of Resident 22's care plan, dated March 20, 2025, indicated, .one half cup soft canned fruit TID (three times a day) between meals . A review of Resident 22's snack labels, undated, indicated, .one half cup soft canned fruit . During a concurrent interview and record review of Resident 22's Nutritional Assessment, care plan, and snack labels, with the Dietary Manager (DM) on May 1, 2025 at 11:27 a.m., the DM stated, cottage cheese was listed as a food request and should have been provided to the resident. The DM stated, the resident should have received cottage cheese, instead of fruit cups. The DM stated all snack labels for Resident 22 indicated one-half cup of soft canned fruit, and there were no labels for cottage cheese. The DM stated Resident 22's food request was not followed and further stated, Resident 22's food preference had not been honored. A review of Resident 22's diet order, dated March 18, 2025, indicated, .CCHO (Consistent Carbohydrate - consistent amount of carbohydrates at each meal and snack) diet, Regular texture . During a concurrent interview and review of Resident 22's diet order with the RD, on May 1, 2025 at 3:23 p.m., the RD stated, there were no contraindications with Resident 22 receiving cottage cheese and the resident should have received it. The RD stated resident's preferences should have been honored. During an interview on May 5, 2025 at 2:15 p.m. with the Director of Nursing (DON), the DON stated if the dietician did not indicate any contraindications for the resident to have cottage cheese, the resident's food preference should have been honored. A review of the facility's policy and procedure titled, Resident Food Preferences, dated November 2008, indicated, .the staff and physician will strive to .accommodate those preferences .resident's clinical record ( .care plan .) will document the resident's likes .

Based on observation, interview, and record review, the facility failed to provide a safe environment when the Laundry Aide (LA) did not clean the lint trap in the dryer resulting in the lint accumulation. This failure had the potential to result in a fire hazard, putting residents at risk. Findings: On May 1, 2025, at 9 a.m., during a concurrent observation and interview in the laundry room, the Laundry Aide (LA) stated, she cleaned the dryer lint trap every two hours. Dryer # 3 lint trap was checked and observed to have a thick layer of lint covering the entire trap. A review of the facility document titled, Laundry Lint Cleaning Log, undated, indicated the following: .Lint must be cleaned every two hours . Further review of the Laundry Lint Cleaning Log, dated May 1, 2025, indicated: - 7:30 a.m. - signed with initials; - 9 :30 a.m. - signed with initials; - 11:30 a.m. - signed with initials; and - 1:30 p.m. - signed with initials. An additional review of the log indicated that it had been signed ahead of the scheduled times. On May 1, 2025, at 9:18 a.m., during a concurrent interview and record review of the Laundry Lint Cleaning Log with the Laundry Aide, the LA stated, the log should have been completed accurately. The LA stated, the log should reflect the actual time the lint was cleaned and the signature should only be entered once the task was truly completed. On May 1, 2025, at 9:21 a.m., during an interview with LA, LA stated the lint in Dryer # 3 was quite a bit and if not removed , the lint could become a fire hazard. On May 1, 2025, at 9:51 a.m., during an interview with the House Keeping Supervisor, he stated the L.A. should have followed the policy, which requires cleaning the lint trap every two hours. A review of the facility policy and procedure titled, House Keeping/Laundry, dated March 8, 2013, indicated .Remove all lint from dryer every 2 hours and at the end of each shift .

Based on interview and record review, the facility failed, for one of five sampled residents (Resident 1) to notify Resident 1's representative (conservator) following an incident involving contraband ( a metal fork) found in the resident's room. This failure had the potential to exclude the resident's representative from being involved in the care planning and decision-making regarding resident's safety and psychosocial status. Findings: A review of Resident 1's medical records, titled, Resident Information, dated, April 8, 2025, at 9:38 p.m., indicated, resident was admitted to the facility on [DATE], with a diagnosis of unspecified Schizophrenia (a mental health disorder that affects thoughts, feelings and behaviors, characterized by a disconnection from reality, including delusions, hallucinations). A review of Resident 1's Minimum Data Set (an assessment tool) indicated, Resident 1 had a Brief Interview of Mental Status (cognitive assessment) score of 09 out of 15 (moderate cognitive impairment). A review of Resident 1's Progress notes, dated, April 2, 2025, at 8:50 a.m., by Program Counselor (PC) 1, indicated, . At approximately 8:30 A.M. staff conducting a routine room check found a metal fork in (Resident 1's) room, which is considered contraband per unit policy. Staff retrieved the (fork) . (resident) was informed of the unit rules regarding (no) unauthorized items (on the unit). (PC 2) to follow up with 1:1 (one to one) counseling to reinforce unit expectations and discuss appropriate alternatives . A further review of Resident 1's progress notes, indicated, there was no documentation that Resident 1's representative had been notified of the incident. On April 8, 2025, at 1:57 p.m., an interview was conducted with PC 1, who stated, the PC were expected to notify the resident's representative when contraband was found. PC 1 stated, she did not make the notification, believing PC 2 would notify the resident's representative. A review of Resident 1's Progress notes, dated, April 2, 2025, at 9:20 a.m., by PC 2, indicated, . PC met with the resident to discuss the report of the resident hiding a metal fork under his mattress. When asked about the report, (Resident 1) stated, I forgot I had it . PC encouraged (resident) to seek staff assistance when he feels unsafe . PC will continue to monitor (behavior), and interventions as needed . On April 9, 2025, at 1:10 p.m., an interview was conducted with PC 2, who stated, he spoke with Resident 1 about the incident where a contraband was found in the resident's room. PC 2 stated he did not notify the resident's representative and he should have done so. On April 9, 2025, at 1:35 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON), the DON stated, the facility policy required staff to notify the resident's representative when contraband was found. The DON stated, Resident 1's representative was not notified after the incident on April 2, 2025. On April 9, 2025, at 2:55 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1, who stated, when a resident was found with contraband, LVN was to notify the resident's representative. LVN 1 stated, she was the charge nurse on April 2, 2025, when she was informed by PC 1, resident was found with contraband. LVN 1 stated, she did not notify Resident 1's representative, because she thought this was an on-going issue, and did not realize the incident had just happened. LVN 1 stated, she should have notified Resident 1's representative. A facility policy, titled, Change in a Resident's Condition or Status, revised, December 2008, indicated, . Policy Statement: Our facility shall promptly notify the resident . representative . of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care . resident rights, etc.). Policy Interpretation and Implementation . 2. A significant change' of condition is a decline . in the resident's status that: a. Will not normally resolve itself without intervention by staff . c. Requires interdisciplinary review and/or revision to the care plan . 3. Unless otherwise instructed by the resident, the (Facility) will notify the resident's family or representative . when: . b. There is a significant change in the resident's physical, mental, or psychosocial status .

Based on interview and record review, the facility failed to revise the care plan and implement appropriate interventions for one of five sampled residents (Resident 1) after the resident was found with contraband (a metal fork) under his mattress. This failure had the potential for Resident 1 to retain or collect additional contraband without staff knowledge, placing the resident and others at risk for harm. Findings: A review of Resident 1's medical records, titled, Resident Information, dated, April 8, 2025, at 9:38 p.m., indicated, resident was admitted to the facility on [DATE], with a diagnosis of unspecified Schizophrenia (a mental health disorder that affects thoughts, feelings and behaviors, characterized by a disconnection from reality, including delusions, hallucinations). Further review indicated a Brief Interview of Mental Status ({BIMS}-cognitive assessment) score of 09 out of 15 (moderate cognitive impairment). A review of Resident 1's progress notes, dated April 2, 2025, at 8:50 a.m., by Program Counselor (PC) 1, indicated, . At approximately 8:30 A.M. staff conducting a routine room check found a metal fork in (Resident 1's) room, which is considered contraband per unit policy. Staff retrieved the (fork) . (resident) was informed of the unit rules regarding (no) unauthorized items (on the unit). (PC 2) to follow up with 1:1 (one to one) counseling to reinforce unit expectations and discuss appropriate alternatives . A review of Resident 1's care plan titled, Inappropriate Behavior . as evidenced by . (Resident 1) taking a metal fork from dining and leaving it in his room . initiated April 2, 2025, by PC 1, indicated, no behavioral interventions to help prevent resident from taking contraband out of the dining room. On April 8, 2025, at 1:57 p.m., an interview was conducted with PC 1, who stated, when a resident is found with contraband in their room a care plan is updated and/or initiated. PC 1 stated, on (April 2, 2025, at approximately 8:30 a.m.) she was notified by unit staff, a fork was found under Resident 1's mattress, during room checks. PC stated, staff removed the fork from resident's room, PC followed-up with Resident 1, and resident stated he did not remember how the fork got under his mattress. PC stated, she reviewed the unit rules of no contraband with resident, notified Resident 1's assigned Program Counselor (PC 2), other appropriate staff and documented the incident in resident's progress notes. PC stated, she and unit staff discussed starting the new intervention of checking Resident 1 for contraband after meals/prior to leaving the dining room. PC 1 verified, she did update Resident 1's care plan, titled, Inappropriate Behaviors, on April 2, 2025, . As Evidenced by (Resident 1) taking a fork from dining and leaving in his room . PC 1 verified, she did not add the intervention to check Resident 1 for contraband after meals, because she was not Resident 1's assigned PC, stating (PC 2) is (Resident 1's) assigned PC and responsible to add interventions to (resident's) care plan. On April 8, 2025, at 2:10 p.m., a concurrent interview and record review, the Director of Nursing (DON) stated that no new interventions were added to Resident 1's care plan following the incident, and they should have been. The DON stated, appropriate interventions would include using plastic utensils and searching the resident for contraband after meals. The DON verified, new behavioral interventions to help prevent Resident 1 from taking contraband out of the dining room was not included in Resident 1's care plan, and should have been added by a PC or Nurse. On April 8, 2025, at 2:40 p.m., an interview was conducted with Mental Health Worker (MHW) 1, who stated, she was aware Resident 1 was using plastic utensils but was not aware that the resident should be searched for contraband after meals. On April 8, 2025, at 2:45 p.m., an interview was conducted with MHW 2, who stated, he did not know Resident 1 was to be searched for contraband, prior to leaving the dining room. A facility policy, titled, Care Plans - Comprehensive, revised, August 2007, indicated, . Policy Statement: An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Police Interpretation and Implementation: 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 3. Each resident's . Care Plan has been designed to: a. Incorporate identified problem areas: b. Incorporate risk factors associated with identified problems; . d. Reflect treatment goals and objectives in measurable outcomes; . f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels . 5. Care plans are revised as changes in the resident's condition dictate .

Based on interview and record review, facility failed to ensure the resident was treated with dignity and respect for one of three sampled residents (Resident 1), when Mental Health Worker (MHW 1) did not assist the resident after he fell from his wheelchair and failed to provide support when the resident dropped his cigarette. This failure resulted in Resident 1 becoming angry and agitated with staff member. Findings: A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (mental health condition with symptoms of schizophrenia [thoughts or experiences that seem out of touch with reality, disorganized speech or behavior] and a mood disorder [intense and persistent changes in mood, energy, and behavior]) and osteoarthritis (tissues in the joint break down over time) of knee. A review of Resident 1's Progress Notes, dated February 15, 2025, indicated, .Incident Note .Approximately at 1950 (7:50 p.m.), res (Resident 1) was at the patio for smoke break, then res (resident) was noted arguing with a male staff .res accidentally dropped his cigarette on the floor then the male staff that the res doesn't want to touch his cigarette was seen pulling res wheelchair backward and res fell on his knees and hands, then the male staff left res on the floor and walked away, so, another staff helped res to get back on his wheelchair, the res turn around and attempted to pick another cigarette that was on the floor, so the same male staff then kicked the cigarette out of the way . On February 27, 2025, at 10:50 a.m., an interview was conducted with the Administrator (Admin) who stated, on February 15, 2025, at approximately 7:55 p.m., Resident 1 was on the patio during a smoke break with MHW 1. The Admin stated, Resident 1 dropped a cigarette and reached for it when MHW 1 kicked it out of reach, causing Resident 1 to fall from his wheelchair. The Admin stated, MHW 1 did not assist Resident 1 back into the wheelchair or offer another cigarette. The Admin stated, the staff were expected to help residents with tasks they could not perform themselves. On February 27, 2025, at 3:01 p.m., an interview was conducted with MHW 2. MHW 2 stated, on February 15, 2025, at approximately 7:55 p.m., he was inside the facility when he heard Resident 1 outside on the patio, cursing and yelling at MHW 1. MHW 2 stated, he went outside, Resident 1 argued that the cigarette MHW 1 offered was not his. MHW 2 stated, MHW 1 insisted it was and did not attempt to calm the resident. MHW 2 stated, he retrieved the cigarette, which settled the issue. MHW 2 stated, after returning inside, he saw Resident 1 on the ground in front of his wheelchair. MHW 2 stated, MHW 1 stood behind the wheelchair, watching but not assisting. MHW 2 stated, he went outside and helped Resident 1 back into his wheelchair. MHW 2 stated, as the smoke break ended, Resident 1 leaned forward to grab a cigarette from the ground, MHW 1 kicked it away. MHW 2 stated, Resident 1 became upset, stood up, raised his fists. MHW 2 stated, he stepped in between them to prevent a confrontation and escorted Resident 1 inside to calm down. MHW 2 stated, MHW 1 was unprofessional and did not assist Resident 1. MHW 2 stated, he reported the incident to Licensed Vocational Nurse (LVN) 1 immediately. On February 27, 2025, at 3:23 p.m., an interview was conducted with LVN 1, who stated, on February 15, 2025, at approximately 8:00 p.m., MHW 2 told her to review the security cameras due to an incident between MHW 1 and Resident 1 on the patio. LVN 1 stated, she reviewed the footage and saw MHW 1 appearing to antagonize Resident 1 by holding a cigarette in his hand but not giving it to the resident. LVN 1 stated, she saw MHW 2 come outside and hand Resident 1 a cigarette. LVN 1 stated, she then saw Resident 1 drop his cigarette on the ground and reached for it, MHW 1 then Stomped, on the cigarette and swept it out of resident's reach with his foot, resulting in Resident 1 falling out of his wheelchair while reaching for the cigarette. LVN 1 stated, after resident fell out of his wheelchair, MHW 1 was observed walking away from resident, and did not assist resident back into his wheelchair. LVN 1 stated, MHW 2 came out to the patio and assisted Resident 1 back into his wheelchair. LVN 1 further stated, MHW 1 did not treat Resident 1 with respect and dignity, as MHW 1 did not assist resident with his needs. LVN 1 stated, she reported the incident immediately to the Director of Nursing (DON), who instructed her to send MHW 1 home pending investigation. On February 27, 2025, at 5:52 p.m., an interview was conducted with the DON, who stated, she expected staff to treat residents with dignity and respect. The DON stated, on February 15, 2025, at approximately 8:40 p.m., LVN 1 reported, an incident had occurred between Resident 1 and MHW 1 on the patio at approximately 7:55 p.m. The DON stated, she reviewed the cameras and observed Resident 1 dropped his cigarette on the ground, at which time, MHW 1, Kicked and Kicked the cigarette out of resident's reach, causing Resident 1 to slide out of his wheelchair, on to the ground, his hands and knees. The DON stated, when resident slid out of his wheelchair, his pants had partially fallen, exposing half of his buttocks in the presence of other residents. The DON stated, this incident appeared to violate Resident 1's rights as he was not being treated with dignity and respect by MHW 1. The DON stated, the situation (on the patio) was not handled appropriately by MHW 1. The DON stated, she would expect MHW 1 to have handed Resident 1 another cigarette and help resident back into his wheelchair. The DON stated she instructed LVN 1 to send MHW 1 home immediately pending investigation. The DON verified, MHW 1's employment was terminated on February 18, 2025 due to unacceptable conduct and behavior. A review of the facility's Policy & Procedure, titled, Resident Rights, undated, indicated, . Employees shall treat all residents with kindness, respect and dignity . 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity .

Based on interview and record review, the facility failed to report the neglect for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH) within 2-hours. Resident 1 was denied a cigarette and left without assistance back into his wheelchair by Mental Health Worker (MHW) 1. This failure had the potential to result in Resident 1 to remain at risk of further harm and emotional distress. Findings: On February 27, 2025, at 10:50 a.m., an interview was conducted with the Administrator (Admin), who stated, he was the facility's abuse coordinator and that staff were expected to report all witnessed or suspected abuse or neglect within two hours to CDPH and other agencies. A review of Resident 1's record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (mental health condition with symptoms of schizophrenia [thoughts or experiences that seem out of touch with reality, disorganized speech or behavior] and a mood disorder [intense and persistent changes in mood, energy, and behavior]) and osteoarthritis (tissues in the joint break down over time) of knee. A review of Resident 1's Progress Notes, dated February 15, 2025, indicated, .Incident Note .Approximately at 1950 (7:50 p.m.), res (Resident 1) was at the patio for smoke break, then res (resident) was noted arguing with a male staff .res accidentally dropped his cigarette on the floor then the male staff that the res doesn't want to touch his cigarette was seen pulling res wheelchair backward and res fell on his knees and hands, then the male staff left res on the floor and walked away, so, another staff helped res to get back on his wheelchair, the res turn around and attempted to pick another cigarette that was on the floor, so the same male staff then kicked the cigarette out of the way . On February 27, 2025, at 3:23 p.m., an interview with Licensed Vocational Nurse (LVN) 1, was conducted. LVN 1 stated, that facility policy required reporting neglect to CDPH and other agencies within two hours. LVN 1 stated, on February 15, 2025, at approximately 8:05 p.m., while reviewing security footage, she observed MHW 1 and Resident 1 on the patio during a smoke break at approximately 7:55 p.m. LVN 1 stated, she saw MHW 1 antagonizing Resident 1 by withholding a cigarette and later sweeping a cigarette away with his foot when Resident 1 reached for it, causing Resident 1 to fall out of his wheelchair. LVN 1 stated, MHW 1 walked away, leaving Resident 1 on the ground, while MHW 2 assisted the resident back into his wheelchair. LVN 1 further stated, she reported the incident to the Director of Nursing (DON) at approximately 8:50 p.m. LVN 1 stated, the DON instructed her to send MHW 1 home pending and investigation, which she did immediately. LVN 1 stated, she informed the Director of Staff Development (DSD) and asked for assistance in reporting the incident to CDPH and other agencies. On February 27, 2025, at 4:04 p.m., a concurrent interview with the DSD and review of CDPH and other agency reporting times was conducted. The DSD stated, per facility policy , abuse or neglect must be reported to CDPH and other agencies within two hours. The DSD stated, on February 15, 2025, at approximately 9:30 p.m., LVN 1 reported that MHW 1 left Resident 1 on the ground after he slid from his wheelchair and did not assist him. The DSD stated, MHW 2 helped Resident 1 back into his wheelchair . The DSD stated, it was neglect and basic care was not provided. The DSD stated, she was informed of the incident at 9:30 p.m. and knew it had occurred at 7:55 p.m. The DSD stated, she did not report it to CDPH and other agencies until 11:20 p.m. (3 hours later). The DSD stated, she had completed paperwork before making the report making the report and stated I should have called first and then done the paperwork. On February 27, 2025, at 5:52 p.m., a concurrent interview with the DON and review of intake reporting times was conducted. The DON stated, facility policy required staff to report suspected neglect to CDPH and other authorities within two hours. The DON stated, an incident of neglect involving Resident 1 and MHW 1 had occurred on the smoking patio at 7:55 p.m. but was not reported to CDPH via telephone until 11:20 p.m. The DON stated the report had not been made within the required two-hour timeframe. A facility Policy & Procedure, titled, Reporting Abuse & Unlawful conduct to State Agencies and Other Entities/Individuals, undated, indicated, . All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. Allegations of abuse, including injuries of unknown source or causing serious bodily injury must be reported as soon as possible or no later than 2 hours from the time the facility is made aware . 3. The Administrator or his designee will notify the State Licensing/Certification agency of any injuries of unknown injury or incidents of abuse that result in serious bodily injury as soon as possible and no later than 2 hours .

Based on observation, interview, and record review, the facility failed to develop and implement ongoing infection surveillance monitoring for suspected scabies (a highly contagious skin condition caused by mites that burrow into the skin), for six of six residents (Resident 1, 2, 3, 4, 5, and 6). This deficient practice had the potential for a delay in the care and treatment and possible spread of infection throughout the facility. Findings: On September 4, 2024, at 10:50 a.m., an unannounced visit was conducted to investigate infection control issues. On September 4, 2024, at 11:14 a m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed to be sitting up in bed with legs exposed. Resident 1's lower extremities were observed to be red with rash alll over. In a concurrent interview, Resident 1 stated he had scabies for a month, and the facility was just treating him now. Resident 1 stated the physician saw him on September 1, 2024, and told him he had scabies. Resident 1 stated he was treated with some lotion and was given a pill for internal treatment. On September 4, 2024, a review of Resident 1 ' s Admission Record, indicated Resident 1 was admitted on [DATE], with diagnoses of schizophrenia (mental condition of a type involving a breakdown in the relation between thought, emotions, and behavior), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Resident 1 ' s Minimum Data Set (MDS - an assessment tool), dated June 20, 2024, indicated Resident 1 had a BIMS (Brief Interview for Mental Status - mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility) score was 15, indicated cognitively intact. A review of Resident 1's care plan, dated August 1, 2024, indicated a care plan for potential/actual impairment to skin integrity to torso. A review of Resident 1 ' s progress notes indicated the following: - August 1, 2024, at 9:13 p.m., indicated resident monitored for bilateral hand redness and rash, no complain of pain or itching doctor notified and no new orders; - August 8, 2024, at 6:01 p.m., indicated resident remained on monitoring for redness/rash to hands and body. Resident 1 refused topical treatment ordered; - August 31, 2024, at 12:31 a.m., indicated order for Ivermectin (medication to treat scabies) tablet 15 mg (milligram - unit of measurement) for possible scabies and repeat dose again in one week; and - September 1, 2024, at 9:24 a.m., indicated physician ' s visit with order for Elimite (topical cream to treat scabies) External Cream 5% until September 8, 2024. On September 4, 2024, at 11:19 a.m., a concurrent observation and interview was conducted with Resident 2. Resident 2 was observed sitting up at bedside. Resident 2 stated he had not been itching and did not have rash. On September 4, 2024, a Resident 2's record was reviewd. Resident 2's Admission Record, indicated Resident 2 was admitted on [DATE], with diagnoses which included schizophrenia (mental condition of a type involving a breakdown in the relation between thought, emotions, and behavior), and hypertension (high blood pressure). A review of Resident 2 ' s MDS, dated , indicated Resident 2 had a BIMs score of 9, (moderate cognitive impairment). A review of Resident 2's care plan dated August 30, 2024, indicated a care plan for rash and excoriation. A review of Resident 2 ' s Progress Notes, indicated the following: - August 30, 2024, at 3:03 p.m., indicated Resident 2 had redness and rash to the inner thighs, scrotum, left leg and inner arms; - August 31, 2024, at 12:16 a.m., indicated a telephone order for Lotrimin (topical cream to treat rashes) to apply to skin areas; - August 31, 2024, at 1:30 p.m., indicated resident was on monitoring for rash/excoriation to inner thighs around scrotum, left leg and left inner arm. Treatment applied as ordered; and - September 1, 2024, at 09:16 a.m., indicated physician ' s visit with order for Elimite External Cream 5% until September 2, 2024. On September 4, 2024, at 11:22 a.m., a concurrent interview and record review was conducted with Resident 3. Resident 3 was observed walking around in his room. In a concurrent interview, Resident 3 stated he did not have a rash and no itching. A review of Resident 3 ' s electronic medical record (EMR) indicated Resident 3 was admitted on [DATE], with diagnoses of Schizophrenia (mental condition of a type involving a breakdown in the relation between thought, emotions, and behavior), and hypothyroidism (when the thyroid gland does not produce enough thyroid hormone). Resident 3 ' s Brief Interview for Mental Status, (BMI- mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility) was 14, indicated cognitively intact. A review of Resident 3's care plan dated August 29, 2024, indicated a care plan for rash to bilateral feet. A review of Resident 3 ' s progress notes indicated the following: - August 29, 2024, at 6:15 p.m., noted a change of condition charting for rash on Resident 3 ' s bilateral feet; - August 30, 2024, 1:04 p.m., indicated Resident 3 was on monitoring for to bilateral feet rash, possible fungal/athletes ' feet; - September 1, 2024, at 4:12 a.m., indicated Resident 3 was on monitoring for bilateral feet rash. Resident 3 receiving prophylactic medication for scabies; - September 1, 2024, at 4:31 a.m., indicated resident was on monitoring for bilateral feet rash. Resident 3 remains on contact isolation; and - September 1, 2024, at 9:30 a.m., indicated physician ' s visit with order for Elimite External Cream 5% until September 2, 2024. A review of Resident 4 ' s electronic medical record (EMR) indicated Resident 4 was admitted on [DATE], with Bipolar (disorder associated with episodes of mood swings from depressive lows to manic highs), and seizures (uncontrolled electrical activity in the brain cells causes abnormality in muscle tone). Resident 4 ' s Brief Interview for Mental Status, (BMI- mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility) was 15, indicated, cognitively intact. A review of Resident 4's care plan, dated August 30, 2024, indicated prophylaxis treatment to prevent rash. Review of Resident 4 ' s progress notes indicated the following: - August 31, 2024, at 13:18 p.m., indicated a Skin/Wound note indicated resident was on continuous monitoring for prophylactic treatment to prevent rash, isolation precautions. No rashes; - August 31, 2024, at 12:40 a.m., indicated new doctor ' s orders for Ivermectin 15 mg prophylaxis for scabies; and - September 1, 2024, 9:41 a.m., order note indicated new orders for Elimite External Cream 5% to apply to the whole body. A review of Resident 5 ' s electronic medical record (EMR) indicated Resident 5 was admitted on [DATE], with diagnoses of Schizophrenia (mental condition of a type involving a breakdown in the relation between thought, emotions, and behavior), and hypothyroidism (condition where thyroid gland doesn ' t produce enough thyroid hormone). Resident 5 ' s Brief Interview for Mental Status, (BMI- mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility) was 15, indicated, cognitively intact. Review of Resident 5 ' s progress notes indicated the following: - August 30, 2024, at 1 p.m., skin/wound note indicated resident on continuous monitoring for prophylactic treatment to prevent rash, isolation precautions, no rash noted; - August 31, 2024, 12:44 a.m., order note indicated Ivermectin 15mg prophylaxis for scabies; - September 1, 2024, at 9:45 a.m., new telephone order for Elimite External Cream 5%; and - September 1, 2024, at 1:03 p.m., continued monitoring for prophylactic treatment to prevent rash. A review of Resident 5's care plan, dated September 3, 2024, indicated prophylactic treatment to prevent rash. A review of Resident 6 ' s electronic medical record (EMR) indicated Resident 6 was admitted on [DATE], with diagnoses of schizoaffective disorder (mental health illness that causes dramatic changes in thoughts, moods, and behavior) and hypertension (high blood pressure). Resident 6 ' s Brief Interview for Mental Status, (BMI- mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility) was 15, indicated cognitively intact. A review of Resident 6's care plan, dated August 30, 2024, indicated prophylactic treatment to prevent rash. A review of Resident 6 ' s progress notes indicated the following: - August 30, 2024, at 12:47 p.m., skin/wound note indicated, late entry: monitoring for prophylactic treatment to prevent rash, isolation precautions, with no rash at this time; - August 31, 2024, at 12:43 a.m., indicated order note for Elimite 5% cream for rash; - September 1, 2024, at 9:38 a.m., indicated order note for Ivermetin prophylaxis for scabies; - September 2, 2024, at 12:57 p.m. indicated late entry: continue monitoring for prophylactic treatment to prevent rash, on isolation precautions. Resident 6 completed oral and external cream medication and has been cleared by doctor the doctor. On September 4, 2024, at 1:10 p.m., an interview with the designated Infection Preventionist (IP) was conducted. The designated IP stated she became aware of residents being treated for scabies on September 2, 2024, by a mental health worker. The designated IP stated at that point she initiated contact isolation. The IP stated no other residents have been assessed for possible exposure. The IP stated she was not able to provide or describe the facility ' s surveillance process for scabies. The designated IP stated no tracing or surveillance to track other residents in the facility who may have been affected with the rashes was done. On September 4, 2024, at 2:52 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated she was made aware on September 3, 2024, of residents with possible scabies. The DON stated Residents 1, 2, 3, 4, 5, and 6 did not have a confirmed diagnoses of scabies but were treated prophylactically. The DON stated the residents were placed on contact isolation. On September 4, 2024, at 3:50 p.m., a follow up interview with the DON was conducted. The DON stated she did not know the facility ' s identified process for surveillance for prevention and control of scabies. The DON stated, that means I will have to ask each resident if they have any signs and symptoms of scabies. The DON further stated, there was no system in place to verify, assess, monitor, or track if other residents were affected by scabies. On September 4, 2024, at 7:22 p.m., an interview with the Administrator (ADM) was conducted. The ADM stated he was not aware of a current facility ' s process of surveillance for contact precaution for scabies. The ADM stated the facility should have a process to track residents who develop rashes and evaluate for possible scabies. A review of the facility's policy and procedure titled Surveillance of Infections, revised March 15, 2022, indicated, .It is the policy of this facility to scrutnize various aspects of the occurrence and spread of infection and to monitor and investigated the cause of infections via a routine surveillance program . A review of the facility's policy and procedure titled Infection Prevention and Control Program, revised March 4, 2022, indicated, .The elements of our Infection Prevention and Control Program include .A system of surveillance designed to identify possible communicable diseases or infections before they spread to other persons in the facility .

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP - professional who ensures healthcare workers and patients are doing all the things they should to prevent infections) completed the required specialized training for the IP certification program. This failure resulted in the Infection Control and Prevention Program of the facility not having the benefit of a fully qualified and competent IP having the potential to negatively affect the quality of care provided to all the residents. Findings: On September 4, 2024, at 10:50 a.m. an unannounced visit was made to the facility. On September 4, 2024, at 1:10 p.m., an interview with the designated Infection Preventionist (IP) was conducted. The designated IP stated she did not have IP certification at this time. On September 4, 2024, at 2:52 p.m., an interview with Director of Nursing (DON) was conducted. The DON stated the designated IP was not certified. The DON stated the designated IP did not have to be certified to be in the position if in the process of certification. The DON stated she was not overseeing the designated IP and did not know who was. On September 4, 2024, at 7 p.m. an interview with the Administrator (ADM) was conducted. The ADM stated he and the DON were overseeing the IP. The ADM stated the designated IP was not certified and was waiting to finish her certification class. Stated the DON had previous experience as an IP but she was not certified. A review of the facility's document titled Job Description /Job Title: Infection Preventionist, indicated, .The Infection Preventionist plans, organizes, develops and manages the Infection Prevention and Control Program (IPCP) for the facility in accordance with current regulatory requirements .must be qualified by education, training, experience, or certification .must have completed specialized training in infection prevention control . A review of the All Facilities Letter (AFL- a letter from the Center for Health Care Quality (CHCQ), licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C) provided by the DON as the facility ' s policy, indicated, .The IP must have primary professional training as a licensed nurse, medical technologist, microbiologist, epidemiologist, public health professional, or other health related. The Ip must be qualified by education, training, clinical or health care experience, or certification, and must have completed specialized training in infection prevention and control. A review of the facility ' s policy and procedures titled Infection Prevention and Control Program, revised March 4, 2022, indicated, .the IP must be qualified by education, training, experience, or certification, .and have completed specialized training in infection prevention and control .

Based on interview and record review, the facility failed to ensure, for one of three residents sampled (Resident A) did not receive candy infused with cannabis (dried leaves and flowering tops of the Cannabis sativa or Cannabis indica plant which contains active chemicals that cause drug-like effects all through the body) while at facility. This failure had the potential to cause untoward effects of the cannabis to Resident A's overall health and mental condition. Findings: On August 13, 2024, at 11:00 a.m., an unannounced investigation was conducted at the facility for a complaint of resident abuse and quality of care. On August 13, 2024, at 1:30 p.m., an interview was conducted with Program Counselor (PC) 1. PC 1 stated staff donate candy to the facility on a regular basis, the counseling program would collect the candies, and would give out the candy as a reward to the residents. PC 1 stated some canabis infused candies which contained THC (the substance primarily responsible for the effects of marijuana on a person's mental state and gives a high) were mixed in with the regular candies about two weeks ago. PC 1 stated Resident A came to the counselor ' s department, after he received his candy, and Resident A told them that he felt loose, odd. PC 1 stated Resident A did not have drug seeking behaviors and had no history of drug use. PC 1 stated Resident A was the resident who got the candy with cannabis in it. PC 1 stated once we were aware there was candy with cannabis in it, we contacted the Program Director (PD) and the Director of Nursing (DON) and threw away the entire batch of candy to ensure, no one else got the cannabis infused candy. On August 13, 2024, at 1:55 p.m. an interview was conducted with Resident A. Resident A stated he did get candy that made him sick, it was a candy gummy which contained cannabis, and it made him feel weird. Resident A stated he knew the candy had cannabis in it because the label on the package stated it contained cannabis,. Resident A stated never had cannabis before eating the candy, he ate half of the candy in the bag, and it tasted a little weird. Resident A stated the counselors would give out candy to all the residents who turn in the attendance sheets for group each week, and could pick the candy they wanted. Resident A stated he told PC 1 about the candy, another counselor told Resident A he did not have to attend groups the rest of the day. Resident A stated after he ate the candy no one evaluated him. Resident A stated he was nauseous and felt he might throw up, felt mostly sweaty, and went to his room to lay down. On August 13, 2024, at 2:40 p.m., an interview was conducted with PC 2. PC 2 stated the counselors give candy out to the residents for participating in group activities, their attendance, and answering questions. PC 2 stated counselors bring in candy and donate it, someone received candy with cannabis in it. PC 2 stated Resident A came to the counselors and stated the candy Resident A received had cannabis in it. PC 2 stated label on the package stated the candy had cannabis in it. PC 2 stated one of the counselors on the unit had brought in the cannabis infused candy. PC 2 stated he spoke with Resident A and Resident A said he did not share the candies with other residents. PC 2 stated we informed our Assistant Program Director (APD) and Program Director (PD) what had happened and a full unit search was conducted and did not find anything. PC 2 stated it was recommended for Resident A to go to his room and rest. PC 2 stated Resident A was not sent out for an evaluation. On August 13, 2023, at 3:02 p.m., an interview was conducted with the Assistant Program Director (APD). The APD stated there was no policy regarding outside candy being brought into the facility. The APD stated there was absolutely no tolerance for bringing in outside drugs, and the staff was aware of this. On August 13, 2023, at 3:25 p.m., an interview was conducted with PC 3. PC 3 stated she was not aware the candies she had brought in from home contained cannabis. PC 3 stated her partner had put the candy in a bag, she took the candy to work, and put them in the candy bowl for the resident to take as a reward. PC 3 stated Resident A came to her and told her about the candy with cannabis and gave her the package, she reviewed the candy label and it stated there was 600 mg (milligrams-a unit of measure) total of cannabis in the bag. PC 3 stated the bag contained six candies, making each candy containe 100 mg each of cannabis. PC 3 stated Resident A took four of the cannabis infused candies as there was still two candies left in the package. On August 13, 2024, at 6:10 p.m., an inerview was conducted with the Program Director (PD). The PD stated after the incident occurred, PC 3 came to her office and told her about the candy with cannabis in it. The PD stated she went to the DON, and both of them went to the Administrator ' s (Admin) office and explained the situation. On August 13, 2024, a review of Resident A ' s medical record was conducted. Resident A's Admission Record, indicated Resident A was admitted to the facility on [DATE], with a diagnosis of schizophrenia (a mental and behavioral disorder). Resident A ' s Order Summary Report, included physician's order for multiple medications for hallucinations (false thoughts of experience affecting your senses) and delusions (a false belief about external reality). Further review of Resident A ' s medical record did not provide any documentation regarding an incident in which Resident A ate cannabis infused candy, nor monitoring of Resident A after eating the cannabis infused candy, brought in by a staff member. On August 14, 2024, at 9:18 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated one of the counselors brought in some candy with cannabis in it, a resident took it, and self-reported. The DON stated the nurses took vital signs (temperature, pulse rate, blood pressure and respiratory count) on Resident A and were normal. The DON stated Resident A had no obvious complication from the ingestion of the cannabis candy. The DON stated all unusual occurrences should be reported to the state, a staff member bringing in cannabis would be considered an unusual occurrence, it was not reported to the state. The DON stated we do not have a protocol when a resident was under the influence of an illegal substance, however we would monitor the resident's vital signs every two hours, and document in the resident's health record. The DON stated there was not an evaluation completed on Resident A, there was no documentation of the incident, no change of condition was written, and there was no incident report done on Resident A. The DON stated Resident A did take cannabis that was not prescribed by the physician, the nurses informed the doctor and should have written a note in the chart. The DON stated Resident A was monitored through the end of the shift, every two hours, for about six hours. The DON stated no testing was required for Resident A if he had cannabis. The DON stated she believed all the staff, have training on how to deal with a resident under the influence of a substance, after she was informed of the incident the nurses took care of the resident, and nothing else after that. A review of the facility ' s policy and procedure titled Resident Drug Testing Procedure, dated December 5, 2017, indicated, .to create and maintain a working environment free from substance abuse that could result in safety and health hazards to the residents .the following residents will receive an in-house urine drug screen: Resident ' s .who are suspected of having used illegal substances . A review of the facility ' s undated policy and procedure titled Report Abuse & Unlawful Conduct to State Agencies and Other Entities/Individuals, indicated .All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate agencies and other entities or individuals as may be required by law .Should an alleged/suspected violation or substantiated incident .which affects the welfare, safety, or health of resident .notify the following persons or agencies .of such incident .state licensing/certification agency responsible for surveying/licensing the facility . A review of the facility ' s policy and procedure titled Reporting a Change in Condition, dated April 22, 2024, indicated, .A change of condition in a resident can adversely affect his/her medical and psychological status, therefore all significant changes in condition are to be reported .The Director of Nursing will ensure that proper follow up .will be accomplished in a timely manner to ensure the health and safety to all residents .A change of condition will be completed by the charge nurse in the unit when the change of condition was first noted .she will gather .vital signs, do a complete assessment, mental status as well as physical status .document in the medical record the resident ' s change of condition and any new orders received . A review of the facility ' s undated policy and procedure titled Outside Food-Beverage, indicated, .foods and beverages brought from outside facility are to be examined by nurse for quality ( .packaging) to identify potential concerns .

Based on interview and record review, the facility failed to ensure appropriate infection control practices in preventing the transmission of the coronavirus infection (COVID-19 - illness caused by a virus that can be transmitted from person to person) were implemented in accordance with the facility's policy and procedure and Center for Disease Control (CDC) guideline, when the residents and Healthcare Personnels (HCP/staff) were not tested for COVID-19 timely. This failure resulted in a delay in the identification of residents and HCP who were COVID-19 positive, thereby delayed the implementation of infection control measures to prevent further transmission of COVID-19 in the facility. Findings: On January 2, 2024, at 9:18 a.m., an unannounced visit to the facility was conducted for a Focused Infection Control survey and investigation of a Facility Reported Incident. On January 2, 2024, a review of the facility's document titled, (name of facility) - Resident and Employee COVID-19 Tracking (Employees tested Positive), indicated the HCP were positive for COVID-19 on the following dates: - December 22, 2023; two HCP (with symptoms); - December 24, 2023, two HCP (with symptoms); - December 25, 2023, one HCP (with symptoms); and - December 26, 2023, five HCP 9with symptoms). On January 2, 2024, a review of the facility's document titled (name of facility) - Resident and Employee COVID-19 Tracking (Resident tested Positive), indicated 33 residents were tested for COVID-19 at the south unit on December 27, 2023. There was no documented evidence the exposed residents and HCP were tested for COVID-19 after the two HCP were positive for COVID-19 on December 22, 2023. On January 2, 2024, at 9:35 a.m., a concurrent interview and record review with the Administrator (ADM). He stated first COVID-19 cases were December 22, 2023, staff testing commenced on December 26, 2023, and the resident testing commenced December 27, 2023. He stated on December 27, 2023, 33 out of 60 residents in the south wing tested positive for COVID-19 and none of 48 residents at the north wing. He stated there was no documentation the exposed staff and residents were tested for COVID-19 after the onset of COVID-19 on December 22, 2023. On January 2, 2024, at 4 p.m., a follow up concurrent interview and record review with the ADM was conducted. He stated the facility did not begin COVID-19 testing on December 23, 24 or 25, 2023, as he could not verify exposure of cases and if they were facility acquired. He further stated facility begun testing the staff on December 26, 2023, and testing the residents on December 27, 2023, related to the increase of staff reported symptoms. The ADM stated after reviewing the guidelines from the Center of Disease Control (CDC) and California Department of Public Health (CDPH) recommendations for the prevention and control of COVID-19, the facility should have begun testing after the initial positive case of COVID-19 on December 22, 2023, and acknowledged testing the residents and staff earlier could control the transmission of COVID-19 among the residents and staff. A review of the facility document titled, Updated Policies/Procedures dated December 2023, .Recommendations for Prevention of Covid-19, Influenza and Other Respiratory Viral Infections - 2023-2024 .Vista Pacifica Center will follow the recommendations for prevention and control of Covid-19, Influenza and other respiratory viral infections outlined and linked in AFL 23-36, dated 12/5/2023 (unless updated by CDPH in referral to new information . According to the California Department of Public Health (CDPH) Healthcare Associated Infections Program All Facilities Letter 23-36 titled, Recommendations for Prevention and Control of COVID-19, Influenza, and Other Respiratory Viral Infections in California Skilled Nursing Facilities 2023-2-24 dated 12.2023 indicated For asymptomatic SARS-Co-V2-exposed residents or HCP: Test for SARS-CoV-2 immedicately9 but not earlier than 24 hours after the exposure) . According to the Center of Disease Control (CDC) guideline titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated May 8, 2023, indicated, .Responding to a newly identified SARS-CoV-2-infected HCP or resident .A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility have been exposed .Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after first negative test and, if negative again, again in 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 .

Based on interview and record review, the facility failed to ensure an allegation of physical abuse by a resident (Resident A) towards another resident (Resident B) was reported to the California Department of Public Health (CDPH) immediately, or not later than two hours after the allegation was made. This failure had the potential to result in a delay of the implementation of appropriate actions, provisions, and protections to the residents and placed the residents at risk for further abuse. Findings: On July 27, 2023, at 9:30 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On July 27, 2023, at 10:58 a.m., an interview was conducted with the Director of Nursing (DON). She stated she received report in the morning of July 14, 2023, that Resident A and Resident B were involved in an altercation that occurred on July 13, 2023, at around 5 p.m. She stated Resident B spit at Resident A's face and shoved him when Resident A told him to stop spitting on the floor. On July 27, 2023, at 10:10 a.m., an interview was conducted with Resident A. He stated he got into an altercation with Resident B about two weeks ago. He admitted pushing Resident B but denied spitting or shoving him. Resident A could not provide further detail about the incident. On July 27, 2023, at 10:15 a.m., an interview was conducted with Resident B. He stated the incident between him and Resident B happened about 2 weeks ago, while they were in line in the hallway, waiting to go to the dining room for dinner. He stated he told Resident B to stop spitting on the floor, but Resident B got upset and spit at his face and hit him on the chest. He stated Resident B ran and he chased after him until someone stopped him and separated them. He said he told Mental Health Worker (MHW) 1 later that night about the incident between him and Resident B. He further stated he reported the incident it again to another staff the following morning because MHW 1 did not report it to anyone. On July 27, 2023, at 10:35 a.m., an interview was conducted with Resident C. He stated about two weeks ago, while he was in line in the hallway, waiting to go to the dining room, he overheard Resident A called Resident B a bitch. Then, he saw Resident A and B hit each other. He stated Resident B ran after Resident A but he stopped him. He stated later that night of the incident, he told MHW 1 about the altercation between Resident A and Resident B. On July 27, 2023, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included schizophrenia (mental health condition). The Minimum Data Set (MDS - an assessment tool), dated April 21, 2023, indicated Resident A had a BIMS (Brief Interview of Mental Status) of 14 (cognitively intact). The Progress Notes, dated July 14, 2023, at 9:36 a.m., indicated, .This morning at approximately 0845 (8:45 a.m.) resident's peer reported to the primary counselor that resident spit in his face and shoved him while they were standing next to each other in the hall waiting to go to the dining room last evening 7/13/2023 (July 13, 2023) at approximately 5:30 p.m.The (name of state agency) was notified of the altercation . There was no documented evidence an incident of abuse involving Resident A and B was noted in the Progress Notes and or reported to the state agency on the day of the incident on July 13, 2023. On July 27, 2023, Resident B's record was reviewed. Resident B was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (mental health condition). The MDS, dated [DATE], indicated Resident B had a BIMS of 11 (cognitively intact). The Progress Notes, dated July 14, 2023, at 10:02 a.m., indicated, .This morning at approximately 0845 (8:45 a.m.) reported to the primary counselor that a peer spit on his face and shoved him while they were standing next to each other in the hall waiting to go to the dining room last evening 7/13/2023 (July 13, 2023) at approximately 5:30 p.m .Resident attempted to retaliate but staff intervened and separated resident and peer .The (name of state agency) (sic) was notified of the altercation at 0930 (9:30 a.m.) this morning . There was no documented evidence an incident of abuse involving Resident A and B was noted in the residents' Progress Notes and or reported to the state agency on the day of the incident on July 13, 2023. On August 1, 2023, at 3:48 p.m., an interview was conducted with MHW 1. He stated he remembered the incident between Resident A and Resident B on July 13, 2023, at approximately around 5:30 p.m. He stated he was in the hallway monitoring the residents while they were lining up to go to the dining room, when he saw Resident B running after Resident A in the hallway. He stated he got in between the residents and separated them. He stated he did not witness any physical contacts made between Resident A and Resident B. However, he stated after the he separated residents, he was informed by Resident B that prior to him intervening, Resident A spit on his face and hit him. He stated he got busy on the night of the incident and did not report it to the Charge Nurse until 9 p.m. He stated any resident-to-resident altercation must be reported immediately to the Charge Nurse on duty. On August 1, 2023, at 4:58 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. She stated she was aware of the altercation between Resident A and Resident B that happened on July 13, 2023, at around 5:30 p.m. She stated on the night of the incident at around 10:30 p.m., MHW 1 told her that he saw Resident B chasing after Resident A in the hallway but he intervened and separated residents before they got into a physical altercation. She was not aware that prior to this, Resident A spit at Resident B's face and hit him until he spoke to Resident B the following morning on July 14, 2023. She further stated Resident B told her that MHW 1 was aware of the physical altercation between him and Resident A that happened on July 13, 2023. LVN 1 stated all abuse incident, including resident to resident physical altercations, must be reported to the State Agency within two hours from the time facility staff was made aware of the incident. She stated this was not done per facility's abuse protocol. On August 2, 2023, at 9:26 a.m., an interview was conducted with the DON. She stated the resident-to-resident altercation between Resident A and Resident B on July 13, 2023, was not reported until the following day, on July 14, 2023. She stated all abuse incidents must be reported to the State Agency within 2 hours form the time facility staff made aware of the incident, per facility's abuse protocol. The facility's policy and procedure titled, (Name of facility) Preventative Abuse and Reporting Policy, undated, was reviewed. The policy indicated, .Any mandated reporter, who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse or is told by .dependent adult that he or she has experienced behavior constituting physical abuse .or reasonably suspects that abuse shall be report the known or suspected instances of abuse by telephone immediately or as soon as practically possible .

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. 38 insulated plate covers, seven insulated plate bases, and three full sheet metal pans were stacked and stored wet found in the readily to use storage areas; 2. Two various size of cooking pans had dry and heavy black substance buildups on the cooking surfaces and readily available for use; 3. The ice machine was not clean and sanitized properly per the manufacturer's recommendations; 4. The sanitizer concentration was not at the correct range for the manual ware washing in the three-compartment sink; 5. The kitchen did not have the correct manufacturer's instruction to have correct concentration for the sanitizer solution in the red bucket (red buckets are used as a standard of practice to contain sanitizer solution); and 6. The interior of the microwave was found dirty with dry whitish liquid spill and food debris on the side panel. These failures had the potential to cause food-borne illness in a medically vulnerable resident population who consumed food from the kitchen in the facility. The facility census was 106 residents. Findings: 1. During the kitchen initial tour on April 18, 2022, at 9:27 a.m. and 10:05 a.m., conducted with the Dietary Services Director (DS), there were 38 insulated plate covers, seven insulated plate bases, and three full sheet metal pans were found stacked wet and stored in the storage areas readily available for use. In a concurrent interview with the DS, he stated all dishes, pots and pans should be air dried before stored away. During an interview with the Registered Dietitian (RD) on April 20, 2022, at 2:30 p.m., the RD stated the dishes, pots and pans should be air dried before store away in the designated storage areas. She also stated the wetness would lead to bacterial growth. A review of the departmental policy and procedure provided by the facility titled, Cleaning Dishes/Dish Machine, dated 2019, indicated, .Dishes should be air dried on the dish racks .Inspect for cleanliness and dryness and put dishes away .Dishes should not be nested unless they are completely dry . 2. During the kitchen initial tour on April 18, 2022, at 10:08 a.m., two various size cooking pans were observed to have dry and heavy black substance buildups on the cooking surfaces and were stored at the clean storage areas readily available for use. In a concurrent interview with the DS, he verified those two cooking pans had heavy black substance buildups and were not cleanable. The DS stated those pans should be trashed and needed new ones. During an interview with the RD on April 20, 2022, at 2:30 p.m., the RD stated the heavy buildups on the cooking pans would make them difficult to clean. She stated those pans with heavy black buildups should be thrown away and use the new ones. A review of the departmental policy and procedure provided by the facility titled, Director of Food and Nutrition Services Responsibilities, dated 2019, indicated kitchen equipment and tools should be cleaned and sanitized, and kept in good repair. 3. An observation of the ice machine located in the dining room and a concurrent interview with the Maintenance Supervisor (MS) was conducted on April 18, 2022, at 10:58 a.m. The MS was observe to disassemble the top machinery part of the ice machine and was observed to have a significant amount of white substance buildup and orange red residue on the inside of the water curtain (a plastic cover rests over the ice evaporator where the ice dispenses). The orange red residue could be easily wiped off by the paper towel, however, the white substance buildup could not. There was significant amount of orange red residues found on the top and bottom of the ice evaporator panel (a part where water freezes to produce ice and push out from the panel), and on the base of the evaporator unit. In addition, there was a significant amount of white and black substance buildups found on the top side of the ice storage bin and was not easily wiped off with the paper towel. The MS confirmed the residue found in the ice machine. He stated he was responsible for cleaning the ice machine, and he did deep cleaning per the manufacturer's recommended which was every six months. The MS stated he was aware of the calcium deposit (white substance buildup) was the issue, and he increased the frequency of deep cleaning between every six months. He stated his last deep clean was on December 22, 2021 as documented on the cleaning log. He stated he did deep clean also on February 14, 2022, and March 2022, but he did not document in the cleaning log instead documented on his schedule book. The MS explained the steps of the deep cleaning for the ice machine. He stated he would turn off the ice machine and discard all the ice from the ice storage bin. He stated he would disassemble the components of the machinery part of the ice machine and used cleaning solution, without mixing with water, to clean the detached components. Next would be using sanitizing solution, without mixing with water, to sanitize the components. He stated he would reassemble the components back after cleaning and sanitizing. The MS stated he would run the ice machine with the cleaning cycle with putting the cleaning solution in the water reservoir per the manufacturer's recommendation. He stated he would run the ice machine with the sanitizing cycle and putting the sanitizing solution in the water reservoir per the manufacturer's recommendation. The MS stated for the ice storage bin, he would use the same cleaning solution, without mixing with water, and to clean the bin with a towel. Then he would use water to rinse the bin and use the towel to dry it. Next, he would use the sanitizing solution, without mixing with water, and to sanitize the bin with a towel. He stated the air dried would be the final step. A review of ice machine manufacturer's manual provided by the facility, titled, Section 4 Maintenance: Interior Cleaning and Sanitizing, dated 2006, it indicated the procedure of cleaning and sanitizing the ice machine was different from the MS stated and the sanitizer solution should mix with water per manufacturer's recommendation when sanitizing the components and the ice storage bin. On April 20, 2022, at 2:30 p.m., the RD was interviewed. The RD stated the residue and calcium deposits found on the ice machine were not acceptable. She stated the ice machine should be clean and sanitize per manufacturer's recommendations. A review of departmental policy and procedure provided by facility titled Cleaning Instructions: Ice Machine and Equipment, dated 2019, indicated the ice machine should be cleaned and sanitized and follow the manufacturer's cleaning and sanitizing instructions. 4. An observation of manual dish washing by the three-compartment sink and a concurrent interview with Dietary Aide (DA) 1 on April 18, 2022, at 9:46 a.m. was conducted. DA 1 demonstrated and verbalized the process of the manual dish washing. He stated the sanitizing step was to immerse the dishes or cooking equipment in the sanitizer solution for five minutes, and there were several cooking equipment immersed in the sanitizing solution observed. DA 1 then used the test strip to show the effectiveness of the sanitizer solution, and he stated the concentration should be at 100-200 parts per million (ppm, a measurement of concentration on a weight or volume basis). The test strip with the result of the concentration of 100-200 ppm. In a concurrent interview with the DS, he confirmed the result of 100-200 ppm was incorrect and stated the concentration should be at 200 ppm. On April 20, 2022, at 2:30 p.m., the RD was interviewed. The RD stated the staff should be knowledgeable of the correct concentration of the sanitizer solution and the contact time. A concurrent review of the instructions printed on the sanitizer bottle, and it indicated, Sanitization of food processing equipment, utensils, and other food contact articles .sanitizing by immersing articles .(200-400 ppm active quaternary (a chemical sanitizer to sanitize the dishes) for at least 60 seconds . 5. During the initial kitchen tour on April 18, 2022, at 10:15 a.m., Cook (Cook) 1 was observed to make a new sanitizer solution for the red bucket. Cook 1 used the test strip to test the concentration of the sanitizer solution, she stated it should read at 100 ppm. In a concurrent interview with the DS, he stated the kitchen using bleach as sanitizer and the correct concentration should be 100 ppm. A concurrent review of instructions printed on the bleach bottle with the DS, and it indicated, .Sanitizing Non-Porous Food Contact Surfaces: Prepare a sanitizing solution by thoroughly mixing 2 Tbsp (tablespoon) (1 fl. Oz. (fluid ounce) of this product with 2 gallons of water to provide approximately 200 ppm available chlorine by weight . The DS stated he was not aware of the concentration needed to be 200 ppm, and he needed to contact the manufacturer to confirm the concentration. During a follow up interview with the DS on April 19, 2022, at 10:57 a.m., he provided a copy of the manufacturer's information about the bleach solution and confirmed the bleach solution concentration should be at 200 ppm, not 100 ppm. 6. During the initial kitchen tour on April 18, 2022, at 10:35 a.m., the interior of the microwave was found dirty with dry whitish sauce spill on the glass rotation plate and some food debris on the side panel of the interior. In a concurrent interview with the DS, he confirmed the microwave was dirty and stated the spill and food debris should be cleaned and sanitized immediately after used and keep clean at all time. During an interview with the RD on April 20, 2022, at 2:30 p.m., she stated the microwave should be kept clean and free from food debris. The RD also stated the spill should be cleaned up immediately. A review of departmental policy and procedure provided by the facility titled, Cleaning Instructions: Microwave Oven, dated 2019, indicated, .The microwave oven will be kept clean, sanitized and odor free .interior should be cleaned after each use as needed, and at minimum, after each meal service .

Based on interview and record review, the facility failed to ensure: 1. The facility's policy and procedure on Advance Directive (AD - a written instruction such as a living will, relating to the provision of treatment and services when the individual is unable to make decisions) was followed, for 16 of 26 residents reviewed for AD (Residents 1, 23, 36, 42, 51, 53, 54, 57, 65, 67, 70, 75, 76, 83, 86, and 106) when there was no documentation whether the resident chose to complete or decline to formulate an AD when it was offered; and 2. Information regarding formulating an AD was provided to the resident representative (RR), for one of 26 residents reviewed for AD (Resident 16), who did not have the capacity to understand or make a decision for himself. These failures had the potential for the residents to not exercise their right to complete or not complete an AD. Findings: 1. On April 19, 2022, through April 22, 2022, Residents 1, 23, 36, 42, 51, 53, 54, 57, 65, 67, 70, 75, 76, 83, 86, and 106 records were reviewed. There was no documented evidence these residents chose to formulate or decline to formulate an AD. On April 21, 2022, at 4:16 p.m., the Program Director (PD) was interviewed. The PD stated the AD acknowledgement form did not indicate whether the residents chose to or declined to formulate an AD. She further stated there was no documentation in the resident's records whether resident chose to complete or decline to formulate an AD. She stated it should be clearly documented in the resident's records, under the social services notes. 2. On April 19, 2022, Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE]. The Advance Directive Acknowledgement, dated December 28, 2015, indicated Resident 16 refused to sign the acknowledgement form. The Minimum Data Set (MDS - an assessment tool), dated April 7, 2022, indicated Resident 16 had a BIMS (Brief Interview for Mental Status - cognitive assessment) score of 0 (severely impaired). The document titled, Letter of Conservatorship, dated March 11, 2021, indicated, .(name of county) Public Guardian is reappointed conservator (person who was given the rights to make decision on behalf of an individual) of person of (name of resident) .The conservator shall have the right to require the conservatee (person who's rights were given to someone else) to receive treatment related specifically to remedying (improving) or preventing the recurrence of the conservatee's being gravely disabled .The conservatee shall not .have the right to refuse or consent to treatment related to being gravely disabled; have the right to refuse or consent (to sign) to routine medical treatment unrelated to being gravely disabled . There was no documented evidence Resident 16's conservator was provided information regarding formulating an AD. On April 21, 2022, at 12 p.m., the Program Director (PD) was interviewed. The PD stated Resident 16 was under conservatorship and the assigned conservator had the right to make decision on behalf of Resident 16. She stated Resident 16's conservator should have been provided information regarding formulating an AD for the resident. The facility policy and procedure titled, Advance Directives, dated December 1, 2015, was reviewed. The policy indicated, .Advance directives will be respected in accordance with state law and facility policy .Upon admission of a resident to our facility, the Social Service Designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including .the right to formulate advance directives .Information about whether or not the resident has executed an advance directive shall be displayed prominently (clearly) in the medical record .Depending on State requirements, the legal representative may also have the right to refuse or forego treatment .

Based on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet (a diet that is usually a modification of a regular diet. It is modified or tailored to fit the nutrition needs of a particular person. It could be a part of the treatment of a medical condition and normally prescribed by a physician) for lunch on April 18, 2022, and lunch on April 19, 2022, when: 1. Eight residents (Residents 6, 31, 34, 54, 56, 61, and 66) who were on NAS (no added salt) diet received salt packets with their meals; and 2. Four residents (Residents 39, 69, 75, and 104) who were on fortified (enhanced food addition to increase calories and/or protein) diet received regular mashed potatoes with their meals. These failures had the potential to result in compromising the medical and nutrition status of those 11 residents. Findings: 1. During a dining observation of the lunch meal on April 18, 2022, at 12:05 p.m., Resident 6 was observed to have a diet card which indicated NAS, regular texture diet with large portion on his lunch meal tray. Resident 6 received a salt packet on his meal tray. Resident 6 was observed to open the salt packet and used it on his food. In a concurrent interview with Resident 6, he confirmed he opened the salt packet and used the salt on the food. During an observation of the lunch meal service on April 19, 2022, beginning at 11:26 a.m., it was noted Residents 31, 34, 54, 56, 61, and 66, who were on NAS diet received salt packets with their meals. During an interview with the Dietary Services Director (DS) on April 19, 2022, at 3:14 p.m., the DS stated NAS diet meant no added salt and salt packet should not be provided to the residents with NAS diet. During an interview with the Registered Dietitian (RD) on April 20, 2022, at 2:30 p.m., the RD stated NAS meant no added salt and the residents with NAS diet should not receive salt packets with their meals. A review of a document from the diet manual provided by the facility titled, No Added Salt (3000-5000 Milligrams (mg) Sodium), dated 2018, indicated the NAS diet was to provide a minimal sodium restriction and the salt packet should be omitted with meal. It also indicated one salt packet was equal to approximately 3500-4500 mg sodium. 2. During an observation of lunch meal service on April 19, 2022, beginning at 11:26 a.m., it was noted Residents 39, 69, 75, and 104, who were on fortified diet received regular mashed potato. A concurrent review of a departmental document provided by the facility titled, Daily Menu Guide, Cycle A - Spring, Week 1, Day: Tuesday, dated 2018, indicated residents with fortified diet should have received fortified mashed potatoes. During an interview with the DS on April 19, 2022, at 3:14 p.m., the DS acknowledged few residents with fortified diet received regular mashed potatoes with their lunch meal on April 19, 2022, during the meal service observation. The DS stated those residents with fortified diet should have received fortified mashed potatoes. He stated the Cook or dietary aides should follow the menu and the prescribed diets by the physician. During an interview with the RD on April 20, 2022, at 2:30 p.m., the RD stated the staff should follow the menu or spreadsheet and provide the fortified mashed potatoes to the residents with fortified diet. A review of a document from the diet manual provided by the facility, titled, Fortified/Enhanced Foods, dated 2018, indicated fortified diet was modified in nutrients to increase calorie or/and protein. It considered as a treatment for an underlying medical condition which required a physician's order. A review of the undated facility document provided by the facility titled, Job Description, Job Title: Cook, indicated the Cook should ensure the proper preparation, portioning and serving of foods as indicated on the spreadsheets. The Cook also prepared meal trays for the residents according to their diet orders and preferences. A review of the undated facility document provided by the facility, titled Job Description, Job Title: Dietary Aide, it indicated the dietary aide was required to serve foods accurately that were specified by the menu and/or diet for all meals. The facility's Dietary Manual, dated 2018, was reviewed. The manual indicated, .Fortified/Enhanced Foods .All fortified or enhanced food regimes require a physician's order due to the alteration in nutrients and are considered to be a treatment for an underlying medical condition. Fortified/enhanced foods should be used for RPCs (residents) with reduced oral intake to provide maximum nutrition support. These procedures increase calories and protein without a significant increase in food volume .

Based on observation, interview, and record review, the facility failed to implement infection control practice in preventing transmission of COVID-19 ([MEDICAL CONDITION]- an illness caused by [MEDICAL CONDITION] that can be transmitted from person to person) infection when: 1. The facility staff required to wear a tight-fitting N95 respirator were not fit-tested in accordance to CAL/OSHA requirements. This failure had the potential to result in staff not receiving adequate protection from contaminated air. 2. The facility staff were implementing the extended and re-use strategy in optimizing their isolation gown. In addition, the isolation gowns were disinfected not in accordance to the manufacturer's recommendation. These failures had the potential to result in cross-contamination. 3. The facility staff were observed not wearing the appropriate personal protective equipment (PPE) while inside the unit dedicated to residents of unknown COVID-19 status. This failure had the potential to result in transmission of COVID-19 infection to staff and residents. Findings: 1. On November 23, 2020, at 9:05 a.m., upon entering the facility lobby, a posted signage indicated the necessary PPE needed by the staff prior to entering the yellow zone (unit dedicated for the residents of unknown COVID-19 due to exposure to positive confirmed COVID 19 infected person). A box of a N95 respirator, blue isolation gown, and face shields were observed on top of the table available for use. On November 23, 2020, at 9:33 a.m., the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) was interviewed regarding the needed PPE in entering the yellow unit. She stated face shield, N95 and gown were required to be worn prior to entry. On November 23, 2020, at 11:23 a.m., a facility staff was observed coming out of the yellow unit, doffed (removed) gown, and hanged the gown by the wall near the entrance of the unit. The staff was observed not removing her N95. In a concurrent interview, the primary counselor stated she obtain new N95 as soon as she enter the facility. She stated the PPEs are available near the entrance of the facility, which included the blue gown, and the N95. On November 23, 2020, at 2:03 p.m., during an interview with the ADON/IP, she stated they had 58 confirmed COVID-19 positive residents and 18 staff members. During the discussion, fit testing of N95 was discussed with the ADON/IP, and she stated they have not been fit tested at the facility. On November 23, 2020, at 3:15 p.m., a Mental Health Worker (MHW)/ Certified Nursing Assistant (CNA) 1 was interviewed. She stated she uses N95 mask when she goes inside the yellow and red zone (dedicated for confirmed COVID-19 positive). She stated the N95 would be used the whole shift and discarded at the end of the shift. MHW/CNA 1 stated they had not been fit tested for the N95 masks. On November 23, 2020, at 3:18 p.m., the Director of Nursing/ IP was interviewed regarding fit testing of the facility staff wearing a N95. She stated they had not conducted fit testing, and was unaware of the CAL/OSHA requirements. The DON/IP stated they follow the CDC guidelines in PPE use. A review of the Centers for Disease Control (CDC) guidance on N95 use titled, Summary for Healthcare Facilities: Strategies for Optimizing the Supply of PPE during Shortages, dated July 16, 2020, indicated, .Implement just-in-time fit testing . A review of CAL/OSHA requirement titled, Cal/OSHA Interim Guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages, dated August 6, 2020, indicated, .Use Fit Testing Methods that Maximize Respirator Supplies and Fit Testing Efficiency. Initial respirator fit testing is required before an employee uses a respirator, or when an employee changes to a different model, make, or size of respirator. There are no changes to these requirements. Annual respirator fit testing is also required. To reduce usage of respirators and prioritize fit testing equipment and supplies for fit testing of new models, Cal/OSHA will allow a 90-day delay for meeting annual fit testing requirements provided there are no changes on employee's physical condition that could affect respirator fit. Such conditions include, but are not limited to, facial scarring, dental changes, cosmetic surgery, or an obvious change in body weight . 2. On November 23, 2020, at 9:05 a.m., upon entering the facility lobby, a posted signage indicated the necessary PPE needed by the staff prior to entering the yellow zone. A box of a N95 respirator, blue isolation gown, and face shields were observed on top of the table available for use. On November 23, 2020, at 9:33 a.m., the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) was interviewed regarding the needed PPE in entering the yellow unit. She stated face shield, N95 and gown were required to be worn prior to entry. On November 23, 2020, at 9:45 a.m., a blue isolation gown was observed hanging by the wall near the entrance of the unit (North station). The IP stated the blue gowns were being re-used by the same staff, all through out the shift and discarded at the end of the shift. On November 23, 2020, at 10:20 a.m., the ADON/IP was observed disinfecting the isolation gown and hanging the used gown by the wall near the entrance of the north unit, after doffing (removing). In a concurrent interview, the ADON/IP stated the facility staff disinfect the blue gown using a sanitizing spray. On November 23, 2020, at 10:30 a.m., during interview with the ADON/IP and the Assistant Administrator regarding extended and re-use of the blue gown, the Assistant Administrator stated the blue gown was provided by MHOAC (Medical Health Operational Action Coordinator) and was being disinfected with sanitizing spray. The Assistant Administrator stated they had been getting supplies from different providers to ensure they had adequate supply. Concurrently, the ADON/IP stated the blue gown was water-resistant and can be disinfected using the sanitizing spray. The ADON/IP was unable to provide informaton on whether the manufacturer's recommendation on the blue isolation gown indicated the use of sanitizing spray for disinfection. On November 23, 2020, at 10:55 a.m., observed two blue colored gowns hanging on the wall outside the entrance door of the south unit of the facility. Three staff were observed donning the PPE outside the entrance door to the south unit. In a concurrent interview, Mental Health Worker (MHW) 2 stated she removed her gown outside the door of the south unit, hanged it on the wall and sprayed the gown with a disinfectant spray (showed the hooks on the wall and spray bottle labeled, SANITIZER). She stated she wrote her name on the gown, and will be reusing the same gown when she returned back to the unit. On November 23, 2020, at 11:23 a.m., a facility staff (counselor) was observed disinfecting the isolation gown, and hanging the used gown by the wall near the entrance of the north unit, after doffing (removal). In a concurrent interview, the counselor stated that they would sanitize the gown after use, label it with their name, hang it by the wall for use when they needed to re-enter the unit during the shift. On November 23, 2020, at 12:02 p.m., the ADON/ IP provided the manufacturer recommendation for the blue isolation gown. She stated the blue isolation gown was washable. A review of the document provided by the ADON/ IP titled, Level 1 Isolation gown by KSE, indicated, .Blue Isolation Gowns are reusable and launderable and are made out of 100 % (percent) Fluid Proof Polyster .This product is built to last the full 75 full wash cycles . The document did not indicate that the isolation gown can be disinfected using a sanitizing spray. On November 23, 2020, at 12:13 p.m., the ADON/IP was interviewed and stated that all isolation gown would be discarded upon leaving the unit, and no re-use of gown will be implemented. On November 23, 2020, at 3:43 p.m., the DON/IP was interviewed and stated the staff were already made aware that the isolation gowns would not be re-used. She stated the isolation gown should be discarded upon leaving the unit, and don a new one when entering the unit. On November 24, 2020, at 10:42 a.m., the Assistant Administrator stated the facility had adequate isolation gowns and the facility was not in a crisis mode related to PPE availability. A review of the Centers for Disease Control (CDC) guidance on optimizing personal protective equipment titled, Strategies for Optimizing the Supply of Isolation Gowns, updated October 9, 2020, indicated, .CDC's optimization strategies for gown supply offer a continuum of options for use when there are anticipated or known shortages of gowns. Contingency and then crisis capacity measures augment conventional capacity measures and are meant to be considered and implemented sequentially .Conventional Capacity Strategies .Reusable (i.e., washable) gowns are typically made of polyester or polyester-cotton fabrics. Gowns made of these fabrics can be safely laundered after each use according to routine procedures and reused .Crisis Capacity Strategies .Extended use of isolation gowns .Consideration can be made to extend the use of isolation gowns (disposable or reusable) such that the same gown is worn by the same HCP when interacting with more than one patient housed in the same location and known to be infected with the same infectious disease (i.e., COVID-19 patients residing in an isolation cohort) .Re-use of isolation gowns. The risks to HCP and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, and reusable gowns should NOT be reused before laundering, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits . 3. On November 23, 2020, at 9:05 a.m., upon entering the facility lobby, a posted signage indicated the necessary PPE needed by the staff prior to entering the yellow zone. A box of a N95 respirator, blue isolation gown, and face shields were observed on top of the table available for use. On November 23, 2020, at 9:33 a.m., the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) was interviewed regarding the needed PPE in entering the yellow unit. She stated face shield, N95 and gown were required to be worn prior to entry. On November 23, 2020, at 9:50 a.m., during the tour of the yellow zone with the ADON/IP, a licensed nurse walking in the hallway was observed not wearing a face shield or eye protection inside the unit. The residents inside the unit were observed, out of their rooms and ambulating in the hallway. The IP stated the licensed nurse should be wearing a face shield while inside the unit. On November 23, 2020, at 9:54 a.m., a housekeeper was observed wearing a mask on his chin, and was not wearing a face shield. The ADON/IP went to the housekeeper to remind regarding the PPE, and the housekeeper stated, Sorry, I forgot. The ADON/IP stated they should be wearing the appropriate PPE when entering the yellow zone unit. A review of the revised facility mitigation plan with an approval date of November 19, 2020, indicated, .All staff will wear recommended PPE while in the building per current CDPH PPE guidance . A review of the Centers for Disease Control (CDC) guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated Nov. 4, 2020, indicated, .Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection .Personal Protective Equipment. HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection .

Based on interview and record review, the facility failed to ensure Resident 1 was treated with dignity and respect and was not subjected to verbal abuse by a facility staff member on December 28, 2013. Findings: The facility failed to ensure Resident 1 was treated with dignity and respect, and was not subjected to verbal abuse from a facility staff member on December 28, 2013. An interview was conducted with Certified Nursing Assistant 1, (CNA 1) on December 31, 2013, at 10:55 a.m. CNA 1 stated he was assisting CNA 3 with the check- in of residents coming back to the facility from a pass on December 28, 2013, at 8:15 p.m. CNA 1 and CNA 3 checked the returning residents for potential contraband (Items not allowed in the facility for safety reasons). CNA 1 stated he put Resident 1 ' s hat back on Resident 1 ' s head after checking it. Resident 1 expressed that he did not like staff members placing the hat back on his head. CNA 1 stated he apologized to Resident 1 for placing his hat on his head. Resident 1 had made some derogatory (belittling) statements to CNA 1 and CNA 3 about the hat placement. CNA 1 stated CNA 3, Responded by calling (Resident 1) a faggot. CNA 2 continued to state, There was another confrontation in the television room with Resident 1 and CNA 3. CNA 1 further stated, CNA 2 (Name Withheld) saw this. An interview was conducted with a CNA 2 on December 31, 2013, at 12 noon. CNA 2 stated, Staff (CNA 3) crossed the line with the resident. CNA 2 reported she was, Walking in the hallway near the television room with (CNA 3) when Resident 1 came up to CNA 3 and stated, You wanted to kick my ass . he(CNA 3) said, Yes I did .what are you going to do about it .if you ' re not going to do anything about it walk away. CNA 2 stated Resident 1 then became agitated. CNA 1 stated, He started pacing and seemed upset. CNA 2 stated she, Assisted Resident 1 back to his room. CNA 2 stated she Did not want to leave the unit to report the incident, with what had taken place between Resident 1 and CNA 3 (Names Withheld). CNA 2 stated she, Waited ten minutes for her supervisor to return from lunch. An interview was conducted with the evening Charge Nurse on December 31, at 11:55 a.m. The Charge Nurse stated, CNA 2 (Names Withheld) came to me around 8:45 p.m. and told me there was an incident between Resident 1 and CNA 3. The Charge Nurse stated, He (CNA 3) called Resident 1 a faggot .and said if you want to fight we could fight right now. An interview was conducted with Resident 1 ' s conservator on December 31, 2013, at 12:30 p.m. The conservator stated that she was not called regarding the verbal incident which took place between Resident 1 and CNA 3. She stated, I had to call the next day after he (Resident 1) had called me and told me he had a fight with a worker. An interview was conducted with Resident 1 on December 31, at 9 a.m. Resident 1 was asked about the incident that took place with CNA 3. Resident 1 stated, (he) Did not want to go there. An interview was conducted with the Program Director/Administrative Assistant (PDAA) on December 31, 2013, at 9 a.m. The PDAA stated CNA 3 was in complete denial of his actions .blaming the resident (Resident 1) all the way up until (CNA 3 ' s) termination. A record review of Resident 1 ' s clinical record conducted on December 31, 2013, indicated, Resident 1 was admitted [DATE], with [DIAGNOSES REDACTED]. A review of the facility undated document conducted on December 31, 2013 titled, Patients ' Rights/Confidentiality, indicated . Policies and procedures shall ensure that each patient admitted to the facility shall have the following rights and be notified of the facility ' s obligations . (10) To be treated with consideration, respect and full recognition of dignity, and individuality, including privacy in treatment and care of personal needs.

Based on observation, interview, and record review, the facility failed to provide the necessary care and sevices to attain the highest practicable physical well-being for one of 22 sampled residents, (Resident 84), by failing to: 1. Arrange for and ensure the dental consult ordered on December 7, 2012, was conducted timely. The dental consult was not conducted until February 4, 2013, almost two months later. Resident 84 complained of pain and developed swelling and an infection, requiring antibiotic treatment on January 30, 2013. 2. To ensure there was ongoing oral assessment of Resident 84's oral pain, oral status, and difficulty chewing. Resident 84 had an ill-fitting lower denture partial that was digging into her lower gum line, causing mechanical trauma and pain. Findings: 1. Resident 84 was admitted to the facility on [DATE], with psychiatric diagnoses. On January 30, 2013, the Minimum Data Set (MDS, an assessment tool) for Resident 84, dated January 15, 2013, the cognitive patterns indicated "memory ok" for long and short term, moderate impairment, decisions poor, cues/supervision required. Section K of the MDS indicated Resident 84 had no swallowing problems and no weight loss of 5% in the last month or 10% in the last six months. Section L of the MDS indicates Client 84 had no broken or loosely fitting full or partial denture, mouth or facial pain, discomfort or difficulty with chewing. On January 30, 2013 at 7 a.m., during an observation at the South Unit, Resident 84 was seen continuously walking among peers, waiting for breakfast to be served. Resident 84 was observed to have a large bulge appearing on her left lower jaw. The bulge was approximately the size of a golf ball. Resident 84 opened her mouth and observation revealed poor oral hygiene. Her teeth appeared unclean, crooked and some missing. Resident 84 had a type of partial denture not secured and hanging over lower left side of the mouth. There was redness and swelling covering the left lower area of gums in Resident 84's mouth. There was a foul odor evident while Resident 84's mouth was open. On January 30, 2013, at 9 a.m., Resident 84's counselor (Counselor 1) was interviewed. Counselor 1 stated Resident 84 reported to her, "She said she had a little pain on her jaw." Counselor 1 stated, "I asked Resident 84 if she had reported the problem to her CN and explained why (it was important)." On February 1, 2013, at 8:50 a.m., Resident 84 was interviewed. She stated she had "sore teeth and an infection from (her) prior dental work and that it was painful to eat." Resident 84 stated she notified a Charge Nurse (CN) of her sore jaw a week or so ago. Resident 84 stated the nurse told her she would call the doctor. Resident 84 stated she has not seen the doctor or dentist regarding her oral pain and difficulty chewing. On February 1, 2013, at 8:35 a.m., an interview was conducted with Mental Health Worker 1 (MHW 1) on the South station. She stated she heard Resident 84, "telling a Charge Nurse about the pain in her mouth sometime this week " On February 1, 2013, at 9:25 a.m., an interview was conducted with the Program Director. He stated, "We tried everything to address her weight loss problems. It appears the dental issue was forgotten or was not thought of for some reason. She should have been referred to the dentist." On February 1, 2013, at 11 a.m., an interview was conducted with the Dietary Consultant. She stated she prepared a "recommendation sheet" on December 6, 2012. One of the recommendations was for a dental consult for poor dental health. The Dietary consultant stated she then distributed copies to the Charge Nurse, the Director of Nursing, and the Administrator. She stated then nursing takes over to obtain an order from the physician. The Dietary Consultant stated she thought nursing would follow through with the dental consult. The recommendation was presented on December 7, 2012. A record review for Resident 84 was conducted on January 30, 2013. A form titled, "NUTRITIONAL PROGRESS NOTES," written by the Dietary Consultant, was reviewed. An entry dated December 6, 2012, indicated the following: "Diet: Regular diet NCS (No Concentrated Sugars/Sweets) Large with 8 oz. NCS (chocolate super shake with all meals TID (three times daily) B/T (between meals), ice cream lunch and dinner... Intake: frequent refusals Wt. 118 lbs. 12/12 (arrow down) 12 lbs. 9.2% loss 1 month. Significant wt loss appears (secondary) to diet change 10/3/12 (with discontinuation) of super shake coupled with (arrow down) intake with high energy demands D/T (due to) constant activity and pacing. She is also complaining of mouth pain as she has broken tooth Dental health appears poor. Recommendations by the Dietary Consultant: Change texture to MS (mechanical soft-chopped/soft foods) Dental consult Prompt assist table UA with C&S (urinalysis with culture for drug sensitivity Weigh weekly X 1 mo (month). To monitor." On the same Dietary Consultant form an entry dated December 14, 2012, indicated the following: "Weight Monitor Wt 117 lbs 12/10/12 (arrow down, indicating weight loss) x 1 week Diet mechanical soft Food preferences: cookies, smoking Intake: refused 6 meals out of the last 21 meals..texture change with some improvement noted ...she mostly refuses to sit down and eat and continues to leave dining room." There was no documentation in the dietary consultant notes to indicate an oral assessment had been conducted concerning Resident 84's prior oral pain, oral status and difficulty chewing. A physician's orders [REDACTED]. "D/C (discontinue) Reg (regular) Diet Texture---ADD Parameter " MECHANICAL SOFT TEXTURE " TO DIET-BROKEN TOOTH----------------DENTAL CONSULT-----PROMPT and ASSIST---------UA with C/S (urinalysis with culture and sensitivity) (lab test to check for urinary infection) IF INDICATED------X-RAY CXRAY (chest x-ray)-WT LOSS --------WEIGH WEEKLY X (times) 1 MONTH---WEIGHT LOSS " On January 30, 2013, the Dietary Consultants notes were reviewed. The entry dated December 21, 2012, indicated Resident 84 lost four more pounds in one week. The note indicated Resident 84 had a physician's orders [REDACTED]. The resident's intake remained poor and she continued to loss weight. There was no documentation concerning an assessment of Resident 84's oral pain, oral status or difficulty chewing. The Dietary Consultant recommended: "Add fortified diet D/C (discontinue) [MEDICATION NAME]-Client refusing F/U (follow up) on urine culture." A physician's orders [REDACTED]. "Mechanical soft diet-NCS - Add fortified diet-prompt assist. D/C (discontinue) [MEDICATION NAME] 400 mg (milligrams-10 ml-milliliters) PO (by mouth) BID (two times daily) for appetite stimulant x 30 days-as she refuses." On January 30, 2013, the Dietary Consultant's entry dated January 4, 2013, "NUTRITIONAL PROGRESS NOTES" indicated Resident 84 "continues to refuse two of three meals daily...Resident's intake remains poor. Talked with her about consequences of unplanned weight loss...including death...She said she didn't care. Weight loss likely unavoidable. I will notify DON (Director of Nursing) and Counselor." There was no documentation concerning an assessment of Resident 84's oral pain oral status or difficulty chewing. On January 30, 2013, a flow sheet recording vital signs and weights was reviewed. The form indicated the following monthly weights for Resident 84: 07/19/12 -Wt. (weight) -109 lbs (pounds). 08/10/12---Wt., --lbs. 09/10/12-- No Wt. recorded 09/10/12-second entry -Wt. 122 lbs. 10/05/12---Wt.--- 126 lbs. 11/04/12-Wt.---130 lbs. 12/07/12---Wt.---118 lbs. --12 lbs lost in one month 01/03/13-Wt.---114 lbs. --4 lbs lost in one month Resident 84 began losing weight in November 2012, and continued to a significant weight loss of 16 lbs from November 4, 2012 to January 3, 2013 (two months). On January 30, 2013, Care Plans for Resident 84 were reviewed. A care plan dated January 11, 2013, identified "Problem 10" for Resident 84 as "HIGH RISK FOR WEIGHT LOS DUE TO LOSS OF APPETITE." The problems and interventions did not identify poor dental health as a contributor to refusal to eat and weight loss. On January 30, 2013, a care plan dated January 14, 2013, indicated a problem of "MECHANICALLY ALTERED DIET due to poor dentition." The goal included, "complying with diet without choking." There was no identification of the need for dental consult on any of the interventions listed on the care plan. There was no evidence in any of the care plans for interventions for Resident 84 to consult with a dentist. On January 30, 2013, a form titled, "The INTERDISCIPLINARY PROGRESS NOTE," dated entry of January 19, 2013, indicated the following: "High risk for weight loss due to loss of appetite, diet as ordered, and supplements as ordered...due to poor dentition...difficulty of choking with meds." There was no documentation or assessment concerning Resident 84's oral pain, oral status, difficulty chewing, or the December 7, 2012, ordered dental consult. On January 30, 2013, at 7:24 a.m., after the survey team was observed interviewing resident 84 and looking into her mouth, an physician's orders [REDACTED]. "[MEDICATION NAME] VK 500 mg (milligrams) PO (by mouth) x 10 days; [MEDICATION NAME] 400 mg PO Q (every) 6 hours prn (as needed); Dental Consult infected tooth lower left side." On February 4, 2013, Resident 84 saw the dentist. the dentist documented the following: "Called in to (check mark) jaw pain swelling. Pt (patient) wears lower partial left [MEDICATION NAME] (oral cheek area) flange (a portion of the denture partial) was digging into gum sulcus (gum line) causing trauma. Adjusted lower partial to relieve pressure. Pt states feels much better." On January 31, 2013, a facility policy titled, "Recognizing Signs and Symptoms of Abuse/Neglect" dated January 28, 2013, was reviewed. 1b. "Signs which may indicate actual physical neglect: [MEDICAL CONDITION] and dehydration (unexplained weight loss) Poor hygiene... Decayed teeth Inadequate provision of care." The facility neglected to follow their policy and procedures on abuse/neglect by failing to recognize the signs and symptoms of neglect, such as poor oral hygiene, broken and painful teeth and weight loss. Resident 84 sustained an unplanned and significant sixteen pound weight loss from November 4, 2012, through January 3, 2013. The facility neglected to recognize the signs and symptoms Resident 84 was demonstrating, such as ongoing meal refusals and leaving the dining room. The facility neglected to implement the December 7, 2012 ordered dental consult until February 4, 2013, almost two months later. Resident 84 required antibiotic therapy for an oral infection on January 30, 2013.

Based on observation, interview, and record review, the facility failed for one of 22 sampled clients, (Client 84), to provide prompt, physician ordered, dental care on December 7, 2012. This failed practice contributed to infection, pain, and swelling to Client 84's lower jaw. This failed practice placed Resident 84 at risk [MEDICAL CONDITION] (generalized infection), coma, or death. Findings: Resident 84 was admitted to the facility on [DATE], with diagnoses. On January 30, 2013 at 7 a.m., during an observation at the South Unit, Resident 84 was seen continuously walking among peers, waiting for breakfast to be served. Client 84 was observed to have a large bulge appearing on her left lower jaw, approximately the size of a golf ball. Resident 84 opened her mouth and revealed poor oral hygiene. Her teeth appeared unclean, crooked and some missing. Resident 84 had a type of partial denture. There was a foul odor evident while Resident 84 ' s mouth was open. On February 1, 2013, at 8:50 a.m., Resident 84 was interviewed. She stated she had " sore teeth and an infection from (her) prior dental work and that it was painful to eat " . Resident 84 stated she notified the Charge Nurse (CN) of her sore jaw a week or so ago. Resident 84 stated the nurse told her she would call the doctor. Resident 84 stated she has not seen the doctor or dentist regarding her problems with her dental condition. On February 1, 2013, at 11:a.m., an interview was conducted with the Dietary Consultant. She stated she prepared a "recommendation sheet," on December 6, 2012 One of the recommendations was for a dental consult for poor dental health. The Dietary consultant stated she then distributed copies to the Charge Nurse, the Director of Nurses, and the administrator, and then nursing takes over to obtain an order from the physician. The Dietary Consultant stated she thought nursing would follow through with the dental consult. The recommendation was presented on December 7, 2012. On January 30, 2013, a physician's orders [REDACTED]. The order indicated: " D/C (discontinue) Reg (regular) Diet Texture---ADD Parameter " MECHANICAL SOFT TEXTURE " T0 DIET-BROKEN TOOTH----------------DENTAL CONSULT-----PROMPT and ASSIST---------UA with C/S (urinalysis with culture and sensitivity) ( lab test to check for urinary infection) IF INDICATED------X-RAY CXRAY (chest x-ray) -WT (weight) LOSS --------WEIGH WEEKLY X 1 MONTH---WEIGHT LOSS " There was no documentation concerning the dental consult ordered on December 7, 2012, until January 30, 2013. A Physician order [REDACTED].. The consult with the dentist was conducted on February 4, 2013. The Dentist report from February 4. 2013, indicated "Called in to (check) jaw pain and swelling. Pt. (patient) wears lower partial- Left [MEDICATION NAME] flange (a part of the partial denture near the inner cheek) was digging into gum sulcus (gum line), causing trauma. Adjusted lower partial to relieve pressure. Pt. states feels much better."