Every finding on record at Watsonville Post Acute Center

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant E (CNA E) wore gloves when providing toilet hygiene and bed bath to Resident 20 who was on enhanced barrier precautions (EBP, an infection control strategy for healthcare settings, especially nursing homes, to reduce the spread of multidrug-resistant organisms - MDROs, germs that are resistant to many antibiotics - by requiring healthcare personnel to wear gowns and gloves during all high-contact resident care activities); 2. Licensed vocation nurse B (LVN B) did not sanitize her hands when she went from Resident 58's room to Resident 31's room; 3. The oxygen filters of Resident 31's, Resident 49's, Resident 58's, and Resident 60's oxygen concentrators were dirty, and the filter boxes were not dated; 4. Registered nurse D (RN D) threw the used blood lancet (a pricking needle used to obtain drops of blood for testing) on top of the lid of the sharp container; 5. Registered nurse D (RN D) did not disinfect the glucometer (a portable medical device used to measure the sugar level in a small sample of blood) between checking blood sugar level for Resident 94 and Resident 6; 6. Registered nurse A (RN A) placed one cup of medications on top of the medications in the other cup to bring them to Resident 54. RN A also did not disinfect the blood pressure cup before taking Resident 54's blood pressure; 7. Licensed vocational nurse B (LVN B) did not cleanse her hands and change gloves before administering fluticasone nasal spray (used to relieve allergy symptoms in the nose) to Resident 32; and 8. Certified nursing assistant F (CNA F) left the lunch cart door open, the dessert food was not covered while she brought the lunch trays to Resident 11 and his two roommates. These failures had the potential to spread infection to residents and staff. Findings:1. During an observation on 8/25/25, at 10 a.m., CNA E was helping Resident 20 who was on EBP in his room, and she only had gloves on.During a concurrent interview with CNA E, she confirmed that Resident 20 was on EBP. CNA E stated Resident 20 had bowel movement, so she cleansed him and gave him a bed bath. CNA E stated she should wear a gown and gloves when she cleaned Resident 20 and gave him a bed bath.During an interview with the infection preventionist (IP) on 8/29/25, at 11:01 a.m., she stated the CNAs should wear gowns and gloves when cleaning and giving the residents bed baths.Review of the facility's policy, Enhanced Barrier Precautions, dated 8/2022, indicated . 2. EBPs employ targeted gown and glove use during high contact resident care activities . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include a. Dressing . c. providing hygiene d. changing linens e. changing briefs or assisting with toileting. 2. During an observation on 8/25/25, at 10:30 a.m., LVN B checked the filter of Resident 58's oxygen concentrator, then she went to Resident 31's room to check the filter of his oxygen concentrator without sanitizing her hands.During a concurrent interview with LVN B, she stated she should sanitize her hands when she went from one resident's room to another.Review of the facility's policy, Handwashing/Hand Hygiene, dated 10/2023, indicated . 1. Hand hygiene is indicated: . e. after touching the resident's environment . 3. During an observation and interview with LVN B on 8/25/25, from 10:25 a.m. to 10:35 a.m., the filters of Resident 31's, Resident 49's, Resident 58's, and Resident 60's oxygen concentrators were dirty, and the filter boxes were not dated. LVN B confirmed that the filters of Resident 31's, Resident 49's, Resident 58's, and Resident 60's oxygen concentrators were dirty, and the filter boxes were not dated.During an interview with the director of staff development (DSD) on 8/25/25, at 10:52 a.m., she stated the filter boxes should be dated.During an interview with the IP on 8/29/25, at 11:09 a.m., she stated the staff should sanitize their hands when going out of the residents' rooms. The filter of the oxygen concentrator should be kept clean and should be cleansed every week.Review of the facility's Oxygen Concentrator Guide indicated that the recommended cleaning interval for filter door vents was 7 days. 4. During a medication pass observation with RN D on 8/25/25, at 11:47 a.m., after obtaining Resident 94's drops of blood with a lancet for checking his blood sugar level, RN D threw the lancet on top of the lid of the sharp container.During an interview with RN D on 8/25/25, at 11:55 a.m., she confirmed that she threw the lancet on top of the lid of the sharp container. RN D acknowledged that she should have throw the lancet inside the sharp container and not on top of its lid.Review of the facility's policy, Obtaining a Fingerstick Glucose Level, dated 10/2011, indicated . 16. Dispose of the lancet in the sharp disposal container. 5. During a medication pass observation with RN D on 8/25/25, at 11:47 a.m., after obtaining Resident 94's blood sugar level with the glucometer, RN D did not disinfect the glucometer.During a medication pass observation with RN D on 8/25/25, at 12:06 p.m., RN D used the same glucometer to obtain Resident 6's blood sugar level without disinfecting it before use.During an interview with RN D on 8/25/25, at 12:12 p.m., RN D acknowledged that she should have disinfect the glucometer between use on different residents.Review of the facility's policy, Obtaining a Fingerstick Glucose Level, dated 10/2011, indicated . 18. Clean and disinfect reusable equipment between uses . 6. During a medication pass observation on 8/26/25, at 4:02 p.m., RN A placed Resident 54's two tablets of lanthanum carbonate (used to treat too much phosphate in the blood) in one medicine cup and 6 tablets of Resident 54's other medications in another medicine cup. Then RN A placed the cup with two tablets of lanthanum carbonate on top of the 6 tablets of other medications in the other cup to bring the two cups to Resident 54 to take.During a concurrent medication pass observation, RN A needed to obtain Resident 54's blood pressure before administering carvedilol (used to treat high blood pressure) 25 milligrams (mg, a metric unit of mass) one tablet to her. RN A went to look for a blood pressure machine, brought it to Resident 54's room, and applied the blood pressure cup on Resident 54's arm took her blood pressure without disinfecting the cup.During an interview with RN A on 8/26/25, at 4:38 p.m., RN A confirmed that she placed the cup with two tablets of lanthanum carbonate on top of the 6 tablets of other medications in the other cup to bring the two cups to Resident 54 to take, and she did not disinfect the blood pressure cup before applying it on Resident 54's arm. RN A stated she should not place one cup of medications on top of the other cup because the bottom of the cup might not be clean, and she should disinfect the blood pressure cup before taking the residents' blood pressure.Review of the facility's policy, Cleaning and Disinfecting, dated 5/2023, indicated . 4. Non-disposable medical equipment used for that resident is cleaned and disinfected according to manufacturer's instructions and facility policies before use on another resident. 7. During a medication pass observation on 8/27/25, at 9:54 a.m., LVN B put on gloves, took Resident 32's blood pressure, applied lidocaine (used to relieve pain) 4% one patch to Resident 32's left thigh, then without cleansing her hands and changing gloves, LVN B administered one spray of fluticasone 50 micrograms (mcg, a metric unit of mass)/actuation (act, a single puff or spray) to each of Resident 32's nostrils.During an interview with LVN B on 8/27/25, at 10:15 a.m., she acknowledged that she should have cleanse her hands and change gloves before administering fluticasone nasal spray to Resident 32's nostrils.During an interview with the IP on 8/29/25, at 11:14 a.m., she stated the licensed nurse should have place the lancet inside the sharp container not on top of its lid and disinfect glucometer between residents. The licensed nurse should not stack one cup of medicine on top of the medications in the other cup because the bottom of the cup might not be clean. The licensed nurse should have disinfect the blood pressure cup before taking the residents' blood pressure and should have cleanse hands and change gloves before administering the nasal spray to the residents.Review of the facility's policy, Administering Medications, dated 4/2023, indicated . 19. Staff follows established facility infection control procedures for the administration of medications, as applicable. 8. During an observation on 8/25/25, at 12:25 p.m., CNA F pushed the lunch cart to the front of Resident 11's room. CNA F opened the door of the lunch cart and left it open the whole time that she brought the lunch trays to Resident 11 and his two roommates, Resident 12 and Resident 3, prepared the lunch for them, and talked to them in their room. The dessert cups on resident lunch trays in the lunch cart had no lid and were not covered, and there were no other staff around the lunch cart.During a concurrent interview with CNA F, she confirmed that she left the door of the lunch cart open; the dessert cups on resident lunch trays in the lunch cart had no lid and were not covered, and there were no other staff around the lunch cart. CNA F acknowledged she should close the door of the lunch cart while she was in the resident's room.During an interview with the IP on 8/29/25, at 11:11 a.m., she stated the staff should have close the door of the lunch cart while they were in the resident's room.

Based on observation, interview, and record review, the facility failed to provide services that meet professional standards for two of 20 residents (2 and 54) when:1. Registered nurse A (RN A) left two tablets of lanthanum carbonate (used to treat too much phosphate in the blood) with Resident 54 and did not observe Resident 54 taking the medication during meds administration; and 2. RN A did not verify the placement of Resident 2's jejunostomy tube (J-tube, a medical device that is surgically placed through the abdominal wall directly into the middle part of the small intestine to deliver liquid nutrition, fluids, and medications directly to the small intestine) before administering Resident 2's medications through his J-tube, and RN A did not flush Resident 2's J-tube with 30 milliliters (ml, and metric unit of volume) of water before and after administering his medications as ordered by the physician.This failure had the potential to result in the residents not taking medications as prescribed by the physician and being at risk of aspiration. Findings:1. Review of Resident 54's admission Record indicated she was admitted to the facility on [DATE].During a medication pass observation on 8/26/25, at 4:02 p.m., RN A placed Resident 54's two tablets of lanthanum carbonate in one medicine cup and 6 tablets of Resident 54's other medications in another medicine cup.RN A handed the two medicine cups to Resident 54. Resident 54 finished taking the 6 tablets in one medicine cup, but she had not taken the two tablets of lanthanum carbonate yet. RN A started obtaining Resident 54's blood sugar. RN A left the two tablets of lanthanum carbonate there with Resident 54 and went back to her medication cart to chart the blood sugar and draw the insulin lispro (used to treat high blood sugar levels). When RN A went back to Resident 54 to administer insulin lispro to her, the two tablets of lanthanum carbonate were no longer there.During an interview with RN A on 8/26/25, at 4:38 p.m., she acknowledged that she should not leave the two tablets of lanthanum carbonate with Resident 54 and she should have stay and observe Resident 54 taking them. 2. Review of Resident 2's admission Record indicated he was admitted to the facility on [DATE].Review of Resident 2's physician order, dated 3/21/25, indicated he had a physician order for the licensed nurse to flush his J-tube with 30 ml of water before and after medication.During a medication pass observation on 8/26/25, at 4:43 p.m., RN A did not verify the placement of Resident 2's J-tube before administering Resident 2's medications through his J-tub. RN A flushed Resident 2's J-tube with 20 ml of water before medication and two times of 40 ml, total 80 ml of water after medication.During an interview with RN A on 8/26/25, at 5:12 p.m., RN A reviewed Resident 2's physician orders and acknowledged that she should have verify the placement of Resident 2's J-tube before administering Resident 2's medications and flush his J-tube with 30 ml of water before and after medication as ordered by the physician.Review of the facility's policy, Administering Medication through an Enteral Tube, dated 11/2018, indicated . Steps in the Procedure: . 6. Verify placement of feeding tube . 7. Stop feeding and flush tubing with at least 15 ml of water (or prescribed amount) . 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml of water (or prescribed amount).

Based on observation, interview, and record review, the facility had a medication error rate of 22.22% when 6 medication errors occurred out of 27 opportunities during medication administrations for four out of 8 residents (2, 3, 6, and 54). This failure resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the therapeutic effects of the medications. Findings:1. During a medication pass observation on 8/25/25, at 11:32 a.m. with registered nurse D (RN D), RN D obtained Resident 3's blood sugar, and it was 229. RN D set 4 units on Resident 3's insulin pen (look like writing pen except it contains insulin instead of ink, and it uses a needle instead of a pen tip) of insulin lispro (used to treat high blood sugar) 100 units/milliliters (ml, a metric unit of volume) and administered them to Resident 3 without priming the insulin pen (the process of removing any air bubbles from the needle and insulin cartridge before an injection; this is a critical safety step that ensures the correct dose is delivered and that the pen is functioning properly).During a concurrent interview with RN D, she confirmed that she did not prime Resident 3's lispro insulin pen before administering 4 units of insulin lispro to him. RN D stated she should have prime Resident 3's lispro insulin pen with 2 units of insulin lispro before administering 4 units of insulin lispro to him, otherwise it would have been a wrong dose.Review of the facility's Instruction for Use, BD AutoShield Duo, indicated . 1.3 Check if the pen needle is attached correctly - dial 2 units, point the pen up and press the thumb button. 2. During a medication pass observation on 8/25/25, at 12:06 p.m. with RN D, RN D obtained Resident 6's blood sugar, and it was 78. RN D told Resident 6 no insulin and did not administer any unit of insulin to Resident 6.Review of Resident 6's physician order, dated 8/8/25, indicated Resident 6 was to receive 10 units of insulin lispro one time a day for lunch time if his blood sugar was less than 120.During an interview with RN D on 8/26/25, at 12:10 p.m., RN D reviewed Resident 6's physician orders and acknowledged that she should have administer 10 units of insulin lispro to Resident 6 when his blood sugar was 78.Review of the facility's policy, Administering Medications, dated 4/2023, indicated . 4. Medications are administered in accordance with prescriber orders . 3. During a medication pass observation with registered nurse A (RN A) on 8/26/25, at 4:02 p.m., RN A obtained Resident 54's blood sugar, and it was 161. RN A stated per the insulin sliding scale (a regimen that adjusts the dose of insulin based on a resident's current blood sugar level), Resident 54 was to receive 1 unit of insulin lispro. RN A stated per physician order, Resident 54 was also to receive 5 units of insulin lispro in conjunction with the sliding scale. So, she would administer a total of 6 units of insulin lispro to Resident 54. RN A set 6 units on Resident 54's insulin pen of insulin lispro 100 units/ml and administered them to Resident 54 without priming the insulin pen.During an interview with RN A on 8/26/25, at 4:38 p.m., she confirmed that she did not prime Resident 54's lispro insulin pen before administering 6 units of insulin lispro to her. RN A stated she should have prime Resident 54's lispro insulin pen with 2 units of insulin lispro before administering 6 units of insulin lispro to her, otherwise it would be a wrong dose.Review of the facility's Instruction for Use, BD Auto Shield Duo, indicated . 1.3 Check if the pen needle is attached correctly - dial 2 units, point the pen up and press the thumb button. 4. During a medication pass observation with RN A on 8/26/25, at 4:43 p.m., RN A stated she did not have glycopyrrolate (used to treat open sores in the digestive tract) 1 milligram (mg, a metric unit of mass)/5 milliliters (ml, a metric unit of volume) on hand to give to Resident 2.During a concurrent medication pass observation, RN A crushed midodrine (used to treat low blood pressure) one 10 mg tablet, mixed it with 10 ml of sucralfate (used to treat open sores in the digestive tract) 1 gram (gm, a metric unit of mass)/10 ml, then mixed them with water, and administered them to Resident 2 through his jejunostomy tube (J-tube, a medical device that is surgically placed through the abdominal wall directly into the middle part of the small intestine to deliver liquid nutrition, fluids, and medications directly to the small intestine).During an interview with RN A on 8/26/25, at 5:12 p.m., she acknowledged that she should have administer midodrine and sucralfate to Resident 2 separately through his J-tube.Review of Resident 2's physician order, dated 8/18/25, indicated he was to receive 5 ml of glycopyrrolate 1 mg/5 ml three times a day for excessive secretion.Review of the facility's job description, Registered Nurse Supervisor, indicated . Essential Duties and Responsibilities: . Maintaining medicine supply room well stocked.Review of the facility's policy, Administering Medication through an Enteral Tube, dated 11/2018, indicated . General Guidelines: . 3. Administer each medication separately and flush between medications.

Based on observation, interview, and record review, the facility failed to ensure food serving items were air-dried prior to stacking them, when serving trays and plate covers were observed to be wet while stacked. This failure had the potential of causing food-borne illnesses in the resident population of those who ate food from the kitchen.Findings: During the initial kitchen tour on 8/25/2025 @ 9:49 a.m., serving trays and plate covers were stacked on the counter by the steam table, some of them still remained wet. During a subsequent interview with the dietary manager (DM), and the registered dietician (RD) standing there, the DM acknowledged the wet trays and wet plate covers. DM stated they should have been air-dried, if they are still wet they would have been dried with blue cloth Wiper towels by vendor (tm) During a subsequent interview with the dietary aide (DA), she stated the trays and plate covers are usually air-dried, but if they don't dry completely, it was okay to use the blue Wiper towels by vendor (tm) to dry them. During a review of the facility's policy and procedure (P&P) titled Dishwashing Machine Use, revised 03/2010, the P&P indicated 1. The following guidelines will be followed when dishwashing: . After running items through entire cycle, allow to air-dry.

Based on interview and record review, the facility failed to ensure one of two residents (7) receive care and services for the provision of dialysis (procedure to remove waste or toxins from the blood and adjust fluid and electrolyte imbalances) consistent with professional standards of quality when licensed vocational nurse B (LVN B) did not check Resident 7's bruit (an audible vascular sound associated with turbulent blood flow usually heard with the stethoscope).These failures had the potential for delayed detection, reporting, and management of complications from the dialysis shunt for the residents. Findings:Review of Resident 7's admission Record indicated he was admitted to the facility on [DATE] with dependence on renal dialysis diagnosis.Review of Resident 7's physician orders, dated 1/2/25, indicated he had orders for the licensed nurse to monitor bruit and thrill (a vibration that is felt on the skin overlying a dialysis shunt) of dialysis shunt every shift and monitor dialysis shunt to left forearm for tenderness, redness, or bleeding every shift.During an interview with LVN B on 8/28/25, at 12:30 p.m., she stated Resident 7 was a dialysis resident. She checked the thrill at his dialysis shunt, but she did not check the bruit. LVN B stated she did not know how to check the bruit.Review of the facility's policy, Renal Dialysis, Care of Residents, dated 12/2013, indicated . Standard: 1. Access site care will be provided by a licensed nurse, with physician's order. 2. Access site care is checked for condition and patency every shift . Routine Access Site Care Guidelines: . 3. Routine access checks for bruit once per shift.

Based on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when overused-by date insulin was found in Station 3 medication cart. This failure resulted in the overused-by date insulin being administered to Resident 32.Findings:On 8/25/25, at 12:55 p.m., during an observation of Station 3 medication cart with licensed vocational nurse B (LVN B), one insulin Lantus (used to control high blood sugar levels) 100 units/milliliters (ml, a metric unit of volume) pen for Resident 32 dated to be discarded on 8/23/25.During a concurrent observation, interview, and review record with LVN B, she observed Resident 32's insulin Lantus pen and she confirmed that it should have been discarded on 8/23/25. LVN B also confirmed that Resident 32 received 10 units of insulin Lantus from this insulin pen on 8/24/25. Resident 32 had no other insulin Lantus pen in Station 3 medication cart.Review of the facility's policy, Medication Labeling and Storage, dated 2/2023, indicated . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interview and record review, the facility failed to implement fall-related interventions for one of two residents (Resident 32) when staff did not document Resident 32's skid mat (non-slip material) was in place on 6/17/23, when staff did not ensure Resident 32's sensor pad alarm (device that emits an audible alarm when pressure is removed from the sensor pad to alert the caregivers; such as, when the user gets out of a bed or wheelchair) orders were transcribed in the administration records for nurses to document pad placement and functioning, and when the facility failed to provide evidence of periodic staff training on the operation of the sensor pad alarm and daily device testing of the sensor pad alarm per manufacturer's recommendations. These failures in fall-related interventions led up to Resident 32's fall on 6/17/23, from which Resident 32 suffered a fractured clavicle (broken collar bone). Findings: Review of Resident 32's Post-Fall Review, dated 6/17/23, indicated the following: Resident 32 was self-ambulating [moving about] in a wheelchair in the hallway and had an unwitnessed fall on 6/17/23 at 4:23 p.m. Resident was observed lying on his right side in the hallway across from room [ROOM NUMBER]. Resident was several feet away from wheelchair. Resident's knees were bent towards chest and arms were in front, but bent at elbows . IDT [interdisciplinary team, a group of health care professionals from diverse fields who work toward a common goal for residents] met to review Res [Resident 32's] recent falls which resulted in Fx [fracture] to R [right] clavicle . Resident was more alert . and self propelling throughout the facility more than usual. Res was noted with discoloration to right shoulder the following morning, MD [Doctor of Medicine] advised to transfer to ER [emergency room ] where non-displaced [bone cracks or breaks and maintains proper alignment] clavicle Fx was noted . Upon further investigation it was determined that the pad alarm was in place, but did not sound. Facility staff to be provided in-service regarding proper placement/use of pad alarms. Review of Resident 32's Imaging Report, dated 6/18/23 indicated, 4 views of the right shoulder were performed . There is a nondisplaced fracture of the distal clavicle (a break in the collar bone on a side away from a person's midline). Review of Resident 32's Admission Record, printed 3/6/24, indicated the resident was admitted to the facility with diagnoses including dementia (a group of conditions affecting thinking and social abilities that interferes with daily functioning) and chronic obstructive pulmonary disease (a condition that affects airflow in the lungs and makes it difficult to breathe). Review of Resident 32's Post-Fall Reviews for 2022 indicated the resident had 11 fall incidents in 2022. Review of Resident 32's Post-Fall Reviews for 2023 indicated the resident had 12 fall incidents in 2023. Review of Resident 32's Post-Fall Reviews for 2024 indicated the resident had two fall incidents in 2024. Review of Resident 32's minimum data set (MDS, an assessment tool), dated 6/13/23, indicated he required extensive assistance with one person for bed mobility and transfers. Review of Resident 32's Quarterly Risk Data Collection Tool/Fall Risk Assessment, dated 6/14/23, indicated Resident 32 was at risk for falls. Review of Resident 32's physician orders indicated, Pad alarm in wheelchair at all times for fall precautions, dated 2/14/22, Bed alarm [type of sensor pad alarm] when in bed at all times for fall precautions, dated 2/14/22, and [brand name of a skid mat product] to wheelchair cushion at all times, dated 8/24/22. Review of Resident 32's Treatment Administration Record (TAR, record of treatments given) for June 2023, indicated a physician order for, [brand name of a skid mat product] to wheelchair cushion at all times every shift, that was not signed by a nurse on 6/17/23 evening shift (3 to 11 p.m.) to indicate whether the order was carried out. Review of Resident 32's Medication Administration Record (MAR, record of medications given) for June 2023 and TAR for June 2023, yielded a lack of documentation to indicate Resident 32's pad alarms were on his wheelchair and bed at all times and whether they functioned. During an interview and record review with the nurse supervisor (NS) on 3/8/24 at 12:26 p.m., he stated it is the licensed nurse (LN) and certified nursing assistants' (CNA) responsibility to check that fall interventions are in place. The NS stated it is also the LN's and CNA's responsibility to check if safety devices, like pad alarms are functioning. The NS stated Resident 32's fall interventions, including the [brand name of a skid mat product], floor mat, and concave mattress (type of mattress with raised sides) are to be signed by nurses in the MAR or TAR when carried out; however, the physicians' orders for pad alarms were not transcribed in Resident 32's MAR; and that, they should have been in order for documentation of their positioning and functioning. The NS confirmed that Resident 32's Post-Fall Review, dated 6/17/23, indicated the IDT determined Resident 32's pad alarm did not sound. He stated he did not remember the reason Resident 32's pad alarm failed to sound. During an interview on 3/8/24 at 2:29 p.m., the NS confirmed Resident 32's [brand name of a skid mat product] placement was not signed in the TAR for the evening shift of 6/17/23. The NS stated he could not confirm whether the [brand name of a skid mat product] was checked. During an interview on 3/8/24 at 10:15 a.m. with the administrator-in-training (AIT), in-service training on the operation of the pad alarms was requested. During an interview with the director of staff development (DSD) on 3/08/24 at 10:21 a.m., in-service training on the operation of the pad alarms was requested. The DSD did not provide any in-service training on the operation of the pad alarms, even though it was requested of her again on 3/08/24 at 3:05 p.m. During an interview and concurrent record review with the NS on 3/8/24 at 3:04 p.m., he searched through an in-service binder for in-service training regarding the operation of pad alarms. The NS provided a copy of an in-service on pad alarms, dated 10/12/22, and stated it was for checking placement of the pad alarms only, and otherwise excluded instructions on the usage/operation of pad alarms. The NS stated he did not think there was an in-service on the usage/operation of pad alarms. During an interview with the NS on 03/08/24 at 3:13 p.m., he stated he would look in a different binder for in-service training regarding the usage/operation of pad alarms; however, no evidence of such in-service training was provided. Review of the facility's policy, Falls and Fall Risk, Managing, revised 2/7/24, indicated, In conjunction with the attending physician, licensed staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Review of an undated sensor pad(s) manufacturer's Installation and Use Instructions indicated, We recommend that all caregivers receive periodic training in the operation of these systems and that the devices are tested daily.

Based on interview, and record review, the facility failed to develop and implement care plans (a plan that provides direction on the type of nursing care the individual may need) for two of 19 sampled residents (38 and 66): 1. For Resident 38, there was no care plan that addressed the long term care of her gastrostomy tube (g-tube, a surgical opening into the stomach for administration of nutrition and medications), no care plan developed for the use of an anticoagulant (a medication that prevents or reduces blood from clotting); and, 2. For Resident 66, a care plan for diabetes was not developed. These failures had the potential for the facility to overlook care issues and render person-centered care plans lacking measures to address identified needs. Findings: 1. Review of Resident 38's face sheet indicated Resident 38 was admitted to the facility for multiple diagnoses that included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, chronic atrial fabulation (an irregular and often very rapid heart rhythm), and dysphagia (difficulty swallowing). Review of Resident 38's SBAR (Situation, Background, Assessment, Recommendation) communication forms indicated Resident 38 was transferred to the emergency department on 12/20/23 at 12:00 p.m. due to the g-tube coming out, and redness at the site, on 12/23/23 at 12:00 p.m. due to blood-tinged drainage at the g-tube site, and on 2/29/24 at 9:00 p.m. due to a dislodged g-tube. During a concurrent interview and record review on 3/7/24 at 4:22 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 38's medical record and care plans were reviewed. The care plans indicated there was no care plan for the long-term care of a g-tube. MDSC indicated there should be a care plan for the long-term care of Resident 38's g-tube. Review of Resident 38's physician orders, dated 1/6/23, indicated, Apixaban Tablet 5 milligrams (MG) (a unit of measurement) via G-tube, two times a day for CVA [cerebral vascular accident, an interruption in the flow of blood to cells in the brain] prophylaxis [prevention]. Resident 38's medical record lacked a care plan for the anticoagulation medication Apixaban. During an interview and concurrent medical record reviewed with Licensed Vocational Nurse (LVN) B on 3/8/24 at 11:40 a.m., she stated there was no care plan for the care and/or monitoring of Resident 38 for Apixaban and there should be. 36623 2. Review of Resident 66's clinical record indicated she was admitted to the facility with diagnoses including diabetes (a condition which affects the way the body processes blood sugar) and hypertension (high blood pressure). Review of Resident 66's physician orders indicated she had two orders for insulin, one to be given at night and sliding scale insulin (set of instructions for administering insulin dosages based on specific blood glucose readings). Review of Resident 66's care plans indicated the resident had no care plan that addressed her diagnosis of diabetes or use of insulin. During an interview with the minimum data set coordinator (MDSC) on 3/8/24 at 9:32 a.m., the MDSC confirmed Resident 66 did not have a care plan for diabetes. The MDSC stated there should be a diabetes care plan for Resident 66 to monitor for signs and symptoms of hyperglycemia (high levels of sugar in the blood) and hypoglycemia (low levels of sugar in the blood). Review of the facility's policy, Comprehensive Person-Centered Care Plans, revised 3/2023, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 19 sampled residents (Residents 38, 47, and 61) when: 1. For Resident 38, levothyroxine (a medicine used to treat an underactive thyroid gland) was not administered per the manufacturer's specification; 2. For Resident 47, Lorazepam (a prescription medication used to manage anxiety) was signed out of the resident's Controlled Drug Record (CDR, or an inventory sheet that keeps record of the usage of controlled medications) when he did not have a physician order for Lorazepam. 3. Resident 61 did not have a smoking assessment completed. These failures had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 38's face sheet indicated Resident 38 was admitted to the facility for multiple diagnoses that included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, chronic atrial fabulation (an irregular and often very rapid heart rhythm), and dysphagia (difficulty swallowing). Review of Resident 38's physician orders, dated 1/5/23, indicated Levothyroxine Sodium tablet, Give 12.5 mcg (micrograms, a unit of measure) via G-tube (gastrostomy tube is a tube inserted through the belly that brings nutrition /medications directly to the stomach) one time a day for hypothyroidism (condition in which the thyroid gland cannot make enough thyroid hormone to keep the body running normally) Give 12.5 mcg every day. Review of Resident 38's physician orders, dated 4/21/23, indicated External Feed Order in the afternoon for cyclic feed (an alternative to continuous tube feeding given at the same time each day for the same amount of time) Peptamen (a feeding formula) 1.5 at 60 ml (milliliters, unit of measure) x16 hours. Provides 960 mL (milliliters, a unit of measure)/1440 kcals (kilocalories, calories and kcal are units of measure for energy) 65 g (grams, unit of measure) of protein (a nutrient your body needs to grow and repair cells, and to work properly) Initiate at 5 p.m.- 9 a.m. Review of Resident 38's Medication Administration Record (MAR, a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) indicated Resident 38 received Levothyroxine at 9 a.m. everyday. During an interview and concurrent record review on 3/8/24 at 11:50 a.m. with Licensed Vocational Nurse (LVN) B, LVN B stated Resident 38's Levothyroxine tablets were given at 9 a.m. immediately after the g-tube feeding was stopped. Concurrent review of [NAME].com (an online evidence-based referential drug information) indicated, Administer consistently in the morning on an empty stomach, at least 30 to 60 minutes before food. Do not administer within 4 hours of calcium or iron-containing products. Review of Resident 38's tube feeding Peptamen nutritional facts indicated the nutrient composition included calcium and iron. Review of the facility's policy and procedure, Administering Medications, dated April 2023 indicated, Medications are administered in a safe and timely manner, and as prescribed . Medication administration times are determined by resident need and benefit. 46553 2. The Controlled Drug Records (CDRs) for six random residents receiving PRN (as needed) controlled medications were requested for review during the survey. Review of Resident 47's CDR for Lorazepam 0.5 milligrams (mg, unit of measurement) indicated nursing staff signed out one tablet on 2/19/24, 2/20/24, and 2/24/24. Review of Resident 47's physician's orders indicated he had a previous physician's order for Lorazepam 0.5 milligrams to be administered every twelve hours as needed for anxiety with an end date of 2/14/24. It also indicated he had a current physician order for Lorazepam 0.5 milligrams to be administered every twelve hours as needed for anxiety with a start date of 2/26/24. During an interview with registered nurse H (RN H) on 3/6/24 at 3:21 p.m., RN H confirmed Resident 47 did not have a physician order for Lorazepam from 2/15/24 to 2/25/24. During an interview with the Nurse Supervisor (NS), on 3/7/24 09:47 a.m., the NS confirmed there was no active order during the time the three doses of Lorazeam were given. The NS further stated the nurse failed to verify to check the active orders of the Medical Administration Record (MAR). Review of the facility's policy and procedure (P&P), titled, Administering Medications, revised 4/23, it indicated Medications are administered in accordance with prescriber orders, including any required time frame. 36623 3. Review of Resident 61's clinical record indicated he was admitted to the facility with diagnoses including diabetes (a condition which affects the way the body processes blood sugar) and depression. During an interview with Resident 61 on 3/4/24 at 1:11 p.m., he stated he was a smoker. Review of a list of smokers provided by the facility indicated Resident 61 was a smoker. Review of Resident 61's Admission/Readmission Data Tool, dated 1/31/24, indicated for the question, Does resident smoke? the answer was No. The following questions regarding smoking were left blank: What time of day does resident like to smoke? Can resident safely light and extinguish own cigarette? Select any adaptive equipment needed for the resident (smoking apron, cigarette holder, supervision, 1:1 assistance, other); Has a plan of care been developed for safe smoking? Resident 61 did not have a smoking assessment completed. Review of Resident 61's smoking care plan, dated 3/4/24, indicated he was at risk for injury related to smoking. During an interview with the minimum data set coordinator (MDSC) on 3/8/24 at 9:36 a.m., the MDSC confirmed Resident 61 did not have a smoking assessment; and that, he should have one. Review of the facility's policy, Smoking Policy - Residents, dated 1/2024, indicated, Resident smoking status is evaluated upon admission. If a smoker, evaluation includes: a. Current level of smoking frequency. b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. Desire to quit smoking; and d. Ability to smoke safely with or without supervision.

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. An open box of tuberculin (use for skin test to determine exposure to tuberculosis) vial found in the medication refrigerator did not have an open date on the vial; 2. Medications were not properly labeled and stored in one of two inspected medication storage rooms; and, 3. Multiple loose tablets were observed in the two drawers of one medication cart. These failures had the potential for residents to receive medications with reduced efficacy, inadequately monitored medications, and unlabeled medications, which could compromise residents' health and safety. Findings: 1. During a medication room observation on 3/5/34 at 1:11 p.m., with Licensed Vocational Nurse (LVN) C, there was an open box of tuberculin vial in the medication refrigerator without an expiration date or open date written on the vial. During a concurrent observation and interview with LVN C on 3/6/24 at 9:50 a.m., LVN C confirmed there was no open date on the tuberculin vial. LVN C stated it should be thrown out since she did not know when the medication vial was opened. During an interview with the Nurse Supervisor (NS) on 3/7/24 at 9:32 a.m., the NS confirmed the tuberculin vial had no open date. During a phone interview with the Pharmacy Consultant (PC) on 3/7/24 at 4:05. p.m., the PC stated the best practice is to put the open date on the vial once its opened. During a review of facility's policy and procedure (P&P), titled, Medication Labeling and Storage, revised 2/23, the P&P indicated, Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter date for the open vials. 2. During an inspection of Medication Storage Station #3 with LVN B on 3/4/24 at 10:56 a.m., there was one bottle of Magnesium Oxide 400 mg tablet supplement, one bottle of Fish oil 500 mg soft gel dietary supplement, and one bottle of Folic acid 400 mcg tablet with no open dates to each of them. LVN B verified the medications were open with no labels of open date. During an interview with LVN B on 3/4/24 at 11:02 a.m., she stated once a medication is opened, the nurse should label it with an open date. During an interview with the NS on 3/7/24 at 9:27 a.m., the NS stated an opened medication should be discarded if it is found inside the storage room without a label to indicate the open date. Review of facility's policy and procedure (P&P), Administering Medications, revised 4/23, indicated, the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 3. During an inspection of the Station B medication cart B with LVN A on 3/6/24 at 11:02 a.m., there were multiple loose tablets observed in the middle section of the two drawers, which contained bubble packs of medications. These findings were verified by LVN A. She further stated these loose medicines should be in the drug buster (medication disposal system that deactivates non-hazardous medications). During an interview with the Director of Nursing (DON) on 3/7/24 at 9:37 a.m., she stated the assigned nurse should clean the medication cart and throw the loose meds in the drug buster. Review of facility's policy and procedure (P&P), Medication Labeling and Storage, revised 2/23, indicated, the nursing staff is responsible for maintaining medication storage preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review the facility failed to ensure one of 19 sampled residents (Resident 38), was provided the necessary care to maintain good grooming and personal hygiene. This failure resulted in Resident 38 not receiving fingernail care and had the potential for infection and to negatively impact Resident 38's overall health. Findings: Review of Resident 38's face sheet indicated Resident 38 was admitted to the facility for multiple diagnoses that included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, muscle weakness, and dysphagia (difficulty swallowing). A review of Resident 38's Minimum Data Set (MDS, an assessment and care screening tool), dated 2/7/23, indicated Resident 38's cognitive skills (related to thinking, reasoning, decision-making, and problem solving) were severely impaired. The MDS indicated the resident was fully dependent on staff for dressing, eating, personal hygiene, and toilet use. During an observation in the resident dining/activities room on 3/4/24 at 10:35 a.m., Resident 38 sat in a wheelchair, Resident 38's fingers were noted to have brown/black substance under the nails of her right hand. During an observation in the resident dining/activities room on 3/6/24 at 2:04 p.m., Resident 38 sat in a wheelchair with a food tray. Resident 38's fingers were noted to have brown/black substance under the nails of her right hand. During an observation in Resident 38's room on 3/8/24 at 8:25 a.m., Resident 38 lay bed. Resident 38's fingers were noted to have a brown/black substance under the nails of her right hand. During an interview with Certified Nursing Assistant (CNA) D on 3/8/24 at 8:45 a.m., CNA D stated Resident 38's nails were dirty on the right hand. CNA D stated nails should be cleaned during every bath or shower. During an interview with Licensed Vocational Nurse (LVN) F on 3/8/24 at 9:38 a.m., LVN F stated nails should be nice and clean. Resident 38's shower days are Monday and Thursday during the evening (PM) shift and if the resident refused, the reason why should be documented. During an interview with the Nursing Supervisor (NS) on 3/8/24 at 10:08 a.m., the NS stated showers are documented in tasks including refusals and nail cleaning should be done during showers. During an interview with CNA G on 3/8/24 12:59 p.m., CNA G stated bed baths or partial baths, all include cleaning the hands and nails. CNA G stated Resident 38 is scheduled for PM shift; who do the total bath including the hair. During an interview in Resident 38's room with CNA D and CNA E on 3/8/24 at 2:34 p.m., CNA E stated, Resident 38's nails have been dirty all week and they should be cleaning the residents nails. During a review of the undated Resident shower schedule, the schedule indicated Resident 38 was scheduled for showers on PM shift on Mondays and Thursdays. During review of Resident 38's the task list, dated 3/2/24 thru 3/08/24, indicated Resident 38 received a bath/shower/bed bath 3/4/24 (Monday). There was no indication Resident 38 received a bath/shower/bed bath on 3/7/24 (Thursday) and there was no documented resident refusal. During a follow up interview with the NS on 3/8/24 at 2:56 p.m., the NS stated only scheduled days would be documented for showers. The NS confirmed Thursday 3/7/24 was a scheduled shower day that indicated NA, which meant a shower or bed bath was not given; and that, it should be documented if the resident refused. Review of the facility's policy and procedure titled, Care of Fingernails/Toenails, dated February 2023, indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . Nail care includes regular cleaning and regular trimming. Gently, remove the dirt from around and under each nail. Review of the facility's policy and procedure titled, Bathing/Showers, dated February 2023, indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . Documentation . If the resident refused the shower.

Based on interview and record review, the facility failed to monitor the side effects related to the use of Apixaban (an anticoagulant [blood thinner] medication that interrupts the formation of blood clots) for one of 19 sampled residents (Residents 38). This failure had the potential to affect the residents' physical well-being while in the facility. Findings: During a review of Resident 38's Medical Record (MR), the MR indicated Resident 38 was admitted to the facility for multiple diagnoses that included hemiplegia (paralysis of partial or total body function on one side of the body) and hemiparesis (one-sided weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, and chronic atrial fabulation (an irregular and often very rapid heart rhythm). During a review of Resident 38's medical record, the physician orders, dated 1/6/23, indicated, Apixaban Tablet 5 milligrams (mg, a unit of measurement) via G-tube (a gastrostomy tube is a tube inserted through the belly that brings nutrition directly to the stomach) two times a day for CVA (cerebral vascular accident, or a brain attack, is an interruption in the flow of blood to cells in the brain) prophylaxis (prevention). During an interview and concurrent record review with Licensed Vocational Nurse (LVN) B on 3/8/24 at 11:20 a.m., LVN B stated for Resident 38's Apixaban, We should be monitoring for signs and symptoms of bleeding. Reviewing Resident 38's medical record indicated there was no documentation that monitoring for bleeding was documented. LVN B stated, No, it is not being done. Review of facility's policy titled Anticoagulation (Anticoagulants are sometimes referred to as blood thinners, and are drugs that prevent blood from clotting or prevent existing clots from getting larger) Clinical Protocol, dated November 2023, indicated, Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. a. Assess for evidence of effects related to the subtherapeutic (lower than that usually prescribed to treat a disease effectively) or greater than therapeutic drug level related to that drug if applicable. The staff and physician will monitor for possible complications in individuals who are being anticoagulated (a substance that hinders the clotting of blood) and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in the urine) hemoptysis (coughing up blood) or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Based on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the residents' refrigerator readily available for use when two boxes of Jevity (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition) was found unlabeled and expired in the residents' refrigerator. This failure had the potential to result in contaminated food and foodborne illnesses to an already vulnerable facility population. Findings: During a concurrent observation in the nurses' station and interview with the Director of Staff Development (DSD) on [DATE] at 9:31 a.m., two boxes of Jevity were observed in the residents' refrigerator. Both boxes had an expiration date of [DATE] printed on the box. The DSD stated she did not think they were for anyone; the expiration dates should be checked. Review of the facility's policy and procedure titled, Resident Food Refrigerator, dated [DATE], indicated, Foods that are in their original containers and have not been opened will be kept per the manufacturer's expiration date. Licensed nurses are responsible for ensuring food items in refrigerators, and freezers are not past the expiration dates.

Based on observation, interview, and facility record review, the facility failed to ensure infection control practices were followed for one of three residents (Resident 293) when licensed vocational nurse A (LVN A) did not perform hand hygiene during medication administration. This failure had the potential for transmition of infectious agents to residents. Findings: During a medication pass observation with LVN A on 3/5/24 at 8:22 a.m., LVN A took the blood pressure of Resident 293 and sanitized the blood pressure cuff. LVN A proceeded to prepare Resident 293's medications. LVN A administered the medications to Resident 293 without performing hand hygiene. During an interview with LVN A on 3/5/24 at 8:37 a.m., she stated she should have sanitized her hands after taking the resident's blood pressure and before popping out the medicine. LVN A confirmed she did not perform hand hygiene. During an interview with the Nurse Supervisor (NS) on 3/7/24 at 9:43 a.m., the NS stated when a nurse is giving medication, they need to do hand hygiene between each task. Review of facility's policy and procedure (P&P) titled, Handwashing /Hand Hygiene , revised 10/23, the P&P indicated, Personnel are trained and on the importance of hand hygiene . Indication for Hand Hygiene 1.a. immediately before touching resident . c. after contact with blood, body fluids, or contaminated surfaces.

Based on observation, interview, and record review, the facility failed to ensure five out of six sampled residents had adequate supervision to prevent them from leaving the facility unattended between [DATE] through [DATE]. The distances from the facility, identified by the staff members for these residents, were between 800 feet to 1.1 miles. In addition, the facility failed to ensure proper functioning of their Wanderguard alarm system (A signaling system used to alert staff of residents who may wander out of or leave the facility. The system consists of two devices; a signaling device (bracelet) which is attached to the resident or wheelchair and the door monitor device mounted at each exit door. The two devices interact and give off a loud continuous noise when a resident wearing the signal device passes near or through the doorway to alert the staff when a resident with a risk of elopement is leaving the facility unattended). These failures resulted in all five Residents to wander outside of the facility without staff awareness either by not hearing the alarm sound, shutting the alarm off prior to determining if a resident had eloped, and/or a defective sensor. Findings: 1. On [DATE] at 4:14 PM, the facility notified the California Department of Public Health (CDPH) that Resident 1 left the facility unattended. Review of Resident 1's clinical record indicated he was [AGE] years old and admitted to the facility with diagnoses including dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from disease of the brain) and cognitive communication deficit. Review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated [DATE], indicated a Brief Interview Mental Status (BIMS) score of 99 (unable to complete interview). The MDS indicated the resident had short/long term memory impairment, episodes of wandering at least four to six days but less than daily, and was able to ambulate without any assistive devices (cane, walker, or wheelchair) under supervision. Review of Resident 1's Order Listing Report (physician's orders), dated [DATE], indicated an order to have the Wanderguard on at all times as a safety measure and to monitor its function every night. Review of Resident 1's quarterly Elopement Risk Assessment, dated [DATE] at 7:48 AM, indicated he had episodes of pacing, wandering, and/or trying to get out of the facility. It also indicated he had a history of elopement; therefore, resident 1 was considered a risk for elopement. Another annual Elopement Risk Assessment, dated [DATE] at 7:48 AM, indicated he was at continued risk for elopement. Review of Resident 1's Unusual Occurrence-Elopement Final Report, dated [DATE], indicated the Administrator documented that on [DATE] at approximately 10:45 PM, a Certified Nursing Assistant (CNA) went to take vital signs (temperature, pulse, respirations, and blood pressure) and could not find the resident. She documented Resident 1 was found outside the facility and down the street at a restaurant at approximately 11:30 PM. Resident 1's Wanderguard was in place and functioning (alarming) upon return to the facility. The Administrator's documentation showed an interview with a CNA [CLP1] indicated she thought she heard the alarm sound around 10:,d+[DATE]:45 PM for about 30 seconds but was attending to another resident. The CNA stated after she finished attending to the other resident, the alarm did not sound anymore. The CNA did not know who turned the alarm off. Another interview with Licensed Nurse (LN) A was conducted. She reported, at approximately 10:45 PM, she heard the alarm go off at the front door. When she arrived at the door, it was no longer sounding. Another interview statement from another LN [CLP2] indicated he heard an alarm go off, but it was disarmed quickly. He did not see anyone turn the alarm off. A Registered Nurse (RN) [CLP3] statement indicated an evening shift RN found Resident 1 down the street at a restaurant (.6 miles away). The Administrator documented under the Elopement review that Resident 1 had two Wanderguards in place (one on his ankle and one on his wrist). She concluded the Wanderguard bracelets worn by Resident 1 were in place and functional, since the alarm sounded; however, an unknown person disarmed the alarm at the front door. Review of Resident 1's Behavior Note, dated [DATE] at 8:29 AM, indicated on [DATE] at approximately 11 PM, Resident 1 could not be located inside the facility. Resident 1 was located ,d+[DATE] minutes later outside at a local restaurant with a skin tear to his left elbow. The licensed nurse documented Resident 1's Wanderguard was in working order and had not expired. Review of Resident 1's Interdisciplinary Department Team (IDT) Review note, dated [DATE] at 9:39 AM, indicated other risk factors that may have contributed to this elopement: cognitive communication deficit. The IDT recommended possible transfer to a locked facility. During a telephone interview with LVN C on [DATE] at 1:30 PM, he stated he was worked the evening shift on [DATE]. He stated he heard the Wanderguard alarm go off, but someone turned it off, so he thought the resident was found (Resident 1). LVN C stated when the Wanderguard alarm is triggered, the alarm sound stays on continuously until a staff member goes to the wall alarm box to turn it off/reset it. 2. On [DATE] at 9:21 AM, the facility notified CDPH that Resident 2 left the facility unattended. Review of Resident 2's clinical record indicated she was [AGE] years old and had a diagnosis of Alzheimer's Disease (a type of dementia). Review of Resident 2's Health Status Note, dated [DATE] at 10:53 PM, indicated at approximately 8:20 PM, a CNA began to ask staff if they had seen resident 2. Prior to this request, Licensed Vocational Nurse (LVN) A documented Resident 2 had a second Wanderguard (bracelet) added to her right wrist. Review of Resident 2's undated Unusual Occurrence-Elopement Final Report indicated, on [DATE] at approximately 8:20 PM, the same day the resident was admitted for a five-day respite stay (a short-term relief for primary caregivers), Resident 2 went missing from the facility. Resident 2 was found at a local shopping center (1.1 miles away) and returned to the facility at approximately 9 PM, still wearing her Wanderguard bracelet. Review of Resident 2's IDT Review regarding her [DATE] elopement episode indicated, risk factors identified that may have contributed to her elopement included wandering and confusion. Prior to her elopement episode, she had on two Wanderguard bracelets that triggered the alarm to sound when tested . The IDT recommended for Resident 2 to be placed on every 15-minute monitoring. The IDT concluded Resident 2 likely needed to be in a locked facility versus a secure facility. Review of Resident 2's Medical Provider SOAP Note, dated [DATE] at 6:50 PM, indicated the resident had a diagnosis of Alzheimer's dementia and was brought from home to the facility under respite care to give the resident's family member a needed break (from caring for the resident for a few days). The physician ' s assessment indicated the staff just needed to be careful regarding elopement for Resident 2 because she often tried to leave her own home. He documented Resident 2 had a Wanderguard (bracelet) in place and the staff were aware. Review of Resident 2's MDS, dated [DATE], indicated she had severe impaired cognition, ambulated with supervision, and wandered daily. 3. On [DATE] at 9:19 PM, the facility notified CDPH that Resident 3 left the facility unattended. Review of Resident 3's clinical record indicated she was [AGE] years old and was admitted to the facility with a diagnosis of Alzheimer's dementia. Review of Resident 3's MDS, dated [DATE], indicated a BIMS score of 2 (severely impaired cognition). In addition, the MDS identified the resident had daily episodes of wandering and was able to ambulate with supervision without any assistive devices (cane, walker, or wheelchair). Review of Resident 3's Order Listing Report (physician orders), dated [DATE], indicated an order to monitor the function of the resident ' s Wanderguard every night and to have it on at all times as a safety measure. Review of Resident 3's Health Status Note, dated [DATE] at 10:13 PM, indicated the resident was not in the facility at 8:22 PM. At 9:03 PM (43 minutes later), Resident 3 was located down the street at a restaurant 0.3 miles away from the facility. Review of Resident 3's IDT Review note indicated other risk factors that may have contributed to Resident 3 ' s elopement included wandering aimlessly, ambulating without assistance, history of elopement, and impulsivity. Interventions that were in place prior to her elopement included the use of a Wanderguard. Review of Resident 3's Elopement Final Report, dated [DATE], indicated the Administrator documented Resident 3 was last seen on [DATE] at approximately 8 PM before she eloped. Resident 3 was found outside the facility and down the street at a restaurant at 9:03 PM. The facility had a Wanderguard alarm system in place. The preventative maintenance log indicated the Wanderguard system was checked three times a week to ensure the system worked. The facility concluded Resident 3's Wanderguard bracelet triggered an alarm to sound both when she left the facility and when she returned to the facility. However, by the time staff reached the door after Resident 3 eloped, she was already out of site. Meanwhile, another resident with a Wanderguard bracelet simultaneously triggered the same alarm that Resident 3 triggered (upon Resident 3's elopement). This led the Charge Nurse to incorrectly believe it was only that one other resident who set off the alarm. Minutes later, a CNA alerted other staff that Resident 3 was missing. 4. On [DATE] at 1:15 PM, the facility notified CDPH that Resident 5 left the facility unattended. Review of Resident 5's clinical record indicated she was [AGE] years old and admitted to the facility with diagnoses including psychotic disorder with delusions and unspecified dementia. Review of Resident 5's Elopement Risk Assessment (during admission), dated [DATE] at 3:10 PM, indicated she was not independently mobile and had no history of elopement. Another Elopement Risk assessment dated [DATE] at 1:50 PM, indicated she ambulated independently, paces and wanders, and has a history of elopement. This [DATE] assessment also indicated Resident 5 left the facility twice while wearing a Wanderguard and was a danger to herself by inadvertently leaving the facility. Review of Resident 5's Psychiatric Diagnostic Interview, dated [DATE], indicated she was highly anxious, confused and tried to leave the facility. The NP documented Resident 5 was fearful, anxious, frustrated, and had poor attention/concentration, impulse control, insight/judgment, and recent memory. Review of Resident 5's physician ' s orders, dated [DATE], indicated an order to check the Wanderguard placement and functioning once a day. Review of Resident 5's Unusual Occurrence-Elopement Final Report, dated [DATE], indicated on [DATE] at approximately 10 PM, a CNA went into Resident 5's room and noted the resident was not in her bed. The CNA looked outside and saw the Police department were across the street at the car dealership. Resident 5 was seen sitting on a bench outside the dealership. Resident 5's Wanderguard (bracelet) was in place on her left ankle. LVN B saw Resident 5 at around 8 PM and knew the Wanderguard was on her left ankle; however, she could not remember hearing any alarm sound when the resident eloped. LVN B heard the alarm sound when Resident 5 returned to the facility. The Administrator documented Resident 5's interventions, which included changing the location of her Wanderguard from her ankle to her wrist and ordering a Psychiatric evaluation. Review of Resident 5's Medical Provider SOAP Note, dated [DATE] at 1:22 PM, indicated Resident 5 was transferred from skilled nursing facility (SNF) A to SNF B because she kept trying to leave SNF A. While the resident was at SNF B wearing a Wanderguard (bracelet), she made her way outside of the facility without the alarm going off and went across the street to a car dealership. Review of Resident 5's Minimum Data Set (MDS-an assessment tool), dated [DATE], indicated a BIMS score of 9 (moderately impaired cognition). In addition, the MDS identified the resident had episodes of wandering one to three days and was able to ambulate with supervision using a walker. 5. On [DATE] at 3:35 PM, the facility notified CDPH that Resident 6 left the facility unattended. Review of Resident 6's clinical record indicated she was [AGE] years old and admitted to the facility with diagnoses including anxiety disorder and cognitive communication deficit. Review of Resident 6's Order Listing Report, dated [DATE], indicated an order to monitor the function of the Wanderguard once a day and to have the staff check the placement of the Wanderguard every shift on her left ankle. Review of Resident 6's Elopement Risk Assessment (Admission), dated [DATE] at 9:58 PM, indicated she had episodes of pacing, wandering and/or trying to get out of the facility, and she had a history of elopement. Resident 6 was considered a high risk for elopement. Review of Resident 6's MDS, dated [DATE] indicated a BIMS score of 9 (moderately impaired cognition), ambulated with supervision, and had no history of wandering. Review of Resident 6's IDT Review note, dated [DATE] at 9:54 AM, indicated other risk factors that may have contributed to elopement included episodes of wandering and elopement risk. Previous interventions that were put in place prior to the elopement on [DATE] was a Wanderguard (bracelet). The IDT recommended to change Resident 6 from a 1:1 (one staff member always with the resident) to every 15-minute monitoring. Review of Resident 6's Elopement Final Report, dated [DATE], indicated the Administrator documented the resident had diagnoses including dementia without behavioral disturbance and cognitive communication deficit. On [DATE] at 4:50 a.m., a CNA reported she could not find Resident 6. Resident 6 was found outside the facility and down the street speaking with a man. The staff assisted Resident 6 back to the facility at around 5:10 AM and the Wanderguard (bracelet) was replaced to her right ankle. An interview with the Charge Nurse indicated Resident 6's ankle bracelet failed to trigger the alarm upon elopement; and, when the resident was brought back to the facility, the ankle bracelet was immediately replaced. During an interview with the Assistant Administrator (AA) on [DATE] at 10:20 AM, she stated the facility had five exit doors with a Wanderguard system that sounded an alarm when a resident with a Wanderguard bracelet was close to the exit door or had exited the facility. The AA stated a receptionist sat at a desk close to the front door seven days a week from 8 AM - 7:30 PM. She stated the four other exit doors lock from the outside only; and, when they were opened from the inside, an alarm would sound until a staff member would go to the control box to punch in a code that would reset the alarm. When the AA was asked if the facility had done any tracking or trending related to residents that eloped, she replied she was unaware. She stated the Maintenance Director checked the Wanderguard system every week to ensure the system functioned properly. The AA stated: a. Resident 1 was confused, combative and wandered aimlessly for hours on end. b. Resident 2 was confused and at the facility for respite care. The resident wandered around the facility and eloped the 1st day she was admitted to the facility. c. Resident 3 was confused and wandered aimlessly. The resident also had aggressive behaviors towards the staff. d. Resident 5 was confused, yelled, and was combative towards the staff. The resident wandered around the facility and was not easily directed; and, e. Resident 6's Wanderguard bracelet did not sound an alarm when she left the facility; however, it sounded an alarm when she returned. During an observation of a Wanderguard bracelet sensor, on [DATE] at 11:15 AM, the Nursing Supervisor went to the front door with the bracelet and a very loud alarm sounded until the control box on the wall was reset. During an interview with the Social Service Director (SSD) on [DATE] at 1:20 PM, she stated all the facility's exit doors have the Wanderguard alarm system installed. She was not employed at the facility until [DATE] and did not recall the residents. During an interview with Licensed Vocational Nurse (LVN) A on, [DATE] at 1:25 PM, she stated: a. Resident 1 was alert and confused. The resident was non-verbal most of the time and had behaviors including agitation and wandering from morning until night. He ambulated independently. b. Resident 2 was alert, but not oriented and not able to make her needs known. The resident's behaviors included wandering and exit seeking. She ambulated independently. c. Resident 3 was alert to person only and able to make her needs known. The resident's behaviors included wandering and exit seeking. d. Resident 5 was alert to person only. She ambulated with a walker or wheelchair and had exit seeking behaviors. e. Resident 6 was alert to person only and was able to make her needs known. The resident was transferred from SNF A to SNF B because she was exit seeking and this building (SNF B) had the Wanderguard system installed. LVN A stated all exit doors at the facility had the Wanderguard alarm system installed and the Maintenance Director checked the system every other day to ensure the alarm functioned/sounded. During an observation of the facility's exit doors with the AA on [DATE] at 2:50 PM, all five exit doors had alarms that sounded off very loudly when a Wanderguard bracelet sensor was brought near to trigger them. The AA had to manually input a code in the code box on the wall to silence and reset the alarm system. Review of the facility's policy and procedure (P&P) Wandering and Elopements, revised ,d+[DATE], indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If residents are identified to be at risk for wandering/elopement, their care plans will include strategies and interventions to maintain their safety.

Based on observation, interview, and record review the facility failed to ensure the competency of the two of two staff, the Registered Dietitian (RD) and the Dietary Services Supervisor (DSS), responsible for oversight of Food and Nutrition Services, when: 1. The RD did not provide consultation to the DSS regarding multiple kitchen sanitation issues (cross-reference F812); 2. The RD did not provide consultation regarding the palatability and consistency of food texture; 3. The DSS did not report multiple maintenance issues she was aware of including: a. a leaking reach-in refrigerator; and b. a reach-in freezer with significant ice build-up, 4. The DSS did not have a reliable system for ensuring staff cleaned according to the cleaning schedule; 5. The DSS and the RD did not ensure the juice machine was maintained in a clean and sanitary manner. 6. The DSS and the RD did not ensure sanitary handling of drinking ware, utensils, and ready to eat food. These failure had the potential for the functions of the Food and Nutrition Service not to be carried out in a safe and sanitary manner; in manner to provide food prepared by methods that conserved nutritive value, flavor, and appearance; and in a manner for food prepared in a form to meet the needs of residents, for 90 residents who received food from the kitchen. Findings: 1. Review of the document titled Orientation, Inservice, & [and] Personnel Management dated 2018, showed the consultant RD provided oversight of the operations of the Department of Food and Nutrition Services. One of the responsibilities included monitoring and recommending food service standards for sanitation, safety, and infection control. Review of the document titled Agreement to Provide Consultant Services signed 5/17/2019, showed a couple of the consultant dietitian's responsibilities included to review sanitation in accordance with current regulatory standards and to provide written reports of each visit to the facility including audits performed, summary of performance, goals, and recommendations. During observations from 12/6/21 to 12/12/21, multiple sanitation issues in the kitchen (cross-reference F812) included: the wood shelving under a preparation table was dirty and in poor condition; cooking pans ready for use had a significant amount of residue build-up, were significantly scratched on the cooking surface, and had non-stick coating peeling off; the floor area around a reach-in refrigerator and under a preparation table had a significant amount of residue build-up and cobwebs; knives for food preparation residue on the blades, the blades came into contact with dirty wire covers and were stored directly under an insect killer machine which had a fly on the surface; a significant amount of grime was in the grooves of the rubber gaskets (a rubber seal that on the door of the refrigerator to prevent leakage of cold from inside the refrigerator when the door is closed) of 2 refrigerator doors; the light switch into the dry food storage had residue build-up and had dirty tape on the surface; the wall in the dish machine area had black residue build-up; baseboard tiles were in bad repair and pulling away from the wall with grime between the tile and the wall; a counter mounted, industrial can opener had a significant amount of rust and residue build-up on the surface and the blade was in poor condition; a standing mixer bowl had rust on the inside surface; shelves in a beverage refrigerator were rusted; cutting boards stored ready for use had residue on the surface; and a drain cover in a food preparation sink was rusted. Review of the last three untitled documents, the RD used as a tool to inspect the kitchen, were dated 8/21/21, 9/30/21, and 10/29/21. The inspection documents included two pages of safety and sanitation items the RD could check off as Met or Not Met. There was also a column provided for comments. The inspection list included but was not limited to refrigerators and freezers are clean inside and outside, the kitchen work areas are clean and organized, cross contamination prevention in place, shelves, floors, walls, and ceilings are clean, dish machine area is clean, pots and pans area clean, dishes are free of stains, and food preparation utensils and equipment is cleaned properly and sanitized. All of these areas were marked as met on all three inspection dates. Also, no comments were made on any of the documents. In an interview on 12/8/21 at 2:40 p.m., the RD stated she did monthly audits of the kitchen. She stated the DSS did not like her to document issues on her report. The RD stated she did not observe build-up of grime in the kitchen such as the thick sludge residue at the base of the dairy refrigerator, she did not observe rust on the beverage refrigerator racks, she did not observe ripped rubber gaskets on the doors of the beverage refrigerator, she did not observe rust on the can opener, she did not notice tiles coming off the wall near the near the inside kitchen front door. She stated she thought the kitchen might be a little dirty, but it was old. She stated she did not report any cleanliness issues in any of her reports. She stated she was not concerned with a rusty drain cover inside the food preparation sink. She also stated her reports were provided to the Administrator and the Director of Nursing. In an interview on 12/9/21 at 2:15 p.m., the RD stated the DSS tended to limit the time she had to do the audit in the kitchen to about 30 minutes and she felt like she could use at least 45 minutes to an hour to do the audits. 2. During observation from 12/6/21 to 12/12/21, one resident complained about the food and there was bland, overcooked food, as well as pureed food that was not the appropriate consistency. (Cross-reference F804 and F805). Review of the PO [by mount] Diet Roster showed all pureed diets provided were Puree Level 4. In an interview on 12/6/21 at 12:04 p.m., the RD stated if pureed food was too runny, it could be an aspiration (breath in food to the lungs) risk and the resident could choke. She stated the pureed food should be a drop consistency. An observation and concurrent interview with the RD and the DSS on 12/7/21 at 3:30 p.m., indicated a Diet Manual approval dated on 2/14/19 and located in the DSS office area. The diet manual contained a description of various therapeutic diets including diets with modified consistency. The index did not show Puree Level 4 but did other texture modified diets including Pureed National Dysphagia (Difficulty or discomfort in swallowing, as a symptom of disease) Diet (NDD) Level 1, Dysphagia Mechanical Altered NDD Level 2, Dysphagia Advanced Diet NDD Level 3. On page 12 of the diet manual under the title Mechanically Altered/Texture Modified Diets it showed Mechanically altered foods are available for residents with chewing and/or swallowing problems .The Dysphagia diets are specifically for residents with swallowing problems .An evaluation team of speech-language pathologist/speech therapist, physician and registered dietitian will discuss the recommendation and obtain a physician's order for diet and texture appropriate for the resident .[Name of the menu service company] provides four levels of mechanically altered diets on the Menu Spreadsheets. They are as follows: Puree (Dysphagia Blenderized, NDD level 1); Mechanical Soft Ground; Dysphagia Mechanical Altered (NDD level 2); and the Dysphagia Advanced (NDD level 3) which is offered only in some states. The RD stated she was not sure why puree level 4, provided at the facility was not in the diet manual. She stated she had to ask the DSS about why this diet was not in the diet manual. The DSS looked through the diet manual and stated she could not find puree level 4. The DSS went to her office and returned with a document titled Dysphagia Diets Puree IDDSI level 4. Review of the document titled Dysphagia Diets Puree IDDSI [International Dysphagia Diet Standardization Initiative] Level 4 dated July 2019, showed the food on this diet holds it shape on a plate .Any liquids must not separate from the food and the food can fall off a spoon intact. The Food is more easily swallowed and prevents aspiration. In an interview on 12/8/21 at 2:40 p.m., the RD stated she did not observe tray-line and she generally did not include tray-line as part of her audit. She also stated she did not look to see if staff were following recipes when cooking food. (Cross-reference F802) In an interview on 12/10/21 at 10:18 a.m., the RD stated drop consistency meant if the food was on a spoon, it doesn't drop, kind of have to flick it off. To remind the RD what the pureed food looked like on the plate served for lunch on 12/6/21, the RD was shown photographs of the pureed food. The photo showed pureed carrots and pureed meet spread out flat over the surface of the plate and ran into the food items on the plate. Also, the pureed meat had a clear liquid that separated from the food. The photo also showed a scoop of pureed pasta, which held its shape in a mound formation, and a scoop of pureed bread that spread slightly but held a mound shape. The RD stated the foods that had the appropriate consistency for a level 4 puree diet were the carrots and the meat. She stated the pureed pasta and pureed bread were thicker than the carrots and meat and maybe too thick because they held their shape. Review of the document titled Orientation, Inservice, & [and] Personnel Management dated 2018, showed the RD provided oversight of the operations of the Department of Food and Nutrition Services. A couple of the responsibilities of the consultant RD were to monitor and recommend food service standards for safety, also to evaluate and monitor the food service department to assure that the department was providing adequate, acceptable quality food. 3. During observation from 12/6/21 to 12/12/21 equipment was not maintained. This included a reach in refrigerator the facility used to store dairy products, which the DSS stated was leaking and causing the significant amount of residue build-up at the base of the refrigerator and a reach-in freezer with a significant amount of ice build-up inside. (Cross-reference F908) Review of the undated job description titled Dietary Supervisor showed the DSS was responsible for ensuring food service equipment was clean and operable. a. In an interview and observation on 12/6/21 at 9:10 a.m., during the initial tour of the kitchen. the dairy refrigerator had a significant amount of brown, sticky residue build-up at the bottom, front of the refrigerator. The DSS stated the residue was rust because the refrigerator leaked. She stated she reported the leak to maintenance. In an interview on 12/6/21 at 12:32 p.m., the DSS stated she verbally told maintenance about the ice build-up last week, but she did not have documentation. In a telephone interview on 12/9/21 at 9:23 a.m., the pest control technician stated he serviced the facility kitchen on the evening of 12/7/21 due to a report of small flies. He stated the most likely breeding place for the flies was under the dairy refrigerator because there was a lot of dampness under this refrigerator and also a lot of gook. (Cross-reference F925) In an interview on 12/10/21 at 9:54 a.m., the DSS stated when the refrigerator leaked, staff dried it off. She stated it leaked on the floor in the front of the refrigerator. She stated the refrigerator did not move so they were not able to clean under it. She stated it was leaking since October. In an interview on 12/10/21 at 11:01 a.m., Maintenance Supervisor E (MS E) stated he was not made aware of the leaking dairy refrigerator until after it was observed by the surveyors on 12/6/21. b. In an interview and observation on 12/6/21 at 9:10 a.m., during the initial tour of the kitchen, the reach-in freezer had a significant amount of ice build-up on the freezer ceiling and chunks of ice on the freezer floor. In an interview on 12/6/21 at 12:32 p.m., the DSS stated she verbally told maintenance about the ice build-up last week, but she did not have documentation. In an interview on 12/6/21 at 2:15 p.m., MS E stated he did not remember the DSS reporting the ice-build up in the freezer. An observation and interview on 12/7/21 at 10:40 a.m., indicated ice build-up inside the reach-in freezer on the ceiling surface and pieces of ice on the freezer floor. The freezer also had a significant amount of condensation on the outside surface around the freezer doors. The DSS stated she was not really concerned about the ice build-up because the ice pieces were not big. Review of the invoice dated 12/7/21, indicated a technician serviced the reach-in freezer and stated the ice-build up was due to the freezer being too full of boxes stacked to the top which did not allow good air circulation. 4. Review of the undated job description titled, Dietary Supervisor indicated the DSS was responsible for monitoring staff to confirm they adhered to all sanitation, safety, and procedural guidelines within the department, ensuring food service equipment was clean. During observation from 12/6/21 to 12/12/21, multiple sanitation issues were in the kitchen (cross-reference F812). This included the wood shelving under a preparation table was dirty and in poor condition; cooking pans ready for use had a significant amount of residue build-up, were significantly scratched on the cooking surface, and had non-stick coating peeling off; the floor area around a reach-in refrigerator and under a preparation table had a significant amount of residue build-up and cobwebs; knives for food preparation residue on the blades, the blades came into contact with dirty wire covers, and were stored directly under an insect killer machine which had a fly on the surface; a significant amount of grime was in the grooves of the rubber gaskets (a rubber seal that on the door of the refrigerator to prevent leakage of cold from inside the refrigerator when the door is closed) of 2 refrigerator doors; the light switch into the dry food storage had residue build-up and had dirty tape on the surface; the wall in the dish machine area had black residue build-up; baseboard tiles were in bad repair and pulling away from the wall with grime between the tile and the wall; a counter mounted, industrial can opener had a significant amount of rust and residue build-up on the surface and the blade was in poor condition; a standing mixer bowl had rust on the inside surface; shelves in a beverage refrigerator were rusted; cutting boards stored ready for use had residue on the surface; and a drain cover in a food preparation sink was rusted. In an interview and observation on 12/6/21 at 12:32 p.m., the surface of the shelving under the preparation table that held the coffee machine, was covered with residue and grime. (Cross-reference F812) The DSS stated the shelving was not clean and this area was not on the cleaning schedule. In an interview and observation on 12/6/21 at 2:28 p.m., the rubber gaskets around the beverage refrigerator doors were imbedded with brown grime and what resembled food crumbs. The DSS stated the rubber gaskets were not on a cleaning schedule and when they [referring to kitchen staff] get a chance they will clean. In an interview on 12/7/21 at 10:13 a.m., the DSS showed a cleaning schedule attached to the outside of a refrigerator door. The schedule listed multiple tasks listed by day and staff job position. When the DSS was asked how she verified the cleaning was done according to the schedule she stated, sometimes they sign-off, sometimes staff will clean on a different day other than what's shown on the schedule, sometimes I have someone else clean. 5. An observation and concurrent interview with the DSS and Kitchen Staff 1 (KS 1) on 12/6/21 at 10:09 a.m., showed a juice machine with the juice gun submerged in a picture of water. The water was pink. The juice gun had a white, slimy residue between the buttons. Also, the tubing that connect the juice syrup bags to the machine were sticky feeling with fuzzy residue stuck to the surface of the tubing. The DSS stated a juice machine company came to clean the juice machine. She stated she thought they came quarterly. She also stated the cleaning of the juice machine was not assigned to any staff, indicating anyone could clean it. KS 1 demonstrated how he cleaned the machine. He wiped the juice gun with a rag that was soaked in a quaternary [MEDICATION(S)] (a sanitizer) solution. Then he ran the juice gun holder through the dish machine. The DSS stated the juice gun was soaked in a pitcher of hot water about every other day. In an interview on 12/7/21 at 11:36 p.m., the DSS stated she did not have instructions for cleaning the juice machine or the manufacturer's manual for the machine. In an interview on 12/8/21 at 2:40 p.m., the RD stated she did monthly audits of the kitchen. She stated she did not look at the juice machine during her audits. In an interview with Maintenance Supervisor E (MS E) on 12/9/21 at 1:30 p.m., he stated he did not have invoices to show the juice machine company came out to clean the machine and they did not come out on a regular scheduled bases for cleaning. He stated the only times they serviced the juice machine was when he called them because something was wrong with the machine. In an interview with the DSS on 12/9/21 at 2:40 p.m., the DSS stated the current juice machine company did not come out for cleaning of the juice machine, but they should. She stated the last juice machine company came out for regular cleaning, but they started using a different juice machine company. She stated she did not know when this change happened. She stated she did not provide any training to her staff about how to clean the machine. Review of an e-mail document with the subject title RE: Cleaning instructions for the [brand of the juice machine] bar gun dated 12/10/21 and a concurrent interview with MS E on 12/10/21 at 11:35 a.m., showed the dates the company were at the facility and what they did when they serviced the juice machine. On 8/31/2020, the juice machine unit was installed. On 9/17/2020, 10/12/2020, 11/17/2020, and 3/9/2020, the company came out to fix the juice machine. MS E stated there was no cleaning by the company on these dates. On 7/7/21, the e-mail showed the juice machine was leaking so the technician replaced the oring [O-ring; a mechanical seal in the shape of a ring placed between two parts to make a seal] and fittings and cleaned the bar gun. MS E stated the cleaning of the bar gun by the company on 7/7/21 was the only cleaning documentation he had. Review of the undated manufacturer's manual for the juice machine titled [Name of juice machine] Post-mix Beverage Dispenser showed detailed instructions for cleaning. It showed the cleaning solution to use was [Brand name] Chloromelamine (a sanitizer). The preparation of the solution included adding two packets of Chloromelamine sanitizer powder to 5 gallons of warm potable water in a clean 5-gallon bucket. This produces a 100 part per million (ppm; sanitizer strength) chlorine solution. The instructions indicated other chlorinated sanitizers other than [Brand name] could be used and follow instructions to make it a 100 ppm solution. The manual showed detailed instructions for cleaning the Sheathing (a protective case or cover). The instructions for cleaning the nozzle included a cup of the cleaning solution. Then grasp the nozzle and twist back and forth while pulling the nozzle away from the handle. If the nozzle is difficult to remove, immerse nozzle end of the handle in a cup of carbonated water for five minutes before attempting removal again. When the nozzle is removed, place in cup of cleaning solution for 2 minutes. Immerse a clean brush in the sanitizer solution. Scrub nozzle and diffuser with a clean brush until any and all buildup is removed. Then remove the nozzle from the cleaning solution and allow the nozzle and diffuser to air dry. Then reinstall the nozzle onto the diffuser. The manual also gave detailed instruction for cleaning the Post-Mix System which involved filling a sanitizer tank and disconnecting all the connectors to the bags of syrup. Then connect the connectors to the sanitizing tank. The directions showed the sanitizing steps were followed by detailed rinsing steps. During a record review of the facility's policy, Sanitization, revised October 2008, indicated all areas of the kitchen should be kept clean. Review of the document titled Orientation, Inservice, & [and] Personnel Management dated 2018, showed the consultant RD provided oversight of the operations of the Department of Food and Nutrition Services. One of the responsibilities included monitoring and recommending food service standards for sanitation, safety, and infection control. Review of the undated job description titled Dietary Supervisor indicated the DSS was responsible for supervising and training dietary staff, as well as monitoring staff to confirm they adhere to all sanitation, safety, and procedural guidelines within the department. The DSS was also responsible for ensuring food service equipment was clean and operable. 6. An observation and concurrent interview with the DSS on 12/2/21 at 12:30 p.m., showed KS 1 placed items on trays for resident lunches included plastic cups filled with a beverage, utensils, and salads. KS 1 did not wear gloves. The cups with beverages were covered with plastic lids. When he handled the cups, he grabbed the very top so his fingers came into contact with the area a person would put their mouth to drink. When KS 1 handled the utensils, his hands came into contact with the end of the utensil that a person would put in their mouth. The salads KS 1 placed on the trays were in uncovered bowls. He handled the salads by placing his hand over the top of the salad and grabbing the top of the bowl, so the palm of his hand came into contact with the lettuce in the bowl. The DSS stated she did not see a problem with the way KS 1 handled the cups, utensils, and salads. She asked what the difference was between wearing gloves or using bare hands to touch the items. In an interview on 12/8/21 at 2:40 p.m., the RD stated she did monthly audits of the kitchen. She stated she did not observe tray-line food service or watch for hand hygiene when she did her audits. Review of the facilities policy and procedure, Glove Use dated 2017, indicated single use gloves must be worn if bare hands are to contact ready-to-eat food. According to the 2017 Federal Food Code, clean utensils shall be handled so that contamination of food-and lip-contact surfaces is prevented. Knives, forks, and spoons that are not prewrapped shall be presented so that only the handles are touched by employees. Review of the document titled Orientation, Inservice, & [and] Personnel Management dated 2018, showed the consultant RD provided oversight of the operations of the Department of Food and Nutrition Services. One of the responsibilities included monitoring and recommending food service standards for sanitation, safety, and infection control. Review of the undated job description titled Dietary Supervisor showed the DSS was responsible for supervising and training dietary staff, as well as monitoring staff to confirm they adhere to all sanitation, safety, and procedural guidelines within the department.

Based on observation, interview, and record review the facility failed to ensure palatability and nutritive value of cooked foods were maintained when vegetables were cooked for an extended time. In addition, one resident (Resident 78) complained about food being overcooked. This failure had the potential to result in decreased palatability; leading to a decrease in food consumed by residents, and food cooked for extended time periods could lose nutritive value leading to a decreased nutrient intake for 90 residents who received food from the kitchen. Findings On 12/6/2021 at 9:21 a.m., during an observation and interview with Cook 1 and Dietary Services Supervisor (DSS), indicated pans in a hot oven covered with foil. Cook 1 stated the items in the oven were pureed meat and pureed vegetables cooking in the oven for lunch time. DSS stated the meat and vegetables were already cooked and fully heated and ready to place on the tray line that started at 11:45 a.m. Cook 1 and the DSS stated the vegetables were in the oven since 9:00 a.m. The DSS stated this is their kitchen's practice to prepare purees early and continue to hold in the oven until lunchtime. During an interview with the facility's Registered Dietician (RD), on 12/6/2021 at 12:07 a.m., the RD stated food held in the oven for hours can affect the nutrients, especially the vegetables. During an observation and interview with the RD, on 12/7/2021 at 12:38 p.m., a sample test tray was requested due to residents complainting about the food was not good. Both the regular and puree diet were provided for tasting. The regular and the puree vegetables lacked flavor. Also, the regular vegetables were mushy and overcooked. During an interview with Cook 2 on 12/7/2021 at 12:45 p.m., Cook 2 stated she prepared the vegetables by taking the vegetables out of the box and placed them in the oven in a covered pan. She said the only ingredient she added to the vegetables was butter. Cook 2 stated she prepared them and put them in the oven at 10:00 a.m. Cook 2 stated she cooked the vegetables for 35 minutes and left them in the oven until the tray line food service started at 11:45 a.m. Review of the recipe, titled Capri Blend Veg dated 2002-2021, for provided for the vegetables prepared for lunch on 12/7/21, showed ingredients in addition to the vegetables and butter included salt, granulated garlic, and black pepper. The directions showed to steam the vegetables using pressure or without pressure. Using pressure steaming from 1 minute to 12-15 minutes. Without using pressure, the vegetables were to cook for 5-7. The recipe stated, Vegetables should be slightly crisp. The recipe showed to puree they prepared vegetables for the pureed diet. It was noted that Cook 2 did not use a steamer and did not use pressure to cook the vegetables. According to the Academy of Nutrition and Dietetics at Eatright.org, short cooking times help vegetables keep their bright color and crisper texture. When steaming vegetables, nutrients can get lost to the liquid. Also, heat can destroy B vitamins and vitamin C, so shorter cooking times help retain nutrients as well as crisp textures. During an interview on 12/6/2021 at 2:44 p.m., with Resident 78, Resident 78 stated he did not like the food. When asked what was the problem with the food, Resident 78 stated the cooks are the problem with food. Resident 78 elaborated by stating much of it was overcooked, sometimes undercooked, and it was not hot.

Based on observation, interview, and record review the facility failed to ensure food was stored, prepared, and served in a sanitary manner when: a. The wood shelving under a preparation table was dirty and in poor condition; b. Cooking pans ready for use had a significant amount of residue build-up, were significantly scratched on the cooking surface, and had non-stick coating peeling off; c. The floor area around a reach-in refrigerator and under a preparation table had a significant amount of residue build-up and cobwebs; d. Knives for food preparation had residue on the blades, the blades came into contact with dirty wire covers, and were stored directly under an insect killer machine which had a fly on the surface; e. A significant amount of grime was in the grooves of the rubber gaskets (a rubbers seal that on the door of the refrigerator to prevent leakage of cold from inside the refrigerator when the door is closed) of two refrigerator doors; f. The light switch into the dry food storage had residue build-up and had dirty tape on the surface; g. The wall in the dish washer area had black residue build-up; h. Baseboard tiles were in bad repair and pulling away from the wall with grime between the tile and the wall i. An industrial mounted can opener had a significant amount of rust and residue build-up on the surface and the blade was in poor condition; j. A standing mixer bowl had rust on the inside surface; k. Shelves in a beverage refrigerator were rusted; l. Cutting boards stored ready for use had residue on the surface; m. A drain cover in a food preparation sink was rusted; n. no air gaps (a gap in a drainpipe, from a piece of equipment that drains water, to the flood level rim of a floor ;drain or plumbing equipment) to an ice machine drainage or to the food preparation sink in the kitchen; o. There was expired food stored in the dry storeroom available for use and p. A peanut butter container was not clean on the outside. These failures had the potential to cause cross-contamination of food, pest infestation, and utensils for eating, leading to food-borne illness and/or illness from contaminated eating utensils for 90 residents who received food from the kitchen. Findings: Review of the facility's policy, titled Safety and Sanitation, revised 2017, showed spills will be cleaned up as they occur, storage areas will be kept clean, shelving will be kept clean, and floor are to be kept free of broken tiles. Review of the facility's policy, titled Sanitization, dated [DATE], indicated the kitchen areas shall be kept clean; all utensils, equipment, counters, and shelves shall be kept clean and maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning; seals will be kept in good repair; all equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils, kitchen surfaces not in contact with food should be cleaned regularly on a schedule to prevent the accumulation of grime. a. During an observation on [DATE] at 9:57 a.m., the shelving under the preparation table where the coffee station was located, was in bad repair. The shelves were lined with plastic trays and on top of the plastic trays were empty food storage containers ready for use. The wood on the front edges of the shelving, especially along the bottom length of the shelving area, close to the floor, exposed particle board. There was also peeled and chipped paint along the front surface of the shelving. In addition, the shelving surface where the plastic trays and food bins were stored had a significant amount of food crumbs and/or food debris. There was also dried, brown, residue on the shelving surface that looked like dried liquid. In an interview on [DATE] at 12:32 p.m., the dietary services supervisor (DSS) stated the shelving under the coffee area was not clean and the area was not on a cleaning schedule. She confirmed the frame of the wood shelving along the floor was in bad repair. According to the 2017 Federal Food Code, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. b. During an observation and concurrent interview on [DATE] at 9:27 a.m., with the DSS, three large skillet pans had significant black residue buildup on the inside cooking surface, two skillets had dried residue on the inside cooking surface that resembled food residue, and two small skillets had scratches and residue that covered the entire cooking surface and had a coating that was peeling off. One medium sized skillet had a significant number of scratches and orange residue on the inside cooking surface. The skillets were all hanging above the three-compartment sink. The DSS confirmed the pans had residue and scratches. She also stated the pans were ready to be used for food preparation. c. During an observation and concurrent interview on [DATE] at 9:42 a.m., with the DSS, an area under a food preparation table, located between the dairy refrigerator and the food preparation sink, had plastic racks on the floor with cardboard boxes on top of the racks. The cardboard boxes contained disposable plastic lids and aluminum lids. The plastic crates holding the boxes had cobwebs in the grooves. A concurrent observation indicated the dairy refrigerator was sitting directly on the floor with an attached ramp, so a cart could be rolled inside. There was a groove between the ramp and the inside of the refrigerator that had brown residue imbedded. Also, at each side of the ramp area there was thick, orange, black, and brown colored residue. The residue was removable with a paper towel and was sticky and moist. Inside the dairy refrigerator, there was a white substance that covered the surface of the floor. The DSS confirmed there were cobwebs on the plastic crates under the food preparation table. She stated if there were spider webs, then we likely have spiders. She also confirmed the area at the base of the dairy refrigerator had black, orange and brown color grime. The DSS stated the thick residue was rust because the refrigerator leaked. She stated housekeeping scrubbed the floors once a month which included cleaning the floors under the food preparation sink and around the dairy refrigerator. She stated there was no cleaning schedule for staff to clean these areas. The DSS stated the white residue on the floor inside was from a spill. She stated the inside of the refrigerator was cleaned on Tuesdays, but staff should have cleaned the spill when it happened. In an interview and observation on [DATE] at 11:09 a.m., the house keeping manager (HKM) showed areas in the kitchen where he cleaned once a month. He stated he cleaned under the food preparation sink but he did not clean the area where there was residue build-up around the dairy refrigerator. He stated to get to the area where there was residue build-up around the dairy refrigerator, he would need to open the refrigerator door. However, he stated he did not open refrigerator doors and did not move big items such as refrigerators to clean under or around them. He stated he only cleaned under things that were easily moveable. He stated he only cleaned the floors and did not clean other areas in the kitchen such as tile baseboards or walls. d. An observation on [DATE] at 9:36 a.m., showed knives were stored on the wall in a knife holder behind the food preparation sink. Directly above the knife holder was a bug extermination machine. The machine had a fly on the bottom of it. A cord from the machine was plugged into the wall and the cord went behind the knives stored in the knife holder. The cord had a plastic white cover around it. The plastic cover had fuzzy gray residue on the entire surface as well as white residue flaking off of the cover. This cover came into contact with the knife blades stored in the holder. The knives were pulled out of the holder and two knives had dried residue on the blades in addition to a white flaky substance. The holder for the knives also had a dried residue on the surface that resembled food residue. In an interview and concurrent observation of the knife storage area on [DATE] at 12:32 p.m., the DSS confirmed the knife storage holder and knives stored in the holder had to be cleaned. She also said the wall around the knife holder and the cord cover from the bug machine was not clean. e. During an observation on [DATE] at 2:26 p.m., the rubber gaskets on the on two of the four doors of the beverage refrigerator had black grime build up in the grooves of the gasket. The grime wiped off with paper towel. In addition, the gaskets on the two lower doors were ripped and coming detached from the door. During an observation and concurrent interview with the DSS, on [DATE] at 2:27 p.m., the DSS confirmed the observation that the gaskets in the beverage refrigerator had black grime imbedded in the grooves. She stated the gaskets were not on a cleaning schedule and stated, when they [kitchen staff] get a chance they will clean. She also confirmed the gaskets were ripped and said they needed to be replaced. f. During an observation and concurrent interview with the DSS, on [DATE] at 10:30 a.m., the light switch located on the wall to the right at the entrance of the food storage room had silver tape attached. The tape was on the light switch cover and over the switch. The tape was peeling off and had a black residue on the surface. Also, the light switch cover had brown and black grime on the surface. The DSS confirmed the observation of black grime around the light switch cover and stated it was grease. g. During an observation and concurrent interview with Maintenance Supervisor D (MS D), on [DATE] at 10:04 a.m., black residue was on the wall above the sink on the dirty side of the dish machine. The residue was mainly spread on the wall above a plastic strip that ran horizontally along the wall. The residue wiped off with a paper towel. MS D confirmed there was black residue. h. During an observation, on [DATE] at 12:50 p.m., the entry to the kitchen had black grimy build up in the corners and along the edges near the baseboard and two tiles were broken and separated from the wall with grimy buildup between the wall and the backside of the baseboard tile. During an observation and concurrent interview with the DSS, on [DATE] at 12:50 p.m., the DSS confirmed that two tiles in the entry to the kitchen along the baseboard were broken and separated from the wall. The DSS stated she did not notice them previously. i. During an observation on [DATE] at 9:34 a.m., an industrial mounted counter can opener was attached to the food preparation table. One of the three screws that attached to the can opener holder to the table was missing. The missing screw hole had buildup of black grime and food particles. The can opener holder, where the shaft of the can opener was held when the can opener was being stored, was dented, and had a significant amount black and orange grime on the surface including the area that came into contact with the can opener shaft. The can opener shaft had orange residue on most of the surface. In addition, the cogwheel had a significant amount of orange residue in the grooves. The blade was worn so it was flat and not pointed and the coating was peeled off. In an interview on [DATE] at 12:32 p.m., the DSS confirmed the can opener was rusty and had residue on the surface, was missing a screw in the base, and appeared to have food particles and grime on it and the base. j. During an observation and concurrent interview with the DSS and MS D, on [DATE] at 10:14 a.m., the standing mixer had a metal bowl with orange and black residue on the inside surface of the bowl. MS D stated the residue inside the mixer bowl was rust and the mixer should be taken out of the kitchen. The DSS confirmed there was orange build up in the mixing bowl. She stated .it is rusted .and could contaminate food. k. During an observation on [DATE] at 2:26 p.m., the four-door beverage refrigerator located next to the stove, had wire racks for shelving. There was orange build-up covering the entire surface of the racks. During an observation and concurrent interview with the DSS, on [DATE] 2:21 p.m., she stated it looked like rust, in reference to the racks on the beverage refrigerator. l. During an observation and concurrent interview with the DSS, on [DATE] at 9:42 a.m., cutting boards ready for kitchen staff use were observed stored on the food preparation counter near the food preparation sink. The red cutting board had orange spots on it. The white cutting board had black and blue spots on it. The DSS confirmed the cutting boards were stored ready for use and the two cutting boards were dirty. m. During an observation, on [DATE] at 9:40 a.m., a metal strainer that covered the drain hole for the food preparation sink was covered in an orange residue. During an observation and concurrent interview with the DSS, on [DATE] at 12:33 a.m., the DSS stated the drain strainer in the food preparation sink was rusted. n. During an observation and concurrent interview with MS D, on [DATE] at 10:17 a.m., the food preparation sink drain was plumbed directly into the wall. No air gap was observed. MS D stated the food preparation sink was plumbed directly to the sewage drain and confirmed there was no air gap for this drain. During an observation on [DATE] at 10:52 a.m., the ice machine drained water from a plastic pipe attached to the back of the machine. The drainpipe led to a drain in the floor that had a cylinder around it. The end of the drainpipe went into the cylinder. When water drained from the ice machine the cylinder around the drain filled and overflowed not allowing the water to flow out from the drainpipe without backing up, thus there was no air-gap for the ice machine drainpipe. During an observation and concurrent interview with MS E, on [DATE] at 11:37 a.m., MS E confirmed there was no air gap for the ice machine. According to the 2017 Federal Food Code, there is to be an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment that is at least twice the diameter of the water supply inlet may not be less than 1 inch. o. An observation on [DATE] at 9:27 a.m., indicated a plastic container of peanut butter had peanut butter on the rim and side of the container. The container felt greasy to the touch. The container was stored on shelving next to the oven ready for use. In an interview on [DATE] at 12:32 p.m., the DSS confirmed the peanut butter container had peanut butter on the outside surface and stated it was a concern but would be more of a concern if they had bugs. p. During an observation and concurrent interview with the DSS, on [DATE] at 10:32 a.m., four boxes of long grain and wild rice blend were stored in the dry storeroom and ready for use. The dates on the boxes indicated the rice expired on [DATE]. The DSS confirmed the four boxes of rice were expired. During a record review of the facility's policy, titled Food Storage, dated 2017, showed all food items are to be dated upon receipt and used prior to expiration date.

Based on observation, interview and record review, the facility failed to ensure the proper upkeep, maintenance, and safe operating conditions of the kitchen appliances: 1. dairy reach-in refrigerator 2. multi-door reach-in freezer These failures had the potential to attract pests (cross-reference F-925) and impact the ability of the equipment to operate as intended leading to improper storage of food resulting in food that is not safe and/or poor quality for 90 residents who received food from the kitchen. Findings: 1. During an observation on 10/6/2021 at 9:48 a.m., the reach-in refrigerator that held dairy products, located next to the food preparation sink and the entry to the dry food storage, was observed to have a moist grime build up around the front of the refrigerator that would wipe off with paper towel. The DSS stated the grime was rust because the refrigerator leaked. During an observation and concurrent interview with the Dietary Services Supervisor (DSS), on 12/10/2021 at 9:54 a.m., the DSS stated the dairy refrigerator leaked .on and off since October 2021. She said water would accumulate on the floor in front of the refrigerator and once or twice a week staff would wipe up the water. Review of the facility's policy, Maintenance Service, revised December 2009, showed the maintenance department is responsible for maintaining the equipment in the facility in a safe and operable manner at all times, and will keep records of work order requests. According to the 2017 Federal Food Code, equipment is to be maintained in a state of good condition and repair to retain their characteristic qualities under normal use. 2. During observation of the the multi-door, reach-in freezer, on 12/6/2021 at 9:51 a.m., located next to the entrance of the dry storage and the coffee area, was observed to have a significant amount of ice chunks hanging from the top of the freezer ceiling and scattered on the freezer floor. This freezer held a variety of frozen foods such as meat, ice cream, and waffles. During observation, on 12/07/21 at 10:40 a.m., the ice cream cups and waffles were observed to be soft to the touch and not frozen solid. Review of the invoice dated 12/7/21, showed a technician serviced the reach-in freezer and stated the ice-build up was due to the freezer being too full with boxes stacked to the top and not allowing good air circulation During record review of the facility's policy, Maintenance Service, revised December 2009, indicated the maintenance department is responsible for maintaining the equipment in the facility in a safe and operable manner, will develop and maintain a schedule of maintenance, and will maintain receipts of the inspections and maintenance. According to the 2017 Federal Food Code, stored frozen foods are to be maintained frozen. Also, equipment is to be maintained in a state of good condition and repair to retain their characteristic qualities under normal use.

Based on observation, interview, and record review the facility failed to provide an effective pest control program to ensure a pest free environment when the facility had flying black bugs in the kitchen. This failure had the potential to cross-contaminate food and utensils leading to illness for 90 residents who received food from the kitchen. Findings During observation on 12/6/2021 at 9:39 a.m., a small black fly was observed on the underside of the bug extermination machine, which was mounted above the clean, ready for use, knives. During an observation and concurrent interview on 12/6/2021 at 9:45 a.m., with the Dietary Services Supervisor (DSS), she showed a reach-in refrigerator holding dairy products had a significant amount of thick residue at the base of the front, near the floor. The thick residue was orange, brown, and black in color. It was sticky and moist and was removable with a paper towel. The DSS stated it was rust because the refrigerator was leaky. During observation on 12/7/2021 at 10:08 a.m., five small flies were observed on water pitchers. During observation on 12/7/2021 at 10:09 a.m., three small flies were observed on the wall above the dishwashing machine. They also landed on dirty dishes with half eaten food returned from the resident lunch meal. During observation and concurrent interview with the Dietary Services Supervisor (DSS), on 12/7/2021 at 10:04 a.m., she confirmed the observation of black flies in the kitchen and stated they are a concern. During observation and concurrent interview with the Dietary Services Supervisor (DSS) on 12/10/2021 at 9:54 a.m., she confirmed the observation of black, orange, and brown build up around the dairy refrigerator. The DSS stated the dairy refrigerator has leaked .on and off since October 2021 and once or twice a week staff would clean up around the dairy refrigerator. During a telephone interview with a local exterminator the facility used for pest and rodent management, on 12/9/2021 at 9:23 a.m., the Pest Technician (PT 1) stated he was at the facility on 12/1/2021 for a routine service when he was notified of flies in the kitchen. He thought the flies were likely phorid flies and stated he saw about 10 flies on 12/7/2021 when he treated the kitchen for flies. He stated he thought the flies were breeding under the dairy refrigerator and stated the dairy refrigerator sits directly on the floor, it was damp under it, and .had a lot of gook under it. PT 1 stated under the refrigerator there was a mixture of what he thought was rust and food particles and that decomposing wet organic matter is the perfect breeding area for the flies in the kitchen. Review of the facility's policy, Pest Control, revised May 2008, indicated the facility shall maintain an effective pest control program and be kept free of insects. Review of the facility's policy, Sanitization, dated October 2008, indicated surfaces not in contact with food should be cleaned regularly on a schedule to prevent the accumulation of grime. During record review of the facility's policy, Sanitization, revised October 2008, indicated all areas of the kitchen should be kept clean. According to the 2017 Federal Food Code, equipment that is not easily movable shall have access for cleaning along sides, behind, and under equipment. Floor mounted equipment is to be sealed to the floor or elevated on legs that to allow for cleaning.

Based on interview and record review, the facility failed to provide adequate supervision to prevent an accident and injury for one of three sampled residents (1) when Resident 1 eloped (to leave a long term care facility without permission) and was found laying down on a sidewalk by bystanders (people present at the incident). This failure resulted in Resident 1 sustaining a mandibular (jaw) fracture with significant displacement. Findings: Resident 1's clinical record was reviewed. The resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 8/21/16, indicated her cognition was severely impaired. Resident 1 required supervision (staff must have oversight of the resident) when the resident moved to and returned from distant areas on the floor such as the lobby, dining and activity areas. Review of Resident 1's Elopement Risk Assessment (ERA) dated 8/29/16, indicated the total score for ERA was 10 which meant the resident was at risk for elopement (the total score of 5 or above represents at risk for elopement). The ERA included how to address the elopement precaution on the care plan which indicated to implement routine monitoring of the resident's whereabouts. There was no documented evidence the routine monitoring and resident's whereabouts was initiated. Review of Resident 1's Elopement Care Plan dated 4/2/15, indicated the resident had a WanderGuard (small device placed on the ankle or wrist of resident, alarms to notify the staff if resident tries to leave the facility) due to wandering and attempts to leave the facility unattended. It also indicated to notify the responsible party (RP) and the medical doctor (MD) if the resident has increased episodes of wandering even with redirection. Review of Resident 1's Medication Administration Record (MAR) dated 10/1-10/31/16, indicated to monitor Resident 1's episodes of trying to leave the facility every shift. Resident 1's MAR for October 2016 for the 3-11 p.m. shift indicated Resident 1 tried to leave the facility on 10/3, 10/4, 10/5 (twice), 10/6, 10/9 and 10/15 (twice). On 10/15/16, for the 7-3 p.m. shift, Resident 1 attempted to leave the facility five times. There was no documented evidence the RP and MD were notified of the resident's increased episodes of elopement. Review of Resident 1's Physician order [REDACTED]. Review of Resident 1's SBAR (situation, background, assessment, and recommendation, a communication and assessment tool used by nurses for a resident's change of condition) dated 10/15/16, indicated on 10/15/16 at 8:20 p.m., the resident was missing and the staff performed a facility search but could not locate the resident. Review of Resident 1's History and Physical from an acute care hospital dated 10/15/16, indicated the resident was brought in by the paramedics after she was found laying down on a sidewalk by bystanders. Review of Resident 1's Discharge Summary from an acute care hospital dated 10/17/16, indicated she sustained bilateral sub condylar (jaw) fractures with significant displacement. During an interview with the minimum data set coordinator (MDS C) on 10/21/16 at 2:05 p.m., she stated Resident 1 required supervision from the staff when moving from one location to another. During an interview with certified nursing assistant A (CNA A) on 10/21/16 at 1:10 p.m., she stated Resident 1 was ambulatory, walks around the facility, and she checked on her from time to time but there was no routine monitoring of the resident's whereabouts. During an interview with the admission coordinator (AC) on 10/21/16 at 1:20 p.m., she stated on 10/15/16 at 11:30 a.m., she saw Resident 1 leave the facility. She immediately followed the resident. The resident walked to the store located next to the facility and staff was able to convince the resident to return to the facility. During an interview with receptionist B (RB) on 10/21/16 at 1:35 p.m., she stated on 10/15/16 during the morning, Resident 1 tried to elope multiple times. During an interview with licensed vocational nurse B (LVN B) on 10/26/16, at 10:50 a.m., she stated the RP and MD were not notified regarding Resident 1's increased elopement episodes. She said she did not document Resident 1's 10/15/16 elopement episode on the morning shift, in the resident's progress notes, or in the 24 hour endorsement log. During an interview with licensed vocational nurse C (LVN C) on 10/26/16, at 11:45 a.m., he stated on 10/15/16 at 8:20 p.m., when they discovered Resident 1 was missing, they initiated a facility search but could not locate the resident. At approximately 8:40 p.m., he received a call from an acute care hospital confirming Resident 1 was a facility resident, and would be admitted to the hospital. During a concurrent interview with CNA A, she stated on 10/15/16 when she returned from her break at 7 p.m., she did not hear the resident's alarm sound. During an interview with certified nursing assistant D (CNA D) on 10/26/16, at 12:15 p.m., she stated on 10/15/16 she did not hear the alarm sounding. During a concurrent interview with LVN C, he stated LVN B did a verbal endorsement regarding Resident 1's elopement episode on 10/15/16, during morning shift. On 10/15/16, on the afternoon (1500-2330) shift, everybody checked the resident but there was no routine monitoring of the resident's whereabouts. During a concurrent interview with LVN B, she stated there was no routine monitoring of Resident 1's whereabouts, and she never used the transmitter tester to test the WanderGuard. She said on her shift, she only checked the placement of the WanderGuard. During an interview with licensed vocational nurse E (LVN E) on 10/26/16, at 11:15 a.m., she stated she did not use the transmitter tester on the graveyard (2300-0730) shift to check if the WanderGuard was functional. She said she would ask Resident 1 to get close to the exit doors and if the alarm went off, it meant it was working. During an interview with the director of nursing (DON) on 11/1/16 at 11:20 a.m., she stated the graveyard shift was responsible to check the WanderGuard's functionality using the transmitter tester. She also acknowledged there was no routine monitoring of Resident 1's whereabouts. Review of the WanderGuard user guide manual, indicated transmitters in use must be tested at least weekly using the transmitter tester. Review of the facility's policy Safety and Supervision of Residents dated 12/2007, indicated resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for two of 16 sampled residents (3 and 5) when the facility failed to implement a different kind of intervention in response to Resident 3's frequent falls and failed to monitor Resident 5 who was at a high risk for an elopement. These failures resulted in physical injuries to both residents. Findings: Resident 3's clinical record was reviewed and indicated she had [DIAGNOSES REDACTED]. She also had a history of [REDACTED]. Resident 3's Minimum Data Set (MDS, assessment tool), dated 2/3/16 indicated she had a score of 2 out of 15 on her brief interview for mental status (mental capacity). She did not have the capacity to understand or answer questions. Resident 3's long term care plan with a focus on her risk for falls, initiated on 11/6/14, indicated she had interventions to prevent falls including encouraging her to participate in activities with a focus on exercise, physical activity for strengthening, improved mobility, diversion, and distraction. The long term care plan was last updated on 12/18/15 with new interventions such as placing a fall mat at the bedside and pad alarm to monitor her attempts of getting out of bed unassisted. The long term care plan was not updated after the 12/29/15 fall. Resident 3's Fall Risk Assessment, dated 12/11/15, indicated she had a score of 18, which was indicative of a high fall risk. Her Fall Risk Assessment, dated 12/29/15, indicated she had a score of 22, which was indicative of a high fall risk. Resident 3's Interdisciplinary Team (IDT, staff members from different departments who coordinate a resident's care) Note, dated 9/21/15, indicated the recommendation from the IDT after her 9/18/15 fall was to offer bathroom assistance every two hours and as needed. The IDT note, dated 12/14/15, indicated Resident 3 was to be monitored every 15 minutes because of her history of turning off alarms and getting out of bed or her wheelchair unassisted. After the 12/11/15 fall, the IDT recommended continuing to monitor the resident every 15 minutes. A Change of Condition Note, dated 12/29/15, indicated Resident 3 was found on the floor after trying to transfer herself to her wheelchair. After the 12/29/15 fall, the IDT note, dated 12/30/15, indicated the IDT recommended continuing to offer bathroom assistance every two hours and activities to Resident 3 and to continue the frequent safety checks. The IDT note did not indicate the specific kind of activity which would be offered to the resident. A Change of Condition Note, dated 3/6/16, indicated Resident 3 was found sitting on the floor. She was previously in bed and had attempted to transfer herself unassisted to her wheelchair. X-rays (photographic or digital images of the internal composition of a part of a body) were ordered and indicated she had a mildly displaced intertrochanteric left femur (hip) fracture (a complete or partial break in a bone). During an interview with the social services director (SSD), on 4/29/16, at 9:10 a.m., she stated she was a member of the IDT which reviewed the falls of all of the residents and recommended new interventions. She stated when a resident fell , the IDT tried to look for new interventions. The SSD stated the disciplines included in the review of the residents' falls were nursing, dietary, activity, and social services. She stated a physician did not join the IDT during the review of the residents' falls. During an interview with the activity director (AD), on 4/29/16, at 9:17 a.m., she stated she was unable to provide any documentation the facility had a new intervention in place after Resident 3's fall on 12/29/15. During an interview with the director of nurses (DON), on 4/27/16, at 12 p.m., she stated the facility was encouraging Resident 3 to attend activities with a focus on cognitive stimulation as a new intervention after the 12/29/15 fall. The DON was unable to provide documentation of the new intervention. Review of the facility's 12/2007 policy, Falls and Fall Risk Managing, indicated the staff will try different kinds of interventions, based on the assessment of the nature of the fall, until falling was reduced or stopped. If the underlying causes cannot be readily corrected, the staff will implement additional or different interventions. The staff, with the attending physician, will also identify and implement relevant interventions to try to minimize the serious consequences of falling. 2. Resident 5's clinical record was reviewed and indicated her [DIAGNOSES REDACTED]. Her MDS, dated [DATE], indicated she needed limited assistance (the staff provided guided maneuvering of the limbs or other nonweight-bearing assistance) during walking and with the activities of daily living (ADLs, such as walking, locomotion, dressing, and hygiene). Resident 5's Elopement Risk Assessment, dated 3/16/16, indicated intermittent confusion and an elopement risk were present. Her elopement risk quarterly and comprehensive assessments, dated 3/9/16, 12/18/15, and 9/22/15, indicated an elopement risk was present. Resident 5's elopement care plan, initiated 3/17/16, indicated interventions including encouraging participation in daily activities and providing a daily routine and redirection as needed. Resident 5's Change of Condition, dated 4/20/16, indicated she was found on the ground of the facility's parking lot at 1 p.m. with swelling and discoloration to her left periorbital (superficial skin around the eyes) area and left cheek bone, and abrasions (scrapes or scratches) on her left cheek, right thumb, left elbow, left shoulder, and left knee. She complained of pain in her left eye and face when touched. Resident 5 was transferred to an acute care hospital on [DATE]. The hospital's discharge summary indicated she had a fall, a facial contusion (bruise or discoloration), and abrasions. During an observation and interview on 4/25/16, at 9:05 a.m., Resident 5 had a greenish discoloration on her left cheek and periorbital area. She stated she went outside the facility and fell . She also stated she hurt her knee and face during the incident. During an interview with registered nurse E (RN E) on 4/26/16, at 8:55 a.m., she stated Resident 5 was sitting in her wheelchair at around 10:30 a.m. before she fell . She confirmed there was no monitoring of Resident 5's elopement risk. During an interview with the director of nurses (DON) on 4/26/16, at 11:35 a.m., she stated Resident 5 came out from her room and wheeled her wheelchair around the facility. She confirmed Resident 5 was an elopement risk but there was no documentation indicating she was monitored for a possible elopement. The facility's policy, Wandering, Unsafe Resident, revised 12/2008, indicated the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who were at risk for an elopement. The staff will institute a detailed monitoring plan, as indicated for the residents who were assessed to have a high risk of elopement or other unsafe behavior.

Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Residents 1, 2, and 3) had adequate supervision to prevent accidents and injuries. * Resident 1 required assistance from staff for ambulation. While Resident 1 was ambulating independently in the lobby, she slipped and sustained a left hip fracture. A few days later, Resident 1 sustained a second fall, in which her pad alarm failed to operate when it was improperly placed in her wheelchair. The facility failed to implement Resident 1's care plan to reduce environmental hazards and anticipate the resident's needs. * Resident 2 required assistance from two staff members for transfers. During a transfer from the shower chair to the bed, with one staff member assistance, Resident 2 sustained a deep laceration (wound), requiring 11 stitches. The facility failed to implement Resident 2's care plan related to transferring with two staff members. * Resident 3 had a history of [REDACTED]. The licensed nurse left Resident 3 alone in the room to call the resident's physician, when Resident 3 stood up, fell and sustained a fractured left hip. The facility failed to providing adequate supervision, by leaving the Resident 3's room, knowing the resident attempted several times to get out of bed unassisted. The facility's failure to implement care plans to prevent injuries and lack of adequate supervision has the potential for increased injuries and fractures to residents. Findings: Review of the facility's 9/8/09 revised policy "Fall Prevention and Incident Management" indicated the facility identifies residents at risk for falls and/or accidents over which the facility has control by adequately planning interventions and implementing procedures to prevent falls and/or accidents. The facility identified a serious injury as a fall with a fracture and lacerations needing suturing. 1. Review of the facility's Unusual Occurrence letter (not dated) indicated on 7/20/13 at approximately 6:30 p.m., the receptionist witnessed Resident 1 slip and fall in the lobby. Clinical record review for Resident 1 was initiated on 8/8/13. Resident 1 was admitted to the facility on [DATE], with her Admission Face Sheet identifying [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/13/13, indicated she had moderately impaired cognition (alertness) and required one staff member to assist with ambulation. Review of Resident 1's 3/11 care plan for risk for falls/injuries, indicated she had fallen on 4/10/12 and 2/25/13. A review of Resident 1's Change of Condition assessment dated [DATE] at 6:25 p.m., indicated she had a witnessed fall in the lobby. Her mental status showed she was confused and forgetful. The narrative notes indicated Resident 1 was observed on the floor in the lobby, leaning on her right side. The resident was lifted onto a wheelchair to further assess her injuries. A second Change of Condition assessment dated [DATE] at 6:25 p.m., indicated later on the same evening, Resident 1 had multiple scattered bruising to her right arm, following her fall. No documentation was available to show immediate first aid was rendered to Resident 1 (i.e., application of ice, elevation of arm). Review of Resident 1's X-ray report dated 7/21/13, showed swelling to her lateral right hip and an intertrochanteric (top of hip bone) fracture. Review of Resident 1's hospital Discharge Summary dated 7/24/13, indicated she had an open reduction internal fixation (ORIF: surgery with pinning) of her right hip for a three-part hip fracture on 7/21/13. During an interview on 8/8/13 at 11:40 a.m., the director of nursing (DON) was unable to locate documentation to show immediate first aid was rendered to Resident 1's bruised arm after the fall. She stated an ice pack should have been applied and her arm elevated. A telephone interview was conducted on 8/9/13 at 1:50 p.m. with the receptionist. She stated on 7/20/13 at around 6:30 p.m., Resident 1 was walking in the lobby independently. The receptionist stated Resident 1 turned around and slipped on the floor. She stated no staff members were present with Resident 1. The receptionist said she did not know if Resident 1 fell because the floor was waxed or the grip on the resident's sneakers did not grasp. A review on 8/8/13 of Resident 1's 8/1/13 at 7:15 p.m., Change of Condition Assessment indicated the licensed nurse documented Resident 1 had an unwitnessed fall. Resident 1 was found on the floor in her room, propped up on her right elbow and was bleeding from her right thumb. Review of Resident 1's Interview Record (not dated) showed "heard a cry saying help me toward her room (Resident 1) and found the resident lying on the floor on her back. The alarm was in place on her chair, but had not made noise. " Review of Resident 1's Interdisciplinary Team (IDT) Notes dated 8/2/13, indicated on 8/1/13 at around 7:15 p.m., Resident 1 was placed on a 1:1 (one staff member to remain with the resident at all times) for safety. On 8/8/13 at 8:30 a.m., Resident 1 was observed sleeping in her bed. Her bed was in the low position and bilateral middle side rails were elevated. No staff member or visitor was at Resident 1's bedside. No identifying indicator was observed outside Resident 1's room or at her bedside to show she was a high risk for falls. During an interview on 8/8/13 at 9:25 a.m., the Director of Staff Development (DSD) stated a resident's fall risk assessment is completed on admission and quarterly. She was unable to locate Resident 1's fall risk assessment in her clinical record. At 9:55 a.m., the DSD stated she was still trying to locate Resident 1's fall risk assessment. During an observation on 8/8/13 at 9:50 a.m., Certified Nursing Assistant 3 (CNA 3) was observed in Resident 1's room. She stated Resident 1 was placed on a 1:1 sitter since the resident's fall on 8/1/13. CNA 3 stated every half hour, a staff member replaced the 1:1 sitter. When CNA 3 was asked if a staff member or visitor was in Resident 1's room today as a 1:1 sitter, when she entered the room, she stated, "No." On 8/8/13 at 10:00 a.m., the DON stated the fall risk assessments are completed when the Change of Condition Assessment is completed. She stated no identifying indicators are placed for residents with a high risk for falls. An interview was conducted with CNA 1 on 8/8/13 at 10:05 a.m. She stated if a resident is a high risk for falls, a yellow arm band is placed on the resident's wrist. The DON stated she was unaware of the yellow arm band for a high risk resident. On 8/8/13 at 10:55 a.m., CNA 2 was assigned as Resident 1's sitter. CNA 2 confirmed Resident 1's wrists had no yellow bracelet or identification bracelet in place. During an interview on 8/8/13 at 11:10 a.m., RN 1 stated on 8/1/13, Resident 1's roommate had called for help to notify the staff that Resident 1 had fallen. She stated Resident 1 was lying on the floor between the two residents' beds. RN 1 stated the pad alarm was located on the back rest of Resident 1's wheelchair, but did not sound. She stated the alarm was not properly placed under Resident 1's buttocks for the alarm to sound. 2. On 8/8/13 a review of the facility's Witnessed Injury letter (not dated) indicated on 7/19/13 at approximately 10:00 a.m., CNA 4 transferred Resident 2 from the shower chair to the bed and the resident sustained [REDACTED]. Clinical record review for Resident 2 was initiated on 8/8/13. Resident 2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 2's MDS (an assessment tool) dated 6/13/13, showed she had moderately impaired cognition and required two staff members to assist with transfers. Review of Resident 2's CNA Activity of daily living (ADL) Flow Sheet for dates 7/1/13-7/18/13, showed two staff members were needed to physically transfer the resident. Review of Resident 2's Impaired Physical Functioning care plan, revised 11/19/12, indicated the resident needs two staff members to assist with transferring. Review of Resident 2's IDT Conference form dated 4/1/13, indicated she sustained a skin tear to her right lower leg due to her fragile skin. On 6/13/13, Resident 2 sustained a skin tear to her left upper arm. Review of Resident 2's Nursing Transfer/Discharge assessment dated [DATE] at 10:48 a.m., indicated during a transfer from the shower chair to the bed, the resident pivoted, got her left leg caught on the side rail and sustained two lacerations to her left lower leg. Review of Resident 2's emergency room assessment dated [DATE] at 11:57 a.m., indicated the resident was complaining of pain at a level five (pain scale 0 - 10, ten being the highest). In addition, Resident 2 had two lacerations to her left lower leg; one required laceration repair. Review of Resident 2's Skin Breakdown Reports dated 7/22/13, indicated Resident 2 sustained two large skin tears on her left lateral lower leg measuring 11.5 centimeters (cm)X 0.3 cm (site 1) and 6.8 cm (site 2). During an interview on 8/8/13 at 2:00 p.m., CNA 4 stated on 7/19/13, she asked Resident 2 to stand up from the shower chair and to hold on to the bed's side rail, in order to assist the resident back to bed. CNA 4 stated when she was swinging Resident 2's legs into the bed, she noticed a skin tear to the resident's left lower leg with slight bleeding and notified the nurse. CNA 4 stated no other staff member was present during the transfer, "only me." On 8/8/13 at 2:25 p.m., an interview was conducted with Registered Nurse 1 (RN 1). RN 1 stated on 7/19/13, CNA 4 notified her of Resident 2's skin tear. She stated Resident 2's left lower leg had a "big chunk" hanging off with minimal bleeding. RN 1 stated she applied a steri-strip (an adhesive strip for wound closures) and notified Resident 2's physician for further treatment. She stated Resident 2 needs two staff members for transferring and was unaware of the reason on 7/19/13, CNA 4 had attempted to transfer the resident by herself. On 8/8/13 at 2:45 p.m., an attempt was made to observe Resident 2's left lower leg, however Resident 2 was out of the facility. LVN 2 stated Resident 2 was at the wound care center for an evaluation of her left leg laceration. 3. Review of the facility's Unusual Occurrence letter dated 8/1/13 at approximately 5:20 p.m., showed Resident 3 was found on the floor in her room by a CNA. The resident had a history of [REDACTED]. The clinical record for Resident 3 was reviewed on 8/8/13. Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 3's MDS dated [DATE], indicated she had severely impaired cognition. Review of Resident 3's Risk for Falls/Injuries care plan dated 7/16/12 indicated she had fallen five times between 7/16/12-6/29/13. Approach plans included redirecting, safety cueing and allowing enough time for the resident to process the information. Review of Resident 3's 3/23/13 Significant Change of Condition form indicated she had fallen on 3/9/13, 3/23/13, 4/26/13, and 6/19/13. Review of Resident 3's Change in Condition assessment dated [DATE], indicated she had an unwitnessed fall and was transferred to the emergency room for an evaluation. Review of Resident 3's emergency room report dated 7/11/13 at 2:13 a.m., indicated Resident 3 was noted to have an external rotation (turned outward) of her left leg following a fall at the facility. Review of the facility's Unusual Occurrence letter (not dated), indicated on 8/1/13 at approximately 5:20 p.m., Resident 3 was found on the floor in her room. The resident had a history of [REDACTED]. Review of Resident 3's Emergency Transfer Communication sheet dated 8/1/13, indicated the resident was being non-compliant and verbally abusive, and was repeatedly asked to sit down. The writer of the note left the resident to call the physician. Later a CNA found Resident 3 lying on the floor. Resident 3 was found on the floor complaining of right hip pain. Resident 3's X-ray report dated 8/1/13 at 9:20 p.m., indicated an acute right femoral (hip) fracture. On 8/8/13 at 4:05 p.m., an interview was conducted with RN 1. She stated on 8/1/13, licensed vocational nurse 1 (LVN 1) left Resident 3's room to call the physician about an elevated blood sugar test. RN 1 stated she heard a thump and found Resident 3 sitting on the floor at the foot of her bed. She stated Resident 3 complained of pain in her right thigh and knee, but insisted on standing up. RN 1 stated two staff members stood up Resident 3 and the resident started to limp, so they put the resident back to bed. She stated Resident 3's leg lengths were uneven and an X-ray was ordered. A telephone interview was conducted on 8/9/13 at 2:20 p.m. with LVN 1. She stated on 8/1/13, at around dinner time, she went to check Resident 3's blood sugar. LVN 1 stated Resident 3 was verbally abusive and threatening to throw her dinner tray at LVN 1. In addition, she stated Resident 3 attempted to get out of bed at least two times, and she had to remind the resident to sit down. LVN 1 stated she left the room to call the physician, when she was told by RN 1 of Resident 1 falling.