Every finding on record at Western Slope Health Center

Based on interview and record review, the facility failed to provide necessary care and services to one of four sampled residents (Resident 1) when appropriate monitoring, care planning, and Resident 1's representative notification were not implemented following the removal of a chronic indwelling catheter (a flexible tube placed in the bladder to continuously drain urine) and by failing to document post voiding residual (a monitoring process to check if the bladder is emptying after indwelling catheter is removed).These failures resulted in inappropriate urinary catheter management and led to Resident 1 requiring an emergency room visit for the replacement for urinary catheter only hours after being discharged from the facility.Findings:Resident 1 was admitted to the facility in mid-2026 with diagnoses that included neuromuscular dysfunction of the bladder (neurogenic bladder, lack of bladder control when the nerve signals between the brain and bladder muscles are broken or damaged), dementia, and chronic kidney disease (kidneys are damaged and lose the ability to filter waste and extra fluid from the blood). Resident 1 was not her own responsible party (RP). During a review of Resident 1's Discharge Summary [DS, instructions and information provided by the hospital to the facility], dated 5/15/26, the DS indicated, .discharge diagnosis.neurogenic bladder with chronic [brand name] catheter.During a review of Resident 1's Order Summary Report [OSR], order date 5/15/26, the OSR indicated, Indwelling Urinary Catheter.For urinary retention. and Resident is not capable of understanding rights and responsibilities, or able to participate in treatment plan.Resident is incapable of making her own health decisions. During a review of Resident 1's Minimum Data Set (MDS, federally mandated resident assessment tool) dated 5/22/26, the MDS showed a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3/15, which indicated severe cognitive impairment.During a review of Resident 1's progress notes (PN) dated 6/24/26 at 7:09 p.m. the PN indicated, Resident pulled catheter during shower. No c/o [complaint of] pain or bleeding. Per NP [Nurse Practitioner] orders started (sic) voiding test. The PN did not indicate Resident 1's RP was notified. There was no physician order to re-insert a urinary catheter for Resident 1.During a review of Resident 1's medical record, no care plans (CP, a written guide outlining a person's health needs, goals, and specific treatments) were found to address Resident 1's chronic indwelling catheter care, management or staff instructions for actions to take if the catheter became dislodged.During a review Resident 1's Medication Administration Record [MAR] dated 6/24/26-6/27/26, the MAR indicated, .Voiding Trial x 72 hours. PVR [post void residual, the amount of urine that remains in the bladder after a person has finished urinating] Q [every] Shift (Ensure Resident Voids Prior to Bladder Scan if Possible). which indicated to document the amount of residual each shift in the MAR; however, there was no documented evidence in Resident 1's clinical record that the PVR was measured during the 72 hours of voiding trial. During a review Resident 1's PN, dated 6/30/26, the PN note indicated Resident 1 left the facility at 1 p.m. The PN did not indicate any voiding assessment of the resident at the time of the discharge.During a review Resident 1's emergency department [ED] visit notes, dated 6/30/26 at 4:49 p.m., the ED notes indicated, [Resident 1 name and age] who presents (sic) urinary retention. Recently discharged from a skilled nursing facility and [brand name] catheter was removed. States unable to urinate since last night.During a review Resident 1's hospital record, Clinical Decision Area (CDA notes), dated 6/30/26 at 10:36 p.m., the CDA notes indicated a urinary catheter was re-inserted at the ED: ED course: High PVR, [brand name] catheter placed.Review of systems.positive for difficulty urinating.During a phone interview on 7/8/26 at 11:10 a.m. with the Assisted Living Facility Administrator (ALF/ADM), the ALF/ADM stated Resident 1 returned to the Assisted Living Facility on 6/30/26 at 1:48 p.m. without an indwelling catheter and was only able to void a small amount. The ALF/ADM stated Resident 1 was sent to the emergency department at 4 p.m. and Resident 1 then returned later that night to the ALF after having an indwelling catheter inserted. During an interview on 7/8/26 at 11:40 a.m. with Licensed Nurse (LN 1), LN 1 stated the protocol for a voiding trial was for staff to scan the resident's bladder after voiding and record the PVR in milliliters (measurement) in the medical record every shift for 72 hours. LN 1 also stated that family notification was required when a catheter was removed.During a concurrent interview and record review on 7/8/26 at 1:17 p.m. with the Director of Nursing (DON) of Resident 1's chart, the DON confirmed Resident 1 had a diagnosis of urinary retention and had a chronic indwelling catheter. The DON reviewed the PN which indicated the nurse had notified the NP when Resident 1 pulled out her indwelling catheter stated the NP, had access the chart as well so she would be able to see it was a chronic catheter. The DON indicated that staff should have documented bladder scan results in the MAR during a voiding trial. The DON confirmed that Resident 1's chart lacked the post void residual amount and stated without the documentation staff would not be able to determine if Resident 1 had any urinary retention. The DON confirmed that no care plan was created for Resident 1's catheter and emphasized the importance of care plans for ensuring appropriate care. During an interview on 7/8/26 at 2 p.m. with the Nurse Practitioner (NP), the NP confirmed that staff called to inform her Resident 1 had pulled out the catheter and had requested a voiding trial. The NP stated she was not told the catheter was chronic and had she known she would have ordered to re-insert a urinary catheter back. The NP stated staff should monitor and document PVR and notify the family, especially if the resident was not their own responsible party.During a review of the facility's policy and procedures (P&P) titled, Change in a Resident's Condition or Status, dated 9/25, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status.Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gatherer relevant and pertinent information for the provider.During a review of the facility's P&P titled, Care Plans, Comprehensive Person- Centered, dated 10/25, the P&P 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.The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial wellbeing.

Based on observation, interview, and record review, the facility failed to adequately assess, identify, monitor, and provide appropriate skin care and treatment for one of four sampled residents (Resident 1) when staff failed to recognize and address an ulcerated skin lesion on Resident 1's left wrist in a timely manner. This failure resulted that the wound became infested with multiple maggots and placed Resident 1 at risk for infection and worsening skin integrity. Findings:A review of Resident 1's admission record indicated the resident was admitted on 3/24 with diagnoses that included Alzheimer's disease (a progressive disease that causes memory loss and confusion) and a personal history of malignant skin cancer.A review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool), dated 3/20/26, indicated a Brief Interview for Mental Status (BIMS) score of 4/15, which indicated the resident had severe cognitive impairment.A review of the Nurse's Note, dated 5/24/26 at 11:29 p.m. signed by Licensed Nurse (LN) 4, indicated that the nurse observed a soiled bandage on Resident 1's left wrist. When the nurse removed the bandage, she discovered a raised, ulcerated skin lesion measuring 2.5 cm (centimeter, a measurement, about 1 inch) x 2.5 cm. The Nurse's Note indicated that there were multiple active white tan larvae (maggots) moving inside the wound and the surrounding tissue.During an interview on 6/17/26 at 1:22 p.m. with LN 2, LN 2 stated that they did not perform daily skin assessments. LN 2 stated that CNAs informed the nurses when they noticed any skin issues of residents, and the nurses then reported the concerns to the treatment nurse.During an interview on 6/17/26 at 2:26 p.m., the Director of Nursing (DON) verified that, on 5/24/26, the evening nurse had called to inform him of Resident 1's wound infestation with maggots. During a phone interview on 6/22/26 at 1:57 p.m., the Medical Doctor (MD) stated the lesion was 100% a tumor. The MD explained that tumors did not appear overnight and that this one had likely been present for years. The MD stated the tumor could grow quickly or slowly, but it typically takes time to grow to that size. The MD also stated, Either somebody failed to check it, or they forgot to document it, and MD further stated that maggot infestation could occur at any time once a wound was open and exposed.A review of Resident 1's previous Nursing Weekly Summaries, dated 4/22/26, 5/13/26 and 5/20/26, signed by LN 1, indicated that Resident 1 had no identified skin impairment: No new skin issues this week. The Nursing Weekly Summaries contained no indication that the resident had refused skin assessments. Review of Resident 1's medical record, there was no documented evidence that the resident's skin lesion was identified, monitored and treated prior to 5/24/26.During a phone interview on 6/23/26 at 10:45 a.m. with LN 3, LN 3 confirmed that there was no documentation regarding Resident 1's wrist lesion prior to 5/24/26.During a phone interview on 6/23/26 at 11:32 a.m. with LN 1, LN 1 stated the Nursing Weekly Summary was based only on what she could observe. LN 1 stated that she could not complete a thorough skin check on Resident 1 during the night shift when she performed the skin assessment for the weeks of 4/22/26, 5/13/26 and 5/20/26. LN 1 explained that Resident 1 did not allow her to remove clothing at night because the resident always felt cold. LN 1 further stated that the only time her left wrist was checked was during the morning medication pass.During a phone interview on 6/23/26 at 12:16 p.m. with the DON, the DON stated that night shift nurses were expected to complete a thorough skin assessment when completing the Weekly Summary before residents went to sleep. The DON stated that although performing a thorough skin check during night shift could be difficult, the assessment was still required. If a resident refused, staff were expected to document the refusal. The DON further stated that nurses needed to complete a full, thorough assessment; otherwise, they should not have documented that the skin was intact.During a phone interview on 6/23/26 at 7:26 p.m. with LN 4, LN 4 stated that during her medication pass on 5/24/26 between 8:00 p.m. and 8:30 p.m., she noticed a skin tear and a soiled, undated bandage on Resident 1's left forearm. LN 4 stated that it was a common bandage that could be purchased anywhere. When she removed the bandage, she was very surprised to see the larvae and the wound. LN 4 also stated in her opinion, the lesion had not developed overnight given its size.According to the peer reviewed article published on 5/31/24, in Proceedings of the Baylor University Medical Center, titled Dermatological Guide for Primary Care Physicians: Full Body Skin Checks, Skin Cancer Detection, and Patient Education on Self Skin Checks and Sun Protection,<https://pmc.ncbi.nlm.nih.gov/articles/PMC11188824/>, retrieved on 6/23/26, indicated a full body skin examination required a systematic, head to toe inspection, including removal of clothing, careful visual assessment of all skin surfaces, and evaluation of any lesions for suspicious features. The article emphasized that individuals with a history of skin cancer required ongoing, comprehensive skin assessments to detect new or changing lesions early and stated that failing to perform a complete skin examination increased the risk of missed malignancies and delayed treatment.A review of the facility's policy and procedure (P&P) titled Charting and Documentation, dated 7/25, showed the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record .Documentation must be legible, objective, factual, and free of personal opinions.Weekly summaries must include overall clinical status, progress toward care plan goals, and significant events during the week.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:1. There were food debris on shelves with clean and ready-to-use sheet pans,2. A container in the clean and ready-to-use storage area was stacked wet,3. Two small cups of yogurt were stored in the refrigerator uncovered and,4. The microwave for residents' food was not clean.These failures had potential to cause food-borne illnesses in a highly susceptible population of 91 out of 91 residents who received food from the kitchen.Findings: 1. During a concurrent observation and interview on 3/3/26 at 8:11 a.m. with Dietary Supervisor (DS) at the kitchen's initial tour, food debris were observed on the shelves that stored clean and ready-to-use sheet pans. DS confirmed there were food debris on the shelves and acknowledged the area should have been kept clean and free from food debris. During an interview on 3/5/26 at 11:05 a.m. with Registered Dietician (RD), RD acknowledged the risk for foodborne illness when food debris were found on the shelves. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .all.shelves.shall be kept clean. 2. During a concurrent observation and interview on 3/3/26 at 8:13 a.m. with DS at the kitchen's initial tour, a half-gallon plastic container was stacked wet in the clean and ready-to-use storage area. DS confirmed the container was wet. DS stated containers should be completely dry before being stored. During an interview on 3/5/26 at 11:05 a.m. with RD, RD acknowledged the risk for foodborne illness when the container was stored wet. During a review of the facility's policy and procedure (P&P) titled, Dishwashing, undated, the P&P indicated, .dishes are to be air dried in racks before stacking and storing. 3. During a concurrent observation and interview on 3/3/26 at 8:15 a.m. with DS at the kitchen's initial tour, two small containers of yogurt were stored uncovered in the refrigerator. DS confirmed the two containers of yogurt were uncovered. DS stated the yogurt should have been covered. During an interview on 3/5/26 at 11:05 a.m., RD acknowledged the risk for foodborne illness when the yogurt was stored uncovered in the refrigerator. During a review of the facility's P&P titled, Labeling and Dating of Food, dated 2023, the P&P indicated, .all prepared foods need to be covered. 4. During a concurrent observation and interview on 3/4/26 at 2:34 p.m. with Activities Director (AD), the interior part of the microwave for residents' food had splashes of dry food. AD confirmed the microwave was dirty and needed to be cleaned. During an interview on 3/5/26 at 11:05 a.m., RD acknowledged the risk for foodborne illness when the residents' microwave was dirty. During a review of the facility's P&P titled, Sanitation dated 2023, it indicated, .all.equipment shall be kept clean.

Based on interview and record review, the facility failed to ensure nonpharmacological interventions were implemented for two residents (Resident 3 and Resident 4) of 24 sampled residents, when target behavior and side effect monitoring were not performed for Resident 3's and Resident 4's psychotropic medications. These failures had the potential to result in unnecessary medication for Residents 3 and 4 and an increased risk and exposure to side effects associated with psychotropic medications such as sedation, memory loss, falls, abnormal involuntary movements, and death.Findings: Resident 3 was admitted to the facility in January 2026 with diagnoses with included post-traumatic stress disorder (PTSD, symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event). A review of Resident 3's medical record (MR) indicated a physician's order for the following: - Quetiapine (a psychotropic medication, drugs that affect brain activities associated with mental processes and behavior) 100 milligrams (mg, a unit of measurement), give 1 tablet at bedtime for PTSD AEB (as evidenced by) paranoid delusions, dated 2/11/23. - Lorazepam (medication to treat anxiety) 0.5 mg: Give 1 tablet by mouth every 8 hours as needed for anxiety/agitation for 14 days, dated 2/18/26. A review of Resident 3's MR indicated the facility was not monitoring the target behavior and side effects related to lorazepam and non-pharmacological interventions were not implemented along with the use of lorazepam and quetiapine. During a concurrent interview and record review on 3/5/26 at 10:32 a.m., with Licensed Nurse (LN) 2, Resident 3's MR was reviewed. LN2 stated he did not see non-pharmacological interventions were implemented with the use of psychotropic medications for Resident 3. LN2 stated he would expect a resident to be monitored for target behaviors and side effects related to the use of lorazepam and confirmed he did not see it documented as completed in the MR. During a concurrent interview and record review on 3/5/26 at 11 a.m. with Director of Nursing (DON), Resident 3's MR was reviewed. DON confirmed residents with psychotropic medication orders were to be monitored for side effects and target behaviors and non-pharmacological interventions were to be implemented. DON confirmed Resident 3 did not have non-pharmacological interventions implemented was not monitored for target behaviors and side effects related to lorazepam. Resident 4 was admitted to the facility in February 2026 with a diagnosis with included Delirium due to known psychological conditions, and unspecified dementia with unspecified severity with behavioral disturbances. A review of Resident 4's medical records (MR) indicated a physician's order for the following: - Olanzapine (used to treat schizophrenia and bipolar disorder by balancing brain chemicals to reduce hallucinations, mania, and agitation) 5 milligrams by mouth at bedtime for Behavioral and Psychological Symptoms of Dementia (BSPD) as evidence by (AEB) auditory hallucinations behavioral/psychological symptoms of dementia, dated 2/13/26. A review of Resident 4's MR indicated the facility was not implementing and documenting non-pharmacological intervention before administration of Olanzapine at bedtime. During a concurrent interview and record review on 3/5/26 at 10:35 a.m. with LN2, Resident 4's MR was reviewed. LN2 stated he did not see non-pharmacological interventions were implemented before the use of psychotropic medications for Resident 4. During a concurrent interview and record review on 3/5/26 at 11:15 a.m. with Director of Nursing (DON), Resident 4's MR was reviewed. DON confirmed residents with psychotropic medication orders were to be monitored for side effects and target behaviors and non-pharmacological interventions were to be implemented. DON confirmed Resident 4 did not have non-pharmacological interventions implemented or documented. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, revised October 2025, the P&P indicated, 8. Non-pharmacological interventions will be considered as applicable 9. The staff will observe, document, and report to the Physician/Nurse Practitioner for information regarding the effectiveness of any interventions, including psychotropic medications. 10. Nursing staff shall monitor for and report any side effects and adverse consequences of psychotropic medications to the Attending Physician/Nurse Practitioner.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective documentation of controlled medications (those with high potential for abuse or addiction), when:Random controlled medication audits for two out of four residents (Resident 5, and Resident 19) were not reconciled. The medications were documented in the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents; and,Resident 12's controlled medication was observed as given but was not reconciled in CDR at the time of medication administration.These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.Findings: 1. Resident 5 had a physician's order dated 2/28/26 for Oxycodone HCL (hydrochloride) (medication used to relieve moderate to serve pain) 15 mg (milligram, unit of measurement), 1 tablet every 6 hours as needed for moderate to severe pain (4-10 on a pain scale of 1-10 where 1 is lowest and 10 is highest). The CDR indicated 1 tablet was signed out on 2/22/26 at 10:48 p.m. and on 2/25/25 at 6:30 p.m. The MAR did not indicate Oxycodone was administered to Resident 5 on either of those dates and times. Resident 19 had a physician's order dated 10/1/25 for Tramadol (a strong painkiller used to treat moderate to severe pain) 50 milligram, 1 tablet every 6 hours as needed for moderate pain of 4-6. The CDR indicated 1 tablet was signed out on 2/12/26 at 9:30 a.m. The MAR did not indicate Tramadol was administered to Resident 19 on these dates or times. During a concurrent interview and record review on 3/4/26 at 11:30 a.m. with Director of Nursing (DON), DON confirmed the CDRs and MARs for Resident 19 (Tramadol) and Resident 5 (Oxycodone) were not accurate and missed documentation in MAR. DON stated nursing staff were expected to document in both the CDR and MAR any time a controlled medication was removed from the cart and administered. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 10/2025, the P&P indicated, 15. The individual administering the medication documents in the resident's eMAR. 2. During a medication administration observation on 3/3/26 at 8:36 a.m. with Licensed Nurse (LN) 1, LN 1 was observed preparing medication for Resident 12 including two oxycodone (a controlled medication to treat pain) 5 mg tablets. LN 1 removed the medication from the bubble pack (a unit dose medication packaging system) and administered the medication to Resident 12 without documenting the dose on the CDR at the time of administration. During a concurrent interview and record review on 3/3/26 at 12:06 p.m. with LN 1, Resident 12's oxycodone 5 mg MAR and CDR were reviewed. LN 1 confirmed she had not signed out the tablets in the CDR at time of administration. She acknowledged to document in both required areas immediately to reduce the risk of error or miss count. During a concurrent interview and record review on 3/4/26 at 11:30 a.m. with Director of Nursing (DON), DON stated nursing staff were expected to document in both the CDR and MAR any time a controlled medication was removed from the cart and administered. DON's expectation was for documentation to be completed right away. During a review of the facility's policy and procedure (P&P) titled, Controlled Substance, dated 10/2025, the P&P indicated, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is .reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The system of reconciling the . dispensing and disposition .includes the following .b. Medication administration records and c. Declining inventory records .

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when:Resident 58's nebulizer mask (neb mask-a face mask that fits over the nose and mouth to deliver medication into the lungs) and CPAP mask (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) and Resident 64's nebulizer mask were not stored in antimicrobial bag and Resident 64's oxygen tubing was on the floor.Meal trays, with uncovered salad, were transported to residents' rooms. Resident 12's foley catheter (a device that drains urine from the bladder) drainage bag was touching the floor. Enhanced Barrier Precautions (EBP - healthcare workers wear gloves and a gown during certain care activities to stop germs from spreading between residents) not followed during wound care for Resident 1. These failures had the potential to compromise resident's health and safety, and potentially lead to the spread of communicable illnesses. 1.During a review of Resident 58's admission Record (AR), the AR indicated, Resident 58 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with exacerbation and obstructive sleep apnea (OSA- sleep disorder that occurs when the airway becomes blocked while sleeping). During a review of Resident 58's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated March 2026, the MAR indicated, Resident 58 had an order for CPAP to be used continuously while sleeping, and Resident 58 last received a dose of ipratropium-albuterol inhalation solution (inhaled medication to treat chronic, ongoing breathing problems given via nebulizer machine) 0.5-2.5mg/3mL (milligram-unit of measurement; milliliters-unit of measurement) on 3/2/26 at 3:40 a.m. During a concurrent observation and interview on 3/3/26 at 9:20 a.m. with Licensed Nurse (LN) 4 in Resident 58's room, Resident 58's neb mask was observed on top of the bedside table, and the CPAP mask was hanging on the bedside rail, both not stored in an antimicrobial bag. LN 1 confirmed the nebulizer mask and CPAP mask were not stored in an antimicrobial bag. LN 1 stated the night shift may have administered a nebulizer treatment and stated that when masks were not in use, they should be stored in an antimicrobial bag due to the potential for bacterial contamination. During a review of Resident 64's AR, the AR indicated, Resident 64 was re-admitted on [DATE] with diagnoses which included hypoxemia (condition where body tissues and organs do not receive enough oxygen), OSA, shortness of breath and dependence on supplemental oxygen. During a review of Resident 64's MAR, dated March 2026, the MAR indicated Resident 64 had an order for ipratropium-albuterol inhalation solution 0.5-2.5mg/3mL via nebulizer as needed and oxygen at 4 liters per minute via nasal cannula continuously. During an observation on 3/3/26 at 11:07 a.m. in Resident 64's room, Resident 64's nebulizer mask was on top of the nebulizer machine without a bag. Resident 64 was receiving oxygen via nasal cannula, and the oxygen tubing was on the floor, dragging from Resident 64's bed under the roommate's bed and extending into the restroom. The oxygen concentrator was stored in the restroom, and the oxygen tubing was also touching the restroom floor. During an interview on 3/3/26 at 11:36 a.m. with Infection Preventionist (IP), IP stated the expectation was for nebulizer masks and CPAP masks to be stored in an antimicrobial bag when not in use due to the risk of bacterial contamination and infection. IP also stated oxygen tubing should not touch the floor due to the risk of exposure to infectious material. During a review of the facility's policy and procedure (P&P) titled, Respiratory Therapy-Prevention of Infection, revised 10/25, the P&P indicated, .Infection Control Considerations Related to Oxygen Administration: 3. Change the oxygen cannula every seven (7) days or as needed. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 9. Take care not to contaminate internal nebulizer tubes.11. Store the circuit in a marked antimicrobial bag. A P&P for the storage of CPAP mask and oxygen tubing touching the floor was requested; however, the facility did not provide one. 2.During a concurrent observation and interview on 3/4/26 at 12:31 p.m. in Hallway 1 with Certified Nursing Assistant 1(CNA 1), meal trays with uncovered salad were transported from the dining cart through the hall into rooms 112-116. CNA 1 confirmed the dining cart was parked in the middle of the hall and trays were transported through the hall with uncovered salad. During an interview on 3/5/26 at 11:05 a.m. with Registered Dietician (RD), RD stated if meal trays were being transported from the dining cart to a resident's room, the cart should be parked outside the room to avoid uncovered food from being contaminated. RD acknowledged the risk of foodborne illness when uncovered food was being transported through the hall. During a review of facility's P&P titled, Covering Food During Transport, dated 2023, the P&P indicated, .Carts may be parked outside of each resident's door as their tray is delivered; minimizing transport of food through a common area (hall) to protect it from contamination. 3.During a review of Resident 12's AR, the AR indicated Resident 12 was admitted to the facility February 2025 with multiple diagnosis including obstructive uropathy (a blockage in the urinary tract). During a review of Resident 12's Physician's Orders, the Physician's Orders indicated Resident 12 had a foley catheter. During a concurrent observation and interview on 3/3/26 at 10:40 a.m. in Resident 12's room with CNA 2, Resident 12's foley catheter drainage bag was hanging from the bottom of his wheelchair and touching the floor. CNA 2 confirmed the drainage bag was touching the floor. During an interview on 3/4/26 at 3:22 p.m. with IP, IP stated the foley catheter drainage bag should be kept off the floor. IP further stated there was a risk for infection and damage to the drainage bag when the drainage bag was not secured high enough to prevent it from touching the floor. During a review of the facility's P&P titled, Indwelling Catheters, dated September 2025, the P&P indicated, .Be sure the catheter tubing and drainage bag are kept off the floor. 4.During a review of Resident 1's AR, AR indicated, Resident 1 was admitted on [DATE] with diagnoses including Pressure Ulcer Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) of sacral region (lower back right above the buttocks). During an observation of wound care on 3/5/26 at 10:15 a.m. in Resident 1's room, LN 5 and LN 6 were preparing for the wound treatment for Resident 1's sacral pressure ulcer. Resident 1's room did not have an Enhanced Barrier Precautions (EBP - infection control measures in nursing homes requiring staff to wear gloves and gowns during high contact care to stop the spread of dangerous germs) sign posted at the door or in her room. LN 5 and LN 6 performed hand hygiene, donned gloves, but did not wear a gown while providing direct wound care involving contact with the resident's sacral area and surrounding linens. During a review of Resident 1's active Order Summary Report (OSR – a list that shows all the medical orders a doctor has given for a resident) printed on 3/5/26 at 11:46 a.m. Resident 1's OSR confirmed EBP order remained active at the time of observation on 3/5/26. OSR indicated, Enhanced Barrier Precautions related to chronic sacrum wound every shift for Proper Personal Protective Equipment. During a review of care plan (CP) on 3/5/26 at 11:46 a.m., initiated 2/9/26, the CP indicated, .Resident requires enhanced barrier precautions during high contact resident care activities due to the presence of chronic wound to lower sacrum. During an interview on 3/5/26 at 3 p.m. with Infection Prevention (IP) nurse, the IP nurse stated, EBP Precautions must be followed as ordered. IP nurse confirmed that during the wound care observation with the treatment nurses LN 5 and LN 6, the EBP precaution order, EBP care plan were in place, and the EBP precautions were not followed as ordered. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated 2001, indicated,.Enhanced Barrier precautions refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms during high contact resident care activities.examples of high contact resident care activities requiring the use of gown and gloves for EBP include.j. wound care (any skin opening requiring a dressing) .

Based on observation, interview and record review, the facility failed to provide necessary assistance with nail care and hand hygiene for one out of 24 sampled residents (Resident 11).This failure to maintain clean and trimmed fingernails may increase the risk of infection.Findings:During a review of Resident 11's admission Record (AR), the AR indicated, Resident 11 was admitted on [DATE] with diagnoses including Acute and Chronic Respiratory Failure (the lungs cannot do their job well enough to keep the body alive and functioning properly) with hypoxia (body or brain is not getting enough oxygen); Morbid Obesity (a person has so much extra body weight that it seriously affects their health and increases the risk of life-threatening medical problems).A review of Resident 11's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/22/26, indicated, Resident 11 needs maximal assistance (Helper does more than half the effort) for personal hygiene.During an observation on 3/3/26 at 9 a.m. in Resident 11's room, Resident 11's fingernails were long and had brownish black sediments underneath each fingernail. Resident 11 was asked if nail care was offered, Resident 11 stated, No. They were too busy.During an observation on 3/4/26 at 10 a.m. in Resident 11's room, Resident 11's fingernails were long and had brownish black sediments underneath the fingernails. Resident 11 stated, No one asked me and no one offered to clean my nails.During an observation on 3/5/26 at 1:30 p.m. in Resident 11's room, Resident 11's fingernails were long and had brownish black sediments underneath the fingernails.During a concurrent observation and interview with the Director of Staff Development (DSD), on 3/5/26 at 1:52 p.m. at Resident 11's room hallway, DSD stated, the expectation was for the Certified Nurse Assistant (CNA) to do the nail care. The DSD and Nurse surveyor entered Resident 11's room. DSD held Resident 11's hand, confirmed it was long and had brownish black sediments underneath each nails. The DSD asked Resident 11 if they could clean her fingernails. Resident 11 agreed to the nail care. During a review of Resident 11's care plan initiated on 10/9/25, there was no evidence of a person-centered care plan related to ADLs ( Activities of Daily Living) including nail care.During a review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, revised 10/2025, indicated, .Residents will be provided ADL care to ensure that their activities of daily living (ADLs) are met .care and services will be provided for residents who are unable to carry out ADL independently.

Based on interview and record review, the facility failed to ensure Resident 1 was free from significant medication error when Resident 1 did not receive prescribed antiarrhythmic medication (treat and prevent irregular heartbeats) in accordance with the physician's order.This failure had the potential to result in Resident 1 to have experienced irregular heartbeats and other unnecessary side effects which could have negatively affected Resident 1's health.Resident 1 was admitted to the facility in January 2025 with multiple diagnoses which included paroxysmal atrial fibrillation (fast, irregular heartbeat that comes and goes) and unspecified atrial flutter (abnormal heart rhythm that's too fast). A review of Minimum Data Set (MDS, an assessment tool), dated 1/29/25, indicated Resident 1 had intact cognition.A review of Resident 1's Order Summary Report, with start date 1/25/25, indicated, Amiodarone HCl [medication to treat and prevent irregular heartbeats] Oral Tablet 200 MG [milligrams-unit of measurement] Give 200 mg by mouth one time a day for AFIB [atrial fibrillation-irregular heartbeat].A review of Resident 1's Medication Administration Record (MAR-a legal document used to record medications given to the residents), for the month of January 2025, indicated Resident 1 did not receive the physician prescribed Amiodarone medication on 1/25/25, 1/26/25, 1/27/25, 1/28/25 and 1/29/25. During a concurrent interview and record review on 8/5/25, at 12:21 p.m., with the Director of Nursing (DON), the DON confirmed the expectation was for nursing staff to follow physician's orders and if a medication was not given, the physician was supposed to be notified. The DON reviewed Resident 1's MAR and confirmed Resident 1 did not receive the prescribed Amiodarone medication on 1/25/25, 1/26/25, 1/27/25, 1/28/25 and 1/29/25 because the medication was not available at the facility. The DON also reviewed Resident 1's medical chart and confirmed the physician was not notified on those days. DON stated Resident 1 did not receive her prescribed medication for five days and the physician should have been notified. DON further stated, Five days not receiving her heart medication .could be bad for her afib and heart condition.A review of the facility's policies and procedures (P&P) titled, Administering Medications, revised 4/2023, indicated, 2. Medications are administered in accordance with prescriber orders, including any required time frame.A review of the facility's P&P titled, Physician Orders, dated 10/2024, indicated, Physician medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order.A review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 4/2024, indicated, The nurse will notify the resident's Attending Physician/physician on call/nurse practitioner/physician assistant when there has been a(an).f. refusal of treatment or medications.

Based on observation, interview, and record review, the facility failed to safely store foods according to professional practice standards for a census of 90 residents when: 1. Potentially Hazardous Food (PHF) such as unpasteurized eggs, cheese, half and half, turkey, and ham was left unattended on the floor and shelving outside of the kitchen refrigerator for longer than two hours; 2. Expired banana pudding was found in the kitchen refrigerator available for use; and, 3. Twelve individual containers of salad dressing were stored unlabeled and undated in the kitchen refrigerator available for use. These failures had the potential to cause a widespread foodborne illness among residents from consumption of contaminated, spoiled or unlabeled foods. Findings: 1. During a concurrent initial kitchen observation and interview on [DATE] at 8:46 a.m. with [NAME] (CK) in front of the walk-in refrigerator in the kitchen, there were boxes of unpasteurized eggs, cheese, half and half, turkey, and ham observed left unattended on the floor and shelving. CK verified the words Keep Refrigerated were printed on the boxes. CK stated the boxes had been there since she arrived at work that morning before 6 a.m. CK stated her boss usually put the food away, but he was on vacation. When asked if the food was safe, the CK stated, I don't know if it's still good. During an interview on [DATE] at 9:07 a.m. with Registered Dietitian (RD) in the kitchen outside of the refrigerator, RD stated the boxes of food delivered should be out no more than two hours. RD would check the invoice delivery time and throw out the boxes if greater than two hours. During an interview on [DATE] at 11:23 a.m. with the Dietary Manager (DM), DM reported food delivered should be put away immediately as soon as it arrived. DM stated, We don't want refrigerated food sitting out longer than one to two hours. The DM reported if refrigerated food was left out longer than two hours, staff would go by protocol and toss the food out. During an interview on [DATE] at 10:20 a.m. with Dietary Consultant (DC), Registered Dietitian (RD), and Dietary Manager (DM), DC, RD, and DM all verbalized refrigerated food should be thrown out after two hours if not stored in the refrigerator. During a review of the facility's policy and procedure titled, General Receiving of Delivery of Food and Supplies, dated 2023, indicated, Deliveries will be scheduled .when trained staff are available to .store food promptly and in a safe manner. The policy further indicated, Deliveries are to be put away as quickly as possible. Begin with refrigerated items . During a review of 4 Steps to Food Safety, Foodsafety.gov, 18 Sep. 2023, <https://www.foodsafety.gov/keep-food-safe/4-steps-to-food-safety>, retrireved on [DATE], it was recommended to, Never leave perishable foods out of refrigeration for more than 2 hours and Refrigerate perishable foods within 2 hours as Bacteria that cause food poisoning multiply quickest between 40 F (4 C) and 140 F (60 C). 2. During a concurrent initial kitchen observation and interview on [DATE] at 9 a.m. with CK in the facility's refrigerator, CK verified a container labeled, Banana Pudding with a prepared date of ,d+[DATE] and a use by date of ,d+[DATE]. CK stated, It's [pudding] not good. CK also reported the label was dated incorrectly and should have had a prepared date of ,d+[DATE] and a discard date of ,d+[DATE]. During an interview on [DATE] at 11:23 a.m. with DM, the DM indicated the banana puddings should have been discarded, as he did not want any of his residents to get sick. During a review of the facility's policy and procedure titled, Refrigerated Storage Guide, dated 2023, indicated, the maximum refrigeration time for prepared desserts .including puddings . was three days. 3. During a concurrent observation and interview on [DATE] at 9 a.m. with CK in the facility's walk-in refrigerator, CK verified there were twelve individual containers of salad dressing stored on a tray were not labeled either on the individual containers or on the tray the containers were stored on. During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2023, indicated, All prepared foods need to be covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray with masking tape if going to be used for meal service [i.e. salads, drinks, and other miscellaneous items for tray line.]

Based on interview and record review, the facility failed to follow physician orders for two of 23 sampled residents (Resident 94 and Resident 6) when: 1. Anti-anxiety medication was given without first offering nonpharmacological interventions for Resident 94, and 2. Bladder scan was not completed for Resident 6. These failures placed Resident 94 at risk for unnecessary medication and increased the risk for Resident 6 for unmet care needs. Findings: 1. Resident 94 was admitted to the facility in late 2024 with diagnoses which included nerve pain, generalized anxiety and difficulty recovering after experiencing or witnessing a traumatic event. During a review of Resident 94's Minimum Data Set (MDS, an assessment tool), dated 11/26/24, the MDS indicated Resident 94 was able to independently make decisions regarding tasks of daily life without memory impairment. During a review of Resident 94's Clinical Physician Orders, the physician order indicated, Lorazepam [an anti-anxiety medication] Oral Tablet 0.5MG [milligram, unit of measurement for medication dosage] with start date of 11/13/24 at 5 p.m. During a review of Resident 94's Clinical Physician Orders, the physician order indicated, Attempt Non-Pharmacological Approaches Prior To Anti-Anxiety Med .Document On Emar (electronic medication administration) Attempts Taken with start date of 11/13/24 at 4 p.m. During a review of Resident 94's MEDICATION ADMINISTRATION RECORD (MAR), the MAR indicated, Resident 94 received Lorazepam Oral Tablet 0.5 MG on the following dates: 11/14/24, 11/15/24, 11/16/24, twice on 11/17/24, 11/19/24, 11/20/24, 11/21/24, and on 11/26/24 without any documented evidence of attempts for non-pharmacological approach. During an interview on 12/4/24 at 2:42 p.m. with Licensed Nurse (LN 4), LN 4 stated that staff should prioritize non-pharmacological interventions before administering anti-anxiety medications. LN 4 stated that the MAR required documentation of interventions. LN 4 stated that residents may develop medication tolerance due to frequent administration, especially when non-pharmacological approaches could be effective. During a concurrent interview and records review on 12/4/24 at 3:01 a.m. with the Director of Nursing (DON), the DON confirmed that Lorazepam 0.5 MG was administered without documentations of non-pharmacological approach on the MAR. The DON stated he expected the nurses to make sure to follow physician orders before administering medications for residents. 2. Resident 6 was admitted to the facility in mid-2022 with diagnoses which included discomfort when urinating, difficulty emptying the bladder and improperly functioning bladder muscles. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 15 out of 15, with no memory impairment. During a review of Resident 6's AFTER VISIT SUMMARY, dated 11/21/24, the summary indicated, Instructions .Please bladder scan x 3 [three times in the AM, PM and evening] after each void please records (sic) results please complete by 11/25 . During a review of Resident 6's MEDICATION ADMINISTRATION RECORD [MAR], dated 11/22/24, the MAR indicated, Bladder scan resident 3x day and record results . Bladder scan results were not recorded in the MAR for 11/22, 11/23, 11/24, or 11/25/24. During an interview on 12/2/24 at 3:44 p.m. with Resident 6, Resident 6 stated, I am supposed to be bladder scanned after every pee. They said they lost the bladder scanner. They have not scanned my bladder once. During an interview on 12/4/24 at 10:12 a.m. with LN 4, LN 4 confirmed there was no documented bladder scan completed for Resident 6 and stated, I don't see anything about the physician being notified it [bladder scan] was not done . LN 4 indicated the bladder scan was important to determine if Resident 6 was having urinary retention and Stated, Urologist requested it. If it's important to him, it's important to us . During an interview on 12/5/24 at 10:15 a.m. with the DON, the DON stated he expected physician orders to be carried out by the nurse. Our bladder scan was taken. I had instructed the nurse to notify the physician .from what I see in the notes it was not documented . During a review of the facility's policy and procedure (P&P) titled, Physician Orders, dated 10/24, the P&P indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician/nurse practitioner order .The licensed staff shall carry out physician/nurse practitioner's orders as prescribed . 48860

Based on observation, interview, and record review, the facility failed to ensure opened medications were dated and properly stored for two residents (Resident 31 and Resident 16) for a census of 90. This failure had the potential for residents to receive medications with unsafe or reduced potency from improper storage for Resident 16 or being used past their expiration date for Resident 31. Findings: During an observation and interview on [DATE] at 9:32 a.m., with the Director of Nursing (DON) in Medication room [ROOM NUMBER], an opened Ozempic (a medication used to treat Type 2 Diabetes) injection pen for Resident 31 was observed to be stored inside a resealable bag without a written opened date on the label. There was another open Ozempic injection pen for Resident 16 in the resealable bag without a pen cap to cover the pen window where the needle was attached. During an interview on [DATE] at 9:30 a.m. with Licensed Nurse 5 (LN 5), LN 5 stated the importance of dating and labeling Ozempic when opened to avoid using expired medication which could be less effective. LN 5 stated that storing Ozempic without a cap could increase the risk of contamination and potentially leading to adverse effects for residents. In an interview on [DATE] at 2:59 p.m., the DON stated staff should verify expiration dates on Ozempic injection pens, record the date when a pen was first opened, and ensure proper storage of these medications. Review of manufacturer's instruction for Ozempic, dated ,d+[DATE], indicated, Store your pen in use for 56 days at room temperature .The OZEMPIC pen you are using should be disposed of (thrown away) after 56 days, even if it still has OZEMPIC left in it .Keep the pen cap on when not in use .

Based on observation, interview and record review, the facility failed to follow infection prevention guidelines for a census of 90 residents when: 1. Personal wash basins were unlabeled, and 2. Male urinals were inconsistently labeled. These failures had the increased potential to place the residents at risk for infection. Findings: 1. Resident 299 was admitted to the facility in the summer of 2024 with diagnoses which included adult failure to thrive. During a review of Resident 299's Minimum Data Set (MDS, an assessment tool), dated 9/19/24, the MDS indicated Resident 299 had moderate memory impairment and required set up or clean up assistance with toileting and personal hygiene. During a review of Resident 299's care plan (CP) titled ADL/Mobility .Resident .is at risk for .decline and requires assistance related to .failure to thrive, dated 6/16/24, the CP indicated Hygiene .set up assist . During an observation on 12/2/24 at 9:44 a.m., a poster titled Enhanced Barrier Precautions [EBP, an infection control method that involves wearing gowns and gloves during high-contact care activities for residents in nursing homes] was pinned outside the door of Resident 299 and Resident 75's shared room. Resident 75 was admitted to the facility in the spring of 2024 with diagnoses which included resistance to drugs that kills microorganisms. During a review of Resident 75's MDS, dated [DATE], the MDS indicated Resident 75 was alert, oriented, and dependent on staff for showers, bathing and personal hygiene. During a review of Resident 75's CP, titled ADL[Activities of Daily Living, basic self-care tasks people perform to live independently including eating, dressing, bathing, toileting, etc]/Mobility .requires assistance related to bed-bound status , dated 3/29/24, the CP indicated, Hygiene .Assist of (dependent) . During and observation on 12/2/24 at 9:47 a.m., Resident 75 was in bed, snoring with a urinary catheter hanging from the left side of the bed frame. During a concurrent observation and interview on 12/2/24 at 9:50 a.m., with Certified Occupational Therapy Assistant (COTA) 1, COTA 1 verified two gray basins on back of the toilet shared by Resident 299 and Resident 75 had no names. The COTA stated, I believe they are supposed to be labeled with [a] minimum [of] first and last name and the bed, at least .I would. I discussed it with the Director of Rehab [rehabilitation], and we don't put names on because of HIPPA [HIPAA is an acronym for the Health Insurance Portability and Accountability Act, a federal law that protects the privacy and security of medical records and other personal health information] but you should have the room number. Resident 70 was admitted to the facility in the summer of 2023 with diagnosis which included inflammation of the tube leading from the throat to the stomach and a condition in which small, bulging pouches from the walls of the colon that could become inflamed and infected. During a review of Resident 70's MDS, dated [DATE], the MDS indicated Resident 70 was alert and oriented, able to make her needs known. She required maximal assistance for personal hygiene and was dependent on staff for showering and bathing. During a review of Resident 70's CP titled ADL/Mobility .requires assistance related to fluctuating ADLs ., dated 12/4/24, the CP indicated Hygiene .Assist .partial/mod [moderate] . During an interview on 12/2/24 at 10:22 a.m. with Resident 70, she was lying in bed in her room across from Resident 43 and stated she had been experiencing diarrhea for two months. Resident 43 was readmitted to the facility in the winter of 2021 with diagnoses which included a condition that causes a gradual decline in memory and inability to control of feces and urine. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 was alert and oriented but dependent on staff for personal hygiene, showers and bathing. During a review of Resident 43's CP titled, ADL .Requires assist in the following areas .Personal Hygiene .Bathing, dated 12/16/22, the CP indicated. Assist with maintaining good personal hygiene . During a concurrent observation and interview with Resident 43 on 12/2/24 at 10:31 a.m., Resident 43 indicated she was incontinent of both urine and feces. During a concurrent observation and interview on 12/2/24 at 10:36 a.m. with Certified Nurse's Assistant (CNA) 2, there was an unlabeled gray basin on the back of the toilet in the bathroom shared by Resident 43 and Resident 70. CNA 2 verified the basin was unlabeled and said, I personally use these for bed baths .I don't know whose it is. During an interview with the Director of Staff Development (DSD) on 2/5/24 at 9:09 a.m., the DSD stated her expectation for CNAs was to label the basins with the name, not the room number, because of frequent room changes. They should be labeled. During a review of the facility policy and procedure (P&P) titled Infection Prevention and Control, revised 8/24, the P&P indicated Important facets of infection prevention include .instituting measures to avoid complication or dissemination .educating staff and ensuring that they adhere to proper techniques and procedures . 2. Resident 67 was admitted to the facility in the mid 2024 with diagnoses which included paralysis of the arm, leg, and trunk on the same side of the body and one-sided muscle weakness. During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67 had occasional urinary and bowel incontinence. During a review of Resident 67's undated Care Plan indicated Bladder: (Resident name) is at risk for complications with urinary system related to both stress and urge . During an observation on 12/2/24 at 9:11 a.m., in Resident 67's room, an undated male urinal with Residents 67's last name and UA collection written was hanging on bedside with amber colored liquid inside. Resident 45 was admitted to the facility in the mid 2024 with diagnoses which included heart failure and lung problem. During a review of Resident 45's undated Care Plan indicated, Bladder: is at risk for complications with urinary system related to Benign Prostatic Hyperplasia [enlargement of the prostate gland that could cause frequent urination, difficulty starting or stopping urination] . During an observation on 12/2/24 at 9:11 a.m., in Resident 45's room, an empty male urinal dated 7/12/24 with Resident 45's last name was hanging on bedside. Resident 79 was admitted to the facility in the mid 2024 with diagnoses which included chronic lung problem and shortness of breath. During a review of Resident 79's undated Care Plan indicated Bladder: at risk for complications with urinary system related to resolved hx [history] of AKI [Acute Kidney Injury] . During an observation on 12/2/24 at 10:49 a.m., in Resident 79's room, an unlabeled empty male urinal was hanging on bedside. Resident 43 was admitted to the facility in the early 2023 with diagnoses which included a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord and difficulty swallowing. During a review of Resident 43's undated Care Plan indicated Bladder: At risk for complications with urinary system related to urinary retention. During an observation on 12/2/24 at 10:49 a.m., in Resident 43's room, a male urinal that contained a dark ambered liquid with Residents 43's room and bed was on Resident 43's bedside table. Resident 43 stated, I can't remember them changing it [urinal]. During an interview on 12/4/24 at 9:45 a.m., with License Nurse 6 (LN 6), LN 6 confirmed the findings acknowledged that urinals should be changed because of risk for urinary tract infection especially for patients in long term care. LN 6 stated that the urinals should be dated so staff knew when to change them. During an interview on 12/4/24 on 11:58 a.m., with the DON, the DON confirmed the findings and stated he expected nurses and CNAs to make sure that male urinals were changed every two weeks and that it should contain residents name and date of when the male urinals were changed. 48860

Based on interview and record review, the facility failed to ensure the minimal staffing reqirements were met when: 1. A minimum of 3.5 direct care services hours per day (DHPPD - a tool to assess the value nursing staff provides to patient safety and care quality) were not met for three out of 23 days audited; and, 2. A minimum of 2.4 Certified Nursing Assistant (CNA) DHPPD for 21 out of 23 days audited were not met. These failures had the potential to prevent residents from receiving necessary care and maintaining the highest practicable physical, mental, and psychological well-being. Findings: A review of the facility's NHPPD Scheduled Daily Staffing Overview . forms indicated the facility did not meet a minimum of 3.5 DHPPD on: 9/1/24 with 3.10 hours, 9/8/24 with 3.34 hours, and 9/16/24 - with 3.41 hours. A review of the facility's NHPPD Scheduled Daily Staffing Overview . forms indicated the facility did not meet a minimum of 2.4 CNA DHPPD hours on: 9/1/24 with 2.32 hours, 9/2/24 with 2.32 hours, 9/3/24 with 2.32 hours, 9/4/24 with 2.37 hours, 9/5/24 with 2.29 hours, 9/6/24 with 2.37 hours, 9/7/24 with 2.37 hours, 9/8/24 with 2.29 hours, 9/9/24 with 2.20 hours, 9/12/24 with 2.37 hours, 9/13/24 with 1.62 hours, 9/14/24 with 1.95 hours, 9/15/24 with 1.79 hours, 9/16/24 with 1.77 hours, 9/17/24 with 1.74 hours, 9/18/24 with 2.13 hours, 9/19/24 with 1.91 hours, 9/20/24 with 2.00 hours, 9/21/24 with 1.81 hours, 9/22/24 with 1.98 hours, and 9/23/24 with 2.00 hours. During an interview on 9/23/24 at 2:15 p.m. with the Certified Assistant Nurse/Ward Clerk (CNA/WC), the CNA/WC stated, Call lights are not answered timely since we don't have enough staff on the floor .There are some challenging times when it takes about 30 minutes for the call lights to be answered. Night shift staffing is bad and could contribute to call lights not being answered timely and could lead to falls and accidents. During an interview on 9/23/24 at 2:23 p.m. with CNA 1, CNA 1 stated, .Staffing can be better. It seems like we are always short-staffed .We have many call-offs, and there is registry staff in every shift. We need more CNAs to provide quality care to our residents and not put the residents at safety risk. During an interview on 9/23/24 at 2:37 p.m. with CNA 2, CNA 2 stated, .Facility uses a lot of registries in every shift, and you hear more and more complaints by the residents that call lights are not answered promptly .Call lights are often not answered for 15 to 20 minutes . It would be nice if everyone at the facility answered call lights when they were on. Just find out what the resident needs. During an interview on 9/23/24 at 2:51 p.m. with Licensed Nurse 1, LN 1 stated, CNAs are often short-staffed, leading to call lights not being answered promptly. During an interview on 9/23/24 at 4:03 p.m. with Resident 1, Resident stated, .It takes about 10 to 15 minutes to have my call light answered most of the time and takes even longer during the night shift . There are not enough CNAs to take care of us. During an interview on 9/23/24 at 4:18 p.m. with Resident 2, Resident 2 stated, .Call lights are not answered timely because the CNAs are very busy. During an interview on 9/23/24 at 4:24 p.m. with Resident 3, Resident 3 stated, .The call lights are not answered timely, and there could be a wait of about an hour, especially on the night shift . Registry CNAs do not know our routine, and it's challenging to keep repeating the same thing. I am here to be taken care of and not to give instructions daily on how much care should be given. I need consistency. During an interview on 9/23/24 at 5 p.m. with the DON and ADON, the DON and ADON responded, .It would be nice not to use registry and to have the facility have in-house staff . That could contribute to the call lights not being answered timely. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated April 2024, the P&P indicated, .Answer the resident's call as soon as possible and as practicable . A review of the All Facilities Letters (AFL: a letter to healthcare facilities that communicates policy and guidance) 19-16, issued on 4/9/19, indicated, .To: SKILLED NURSING FACILITIES (SNFs) .The 3.5 DHPPD staffing requirement, of which 2.4 hours per patient day must be performed by CNAs, is a minimum requirement for SNFs. SNFs shall employ and schedule additional staff and anticipate individual patient needs for the activities of each shift, to ensure patients receive nursing care based on their needs . Only direct caregivers shall count toward the 3.5 and 2.4 DHPPD staffing standards . Any facility that falls below either the 3.5 or 2.4 DHPPD staffing requirement for any audited day is out of compliance .CDPH will issue one deficiency for non-compliance with each of the applicable staffing standards .regardless of the number of non-compliant days .

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for a census of 92 when the garbage dumpster was found with garbage bags rising out of the top with the lid not properly closed. This failure had the potential to attract pests to the facility. Findings: During an observation on 7/23/24 at 2:17 p.m. at the garbage disposal area outside the facility, six trash bins and one biohazard bin were observed. One of the trash bins was observed with black trash bags rising out of the bin and the lid was not fully closed. During a concurrent observation and interview on 7/23/24 at 2:36 p.m. with Housekeeping Staff (HS) inside the laundry room, HS was observed holding a fly swatter and stated, There are a lot of flies here, it could be maybe from the garbage out there. During an interview on 7/23/24 at 3:03 p.m. with the Administrator (ADM), when a picture of the trash bin was shown to him, the ADM confirmed the trash bin was not properly closed and bag was propped open, and contacted the Maintenance Director (MTD). The ADM stated, There were residents leaving the door opened .Flies are coming from the outside .Spreading of infection and diseases is the biggest risks for having those things in the facility. During an interview on 7/23/24 at 4:08 p.m. with the MTD, the MTD confirmed the trash bin was not properly closed. During a review of the US FDA 2022 Food Code, section 5-501.15, titled, Outside Receptacles, 1/18/23 version, indicated, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. During a review of the facility's policy and procedure (P&P) titled, Pest Control, revised 4/2008, the P&P indicated, 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. During a review of the facility's P&P titled Garbage and Refuse Disposal, revised 12/2022, the P&P indicated, 2. All garbage and refuse containers are provided with lids or covers and must be kept covered when stored or not in continuous use .4. Garbage and refuse containing food wastes will be stored in a manner that prevent pests .6. Outside dumpsters provided by garbage pickup services will be kept closed.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for a census of 92 when flies were observed in hallways and in Resident 1's room. This failure had the potential to spread infections and diseases among the residents, staff and visitors. Findings: During a concurrent observation and interview on 7/23/24 at 1:39 p.m. with Resident 1 in his room, flies were observed moving around the room, on Resident 1's blanket, and on the curtains. Resident 1 stated, Everybody complains about the flies, and I complained too .They put a blanket on me, so I don't feel the flies. During an interview on 7/23/24 at 1:47 p.m. with Licensed Nurse (LN 1), LN 1 stated, I know you noticed the flies, the rooms are so smelly .we have lights outside the rooms, but they are not effective. During a concurrent observation and interview on 7/23/24 at 2:02 p.m. with LN 2 in Resident 1's room, LN 2 confirmed the presence of flies inside the room, on Resident 1's blanket and on the curtains. LN 2 stated, We have infestation of flies here, they put the lights but it's not effective. During a concurrent observation and interview on 7/23/24 at 2:06 p.m. with LN 3 in the hallway, LN 3 was observed clearing away flies using hands while being interviewed. LN 3 stated, I have seen a lot of flies, they have machine lights, but residents open the door frequently .I should add it in the maintenance log, there's a lot of flies here .it's an infection control issue and dignity issue. During a concurrent observation and interview on 7/23/24 at 2:36 p.m. with Housekeeping Staff (HS) inside the laundry room, HS was observed holding a fly swatter and stated, There are a lot of flies here, it could be maybe from the garbage out there. During an interview on 7/23/24 at 2:44 p.m. with the Maintenance Director (MTD), the MTD stated, We had a lot of trouble with flies, it's because of a lot of traffic .They come from outside . During an interview on 7/23/24 at 2:53 p.m. with the Director of Nursing (DON), the DON stated, I did notice flies around the facility .flies can get in food, everywhere, that's a huge infection control issue. When pictures of flies were shown, the DON stated, That's not good, we should do something about it. During an interview on 7/23/24 at 3:03 p.m. with the Administrator (ADM), the ADM stated, There were residents leaving the door opened .flies are coming from the outside .spreading of infection and diseases are the biggest risks for having those things in the facility. During a review of the facility's policy and procedure (P&P) titled, Physical Environment and Accommodations Policy, undated, the P&P indicated, (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. During a review of the facility's P&P titled Pest Control, revised 4/2008, the P&P indicated, Our facility shall maintain an effective pest control program .1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) met the state's education qualification requirements, as required per federal regulations, to be the DM to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the full time Registered Dietitian (RD) provided frequently scheduled consultation to the DM to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with meal distribution accuracy (Cross Reference F803), and safe food handling and sanitation (Cross Reference F812), which lacked the benefit of a qualified Food and Nutrition Services Director (DM) responsible for the day-to-day food service operation for the skilled nursing facility. In addition, the facility lacked the benefit of the expertise of RD input when there was not sufficient oversight over the food service operations via frequently scheduled consultation to the DM by the RD, when the job description of the RD was essentially based on clinical nutrition. There was a total of 81 out of 83 residents receiving meals from the facility kitchen. Findings: During the annual recertification survey from 11/13 to 11/16, 2023, multiple issues surrounding the delivery of dietetic services were identified: 1. Meal distribution accuracy - the menu/recipes/meal spreadsheets were not followed, and the portion size of food items and fortification for the therapeutic diets were not served correctly, and 2. Safe food handling and sanitation: a. Improper labeling and dating for the food items in dry storage and walk-in refrigerator; b. Improper storage of opened packages of food items in dry storage and walk-in refrigerator; c. Ice machine in the kitchen was not clean with orange slimy and black substances were found in the ice maker (upper machinery unit); d. Lack of thawing process system (items were found in walk-in refrigerator): 1. The thawing meats had no date to show when they could be used and when they should be discarded, and 2. A box of cartons of supplement drinks (nutrition drinks provide additional nutrients and are perishable) were not dated to show when they would be used or discarded. e. Four individual ice cream cups were found in the reach-in refrigerator; f. Several various sizes of metal pans and dishes were found stacked and stored wet at the ready-to-use storage areas; g. Dietary Aide (DA) 1, was in dishwasher position, was not able to demonstrate and verbalized the process of manual dishwashing by the three-compartment sink, and h. Cook (Cook 1) was not able to verbalize the cooling down process of cooked (hot) food. During an initial kitchen tour and concurrent interview with the Dietary Manager (DM) on 11/13/23, at 8:35 a.m., DM stated he had no credential (not a DSS (Dietary Service Supervisor) nor CDM (Certified Dietary Manager), and stated he was still waiting to be approved from the administration to start the class of CDM. DM stated he worked at the dietary manager position for two years and before he worked as dietary assistance and dietary aide since 2021. DM stated his role was to manage the kitchen, staff, ordering, visiting residents to get their food preferences. He stated the facility had a full-time Registered Dietitian (RD) for doing assessments for the residents. During an interview with the RD on 11/13/23, at 12:48 p.m., RD stated she was a full-time in-house (not contracted) RD and worked in facility from Monday to Friday. She stated she was responsible to do monthly kitchen sanitation audits and monthly in-services for the kitchen staff. RD stated she was not overseeing day-to-day operation of the kitchen. She stated her overall workload for the facility was 10 percent for the foodservice work and 90 percent for the clinical work. She stated she would do all the assessments which included new admission, annual, quarterly, and significant changes, and she also completed the MDS (minimum data set - a standardized assessment tool that measure health status in nursing home residents). She stated she was responsible to attend the IDT (interdisciplinary team-development of professional plan to coordinate and deliver personalized health care for the residents) meeting and monitored and documented on weight status of the residents (weekly and monthly). During a follow up interview with the RD on 11/15/23, at 11:25 a.m., RD stated she had been told her primary focus was clinical nutrition and resident nutrition care upon hire. She stated she was not doing any day-to-day foodservice operation, and she did not have time for it because she had a lot to do in the clinical nutrition and visiting/interviewing residents. During an interview with the Administrator (ADM) on 11/15/23, at 2:51 p.m., ADM acknowledged the DM was not qualified for the DM position per federal/state regulation, and the full-time RD was not overseeing day-to-day foodservice operation. ADM stated the company was working on putting the DM on the CDM program. It was noted the DM was not qualified on the last annual recertification on 2022, and the POC (Plan of Correction) stated DM would start the CDM program on June 2022 and would be complete by June 2023. ADM stated he was not aware of it because he had not started working in the facility at that time. He stated the RD was new and still trying her best. He stated he would ask the RD to be more involved in the foodservice since she was the only qualified person. A review of the employee file for the DM, it indicated his hire date was on 10/22/21, and he got promoted to the DM position on 5/1/22. There was no competency or performance evaluation in file. His employee file had a California State Food Handling Training certificate, but no other credentials or certificates. A review of an employee file for the RD, it indicated her hire date on 2/20/23, and had a CDR (Commission of Dietetics Registration - a credentialing agency for the Academy of Nutrition and Dietetics) credential. There was no competency or performance evaluation in file. A review of an undated facility organizational chart, it indicated the DM position was responsible for the dietary department, managing the dietary staff, and reporting to the ADM. The RD position was not responsible for the dietary department and did not manage the dietary staff. The RD also reported to the ADM. A review of facility policy and procedure, titled Personnel Management, dated 2023, it indicated, .A qualified FNS (Food and Nutrition Services) Director (same as Dietary Manager-DM) .is responsible for the total operation of the FNS Department. All FNS is performed under their direction .If a person is not a Registered Dietitian, they must meet the Federal and State Law and receive regular consultation from a RD or have met equivalent requirements. A review of facility job description, titled Job Description: Dietary Supervisor (same as DM), dated 9/2016, it indicated, .Purpose: this position must provide supervision for the Dietary Department, ensuring quality food. The Dietary Supervisor will direct and assist the preparation and service of regular meals and therapeutic diets, order food and supplies, maintain area and equipment in sanitary condition, and assure the smooth operation with other nursing facilities department .Duties: .Direct and participate in food preparation and service of food that is safe .to meet each resident's needs in accordance with physicians order in compliance with approved menu .Assures that proper storage is available, and that handling of food and supplies complies with current state and federal guidelines .Maintain kitchen and food storage area in a safe, orderly, clean and sanitary manner .Check trays for accuracy before they are delivered .Plan and presents in-service education programs for the Dietary Department . Qualification .must be a graduate of an approved dietary manager's course that meet the state and federal care regulations . A review of the state's qualifying pathways to be a dietary manager as listed in the Health and Safety Code (H & SC) 1265.4, 72035. Dietetic Service Supervisor. Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. A review of facility job description, titled Job Description: Registered Dietitian, dated 9/2017, it indicated, .Purpose: Complete nutrition initial, quarterly, annual, and significant change reviews on residents according to federal and state guidelines. Assist in coordination of nutrition care services with Dietary Supervisor. Complete nutritional reviews monthly on high risk residents (significant weight loss/gain, pressure ulcer, hemodialysis, and tube fed) .Supervisory Requirement: Assists with the overall supervision and management of the dietary staff .

Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. Food items with missing or incorrect labeling and dating were found in dry storage and walk-in refrigerator; 2. Food items with opened packages were found not covered properly to prevent cross contamination in dry storage and walk-in refrigerator; 3. Ice machine was not clean; 4. Thawing meats found in the walk-in refrigerator were not dated to show when they were to be used or discarded; 5. A box of supplement shakes (nutrition drinks provide additional nutrients and are perishable) were not dated to show when they were to be used or discarded in the walk-in refrigerator; 6. Four individual ice cream cups were found in the reach-in refrigerator and were soft to touch; 7. Several various sizes of metal pans and dishes were found stacked and stored wet at the ready-to-use storage areas; 8. One dishwasher (Dietary Aide) (DA 1) was not able to demonstrate and verbalized the process of manual dishwashing by the three-compartment sink, and 9. One Cook (Cook 1) was not able to verbalize the cooling down process of cooked (hot) food. These failures had potential to cause food-borne illness in a highly susceptible population of 81 out of 83 residents who received food from the kitchen. Findings: 1. During an initial kitchen tour on 11/13/23, at 10:01 a.m. and 10:35 a.m., there were the following food items found opened and had no or improper labeling (stickers on the packages indicating opened date and used by date): In the walk-in refrigerator: -two bags of yellow shredded cheese (no used by date) -a bag of diced hard boiled eggs (no opened date and used by date) -a bag of Swiss cheese (no opened date and used by date) In dry storage: -six bags of dry pasta (no opened date and used by date) -a bag of croutons (no used by date) During an interview with the Dietary Manager (DM) on 11/13/23, at 10:15 a.m. and 10:45 a.m., he confirmed and stated the opened food items should be labeled with the opened date and used by date. During an interview with the Registered Dietitian (RD) on 11/15/23, at 11:25 a.m., she stated the food item packages were opened should be labeled with opened and used by dates. A review of departmental policy and procedure, titled Labeling and Dating of Foods, dated 2023, indicated Newly opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines . 2. During an initial kitchen tour on 11/13/23, at 10:01 a.m. and 10:35 a.m., there were the following food items found opened and not securely or improperly covered: In the walk-in refrigerator: -a big of Swiss cheese (closed with a paper clip) -a big of diced hard boiled eggs (closed with a paper clip) In the dry storage: -6 bags of dry pasta (were not covered securely) -a bag of croutons (used a rubber band to close the package opening) -a box of hot wheat cereal and a box of cream of rice (were in the ziplock bags individually but not zipped) -a bag of white cake mixed powder (closed with a paper clip) During an interview with DM on 11/13/23, at 10:15 a.m. and 10:45 a.m., he confirmed and stated the opened food items should be stored in a bag or container that could closed securely to prevent pests and rodents. DM stated the use of paper clips to close the opened packages was not acceptable. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the opened food items should be stored in an enclosed bag or container and sealed tightly. A review of departmental policy and procedure, titled Storage of Food and Supplies, dated 2023, it indicated .Dry food items which have been opened, such as .biscuit mix, pancake mix, dry cereal .noodles, etc., will be tightly closed . 3. During an inspection of the ice machine in the kitchen on 11/13/23, at 8:41 a.m., the Maintenance Supervisor (MS) removed the ice machine's top access panel to reveal the water curtain (a white plastic cover to prevent the ice from shooting out and direct the ice back into the ice storage bin). Upon the water curtain dissembled, there was orangish/pink slimy substances found inside part of the curtain and could be wiped off with paper towel. There were orangish/pink slimy substances found at the opening of the ice chute (the passage through which ice falls into the ice storage bin) and could be easily wiped off with paper towel. There were significant black substances on the left and right panels of the ice evaporator unit (a unit that makes cold liquid flow into the evaporator and freeze to make ice). A concurrent interview with the MS, he confirmed and agreed the substances were found. He stated the maintenance department was responsible for the deep cleaning (clean and sanitize the machinery part of the machine and the ice storage bin) monthly. MS stated he would dissemble the part apart to clean, scrub, and sanitize. Also, he would clean and sanitize the ice storage bin. MS stated his last deep clean of the ice machine and ice storage bin was on 10/16/23. He stated the facility hired the outside vendor to run the chemical (cleaner and sanitizer solutions) for the cleaning and sanitizing cycles and changed the water filter together annually. During an interview with RD on 11/15/23, at 11:25 a.m., she stated the ice machine should have regular maintenance, cleaning and sanitizing to keep it clean because ice was food and needed to be in a safe environment. A review of the facility document, titled [Outside Vendor Company Name] Invoice, dated 12/8/2022, it showed maintenance service completed and the water filter was changed on 12/8/2022. It also had a description on the invoice stated the ice machine was leaking. A review of the ice machine manual, titled, [Manufacturer's brand] Instruction Manual, dated 4/16/2019, it indicated, .Maintenance .Maintenance Schedule .More Frequent maintenance may be required depending on water quality, the appliance's environment, and local sanitation regulations .The icemaker must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may require in some water conditions . According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residue that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae). 4. During an initial kitchen tour on 11/13/23, at 9:50 a.m., and a concurrent interview with the DM, there were thawing meats observed on the bottom shelf of the storage rack in the walk-in refrigerator without a pull-out date (date for when pulled out from the freezer and placed in the refrigerator to thaw) and used by date: -a half loaf of ham -a box of turkey breast -a tray of five loaves of pork loins -a box of beef roast -a tray of seven packs of turkey deli meat The interview with the DM, he stated the thawed meats should have a label of pull-out date from the freezer and the used by date. The DM stated the kitchen had a system for thawing meats, but the staff did not date the meats and they needed an in-service. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the staff should put the date when they pulled out the meats from the freezer and the used by date. The RD added, the dates would easily identify when the thawing meats were pulled and when to be used. If not, the thawing meats may pass the used by date and not safe to use. A review of departmental policy and procedure, titled Procedure for Refrigerated Storage, dated 2023, it indicated, .Frozen food should be left in a refrigerator to thaw. Once thawed, uncooked meat is to be used with 2 days. The exception is cured meats, which are to be used within 5 days .Dating the packages or containers will facilitate this practice . 5. During an observation of the walk-in refrigerator on 11/13/23, at 10:27 a.m., there was a box that contained cartons of supplement drinks that did not have the date they were pulled out from the freezer or a use by date after being thawed. A concurrent review of the supplement shake's storage instruction, which was printed on the carton with the DM, it showed the shakes had to be stored frozen and once thawed in the refrigerator the shakes had to be used within 14 days. A concurrent interview with the DM, he stated he could not determine when the kitchen staff started thawing the shakes because they had no dates on them. He stated he was not aware the instructions indicated the shakes needed to be used by 14 days after being thawed. The DM agreed that the kitchen did not have a system to track the shakes and the staff should be trained about the tracking system with the pull-out date and used by date. During an interview with RD on 11/15/23, at 11:25 a.m., she stated the staff should put the pull-out date when they pulled out the supplement shakes from the freezer and the shakes had 14 days to store in the refrigerator for use after thawed. RD stated if the staff did not have a system for storage and handling the shakes, they could not track when they pulled them out, and when they could be used by. She added it could be food safety issue if the shakes still in use when they passed the 14 days of use. A review of departmental policy and procedure, titled Procedure for Refrigerated Storage, dated 2023, it indicated, .Supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. Follow the manufacturer's recommendation (specifications) for shelf life . 6. During an initial kitchen tour on 11/13/23, at 9:30 a.m., there were four individual ice cream cups found in the reach-in refrigerator with internal temperature of 36 degrees Fahrenheits (F) that were soft to touch. A concurrent confirmation with the RD, she stated the ice cream should not be stored in the refrigerator and should be stored in the freezer. During an interview with the DM on 11/13/23, at 10:55 a.m., he stated ice cream should be stored in the freezer and not in the refrigerator, and the ice cream should be solid and not soft to touch. He stated the soft ice cream should be discarded. A review of departmental policy and procedure, titled Procedure for Freezer Storage, dated 2023, it indicated, .Frozen food should be maintained at a temperature of zero-degree F or lower .Freezer Storage Guidelines .All foods which need to be kept in the freezer can be stored frozen .item: .ice cream . 7. During an observation on the initial tour in the kitchen, and concurrent interview with the DM on 11/13/23, at 9:13 a.m. there were the following items found stacked and stored wet in the ready-to-use storage areas: -six of full sheet metal trays -one insulated cover (food cover to maintain freshness and temperature) -one insulated base (food cover base to hold the food plate to help hold the temperature) -11 of one-sixth (1/6) sheet metal pans -four of one-fourth (1/4) sheet metal pans -four of one-half (1/2) sheet metal pans -five of full sheet metal pans The DM confirmed the metal pans were wet and stacked on top of each other. He stated all dishes/pots/pans should be completely dry before they were stored away. The DM stated dishes needed to be dry because the moisture from the wetness would promote bacteria. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the dishes/pots/pans should be completely dry before stored away and should not be wet because the moisture could promote bacteria growth. A review of an undated departmental policy and procedure, titled Dish Washing, it indicated, .Dishes are to be air dried in racks before stacking and storing . According to 2022 FDA Food Code, under section 4-901.11 Equipment and Utensils, Air-Drying Required, it stated, .Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow . 8. During the kitchen tour and a concurrent interview with a Dietary Aide (DA 1) regarding the manual dishware washing by the three-compartment sink was conducted on 11/13/23, at 9:50 a.m. The DA 1 stated she never performed the manual dishware washing with the three-compartment sink. She explained the process and stated there were sinks for washing, rinsing, and sanitizing. The DA 1 did not know what the water temperature of washing and rinsing should be, and the temperature of the sanitizing solution. She stated after washing and rinsing, she would immerse the dishes in the sanitizing solution for five to 10 minutes, and then air dried. She stated she would use the test strips to check the sanitizing solution and it should be at 200 ppm (parts per million, a unit to measure the solution concentration). During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the dietary aide who worked in a dishwashing position should have knowledge about manual dishwashing with a three-compartment sink in case the dishwashing machine was not working or there was a power outage. A review of department policy and procedure, titled 3-Compartment Procedure for Manual Dishwashing, dated 2023, it indicated, .The first compartment is for washing. Fill .with detergent .and hot water (110 degrees - 120 degrees F) .The second compartment is for rinsing .with clean, clear hot water, (110-120 degrees F) .The third compartment is for sanitizing. Fill .with .sanitizer. Test the concentration with the appropriate test strip, which is dipped in the sanitizer solution 10 seconds before reading .must read 150-400 ppm. Immerse all washed items for 60 seconds (one minute) . 9. During the follow up kitchen tour and concurrent interview regarding cooling down process of cooked (hot) food on 11/14/23, at 9:20 a.m. Cook 1 stated she did not do cool down for cooked food but sometimes they kept leftover food. She stated she would put the food in another pan and put in the refrigerator, and then checked if the temperature reached at 40 degrees F in two hours. Cook 1 stated she did not remember the proper process of cooked food cooling down and had the training or in-service a long time ago. During an interview with the RD on 11/15/23, at 11:25 a.m., she stated the Cook should have knowledge of the cool down process of cooked food. A review of departmental policy and procedure, titled Cooling and Reheating Potentially Hazardous Foods, dated 3/2013, it indicated, Cooked potentially hazardous foods shall be cooled and reheated in a method to ensure food safety .when potentially hazardous cooked food will not be served right away it must be cooled as quickly as possible .The Two-Stage Method .cool cooked food from 140 degrees F to 70 degrees F within two hours .then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours .During the cooling process .measure the internal temperature of the food .note menu item, date, time, temperature and cook's initials on the Cool Down Log .

Based on observation and interview, the facility failed to provide a clean environment for the residents and visitors when one out of four garbage disposal bins, located outside by the kitchen, was overflowing with bags of trash and was not securely closed. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During an initial tour observation of the kitchen and a concurrent interview with the Registered Dietitian (RD), on November 13, 2023, at 10:32 a.m., one dumpster garbage bin located just outside the facility kitchen was not securely closed by the lid, and there were bags of trash that were overflowing on top of the bin. In addition, the lid was deformed (bent) which prevented it to completely closed. The RD confirmed and stated the trash should not be overflowing and the lid should completely closed. A review of undated facility policy and procedure, titled Miscellaneous Areas: Garbage and Trash, it stated, .All Food waste must be placed in sealed containers .The trash collection area is a potential feeding ground for vermin and rodents .if a commercial rubbish service is used, arrangements must be made for periodic exchange of trash bins . According to Federal Food Code 2022, section 5-501.15 Outside Receptacles, it indicated the receptacles (containers) and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment must be designed and constructed to have tight-fitting lids, doors, or covers.

Based on observation, interview, and record review, the facility failed to ensure proper storage, handling, and labeling of respiratory care equipment consistent with the facility's policy and procedures (P&P) for three out of 19 sampled residents when: 1. Resident 294's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was left wrapped around Resident 294's bed rail while not being used and was not labeled with the date it was first used; 2. Resident 47's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing was left on top of the nebulizer machine after use and was not labeled with the date it was initially used; 3. Resident 15's nasal cannula was not placed in an infection control pouch and observed touching the floor when oxygen was not in use. These failures had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 294 and Resident 15, and aerosol medication to Resident 47. Findings: 1. A review of Resident 294's clinical record indicated Resident 294 was admitted Spring of 2023 and had diagnoses that included congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of your body) and shortness of breath. A review of Resident 294's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 9/22/23, indicated Resident 294 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 294 had intact cognition. A review of Resident 294's MDS Health Conditions, dated 9/22/23, indicated Resident 294 had shortness of breath or trouble breathing with exertion such as walking, bathing, and transferring, and when lying flat. A review of Resident 294's MDS Special Treatments, Procedures, and Programs, dated 9/22/23, indicated Resident 294 had oxygen therapy while she is a resident in the facility. During a concurrent observation and interview on 11/13/23 at 8:50 a.m. with Resident 294 in Resident 294's room, Resident 294's nasal cannula was observed wrapped around the bed rail of Resident 294's bed while not being used. Resident 294's nasal cannula was also not labeled with the date of when it was first used. Resident 294 confirmed the observation. Resident 294 stated the last time she used her oxygen and nasal cannula was last night and she could not remember when the last time it was changed. During a concurrent observation and interview on 11/13/23 at 8:54 a.m. with Certified Nurse Assistant (CNA) 2 in Resident 294's room, CNA 2 confirmed that Resident 294's nasal cannula was left wrapped around Resident 294's bed rails while not in use and was not labeled with the date it was first used. CNA 2 stated the nasal cannula should be put inside a bag when not being used. CNA 2 further stated, .It [nasal cannula] should be labeled with the date it was first used because its only good for a certain amount of time .If it's not labeled, then we don't know how long it has been used or when to change it It's a risk for contamination and spread of infection. A review of Resident 294's active physicians' order, dated 10/12/22, indicated, O2 [oxygen] @ [at] 2L/min [2 liters per minute- unit of measurement for oxygen administration] via NC [nasal cannula] PRN [Pro Re Nata- as needed] for SOB [shortness of breath] every shift. A review of Resident 294's active physicians' order, dated 1/16/23, indicated, Change Nasal Cannula. every day shift every Wed [Wednesday] AND as needed. During an interview on 11/16/23 at 9:17 a.m., with the Assistant Director of Nursing (ADON), the ADON stated oxygen tubing and nasal cannula should always be placed inside a bag when not being used and should always be dated of when it was first used. The ADON further stated, .the risk [if nasal cannula is not properly stored and labeled] are infection control issues .we will not be able to track how long has it been used and when to change it .the nasal cannula will be exposed to germs which could lead to respiratory problems . A review of the facility's P&P titled, Respiratory Therapy including Oxygen Labeling, revised 11/2021, indicated, .Infection Control Considerations Related to Oxygen Administration .3. Change the oxygen cannula and tubing every seven (7) days, or as needed. 4. Keep the oxygen cannula and tubing used PRN in infection control pouches when not in use . 2. A review of Resident 47's clinical record indicated Resident 47 was admitted Winter of 2023 and had diagnoses that included congestive heart failure, chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), and atelectasis (the collapse of a part or of all part of a lung causing blockage of airflow). A review of Resident 47's MDS Cognitive Patterns, dated 9/5/23, indicated Resident 47 had a BIMS score of 15 out of 15 which indicated Resident 47 had intact cognition. A review of Resident 47's MDS Health Conditions, dated 9/22/23, indicated Resident 294 had shortness of breath or trouble breathing when lying flat. During a concurrent observation and interview on 11/13/23 at 9:29 a.m., with Resident 47 in Resident 47's room, Resident 47's nebulizer mouthpiece and tubing was observed left on top of the nebulizer machine which was placed on top of Resident 47's nightstand. Resident 47's nebulizer mouthpiece and tubing were also observed not labeled with the date it was initially used. Resident 47 confirmed the observation. Resident 47 stated he used the nebulizer yesterday and he does not think they had been putting it inside a bag after use. Resident 47 further stated, .I've been using it for at least 2 months, and I don't think they ever changed it . During a concurrent observation and interview on 11/13/23 at 9:33 a.m., with Licensed Nurse (LN) 6 in Resident 47's room, LN 6 confirmed that Resident 47's nebulizer mouthpiece and tubing was left on top of the nebulizer machine after use and was not labeled with the date it was initially used. LN 6 stated the nebulizer mouthpiece and tubing should be placed in an antimicrobial bag after use and should be labeled with the date it was initially used. LN 6 further stated, the risk [if the nebulizer mouthpiece and tubing was not stored and labeled properly] is that it can get confused with other residents tubing .It's a risk for growing of bacteria, cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), and we would not know when it was first used and when to change it . A review of Resident 47's active physicians' order, dated 10/24/23, indicated, Albuterol Sulfate Inhalation Nebulization Solution [a liquid medicine used to prevent and treat difficulty breathing, shortness of breath, coughing, and chest tightness caused by lung diseases which is administered via nebulizer] (2.5 MG [milligrams- unit of measurement/3ML [milliliters- unit of measurement]) .3 ml inhale orally via nebulizer every 8 hours as needed for SOB [shortness of breath] and wheezing [a high-pitched whistling sound during breathing indicative of airway obstruction] . During an interview on 11/16/23 at 9:17 a.m., with the ADON, the ADON stated she expects nebulizer mouthpiece and tubing to be also treated like the other respiratory care equipment. The ADON further stated, .I expect it [nebulizer mouthpiece and tubing] to be clean, as clean as possible .it should also be bagged after use to prevent exposure to germs and be labelled with the date it was first used so we know when to change it .if not, it could lead to complications and possible respiratory problems . A review of the facility's P&P titled, Respiratory Therapy including Oxygen Labeling, revised 11/2021, indicated, .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 1. Mouthpiece to be stored in infection control pouch when not in use. 2. Discard the administration set-up every seven (7) days. 48445 3. During a review of Resident 15's clinical record, the record indicated Resident 15 was admitted to the facility in June of 2023 with multiple diagnoses which included chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), anxiety disorder (significant and uncontrollable feelings of anxiety and fear), post-traumatic stress disorder (difficulty recovering after experiencing or witnessing a terrifying event), and shortness of breath. A BIMS, dated 10/18/23 indicated, Resident 15 was cognitively intact. During a review of Resident 15's physician order, dated 7/20/23, the order indicated, Oxygen @ [at] 2-4 liters/min [minute] via nasal cannula for respiratory comfort . During an observation on 11/13/23 at 10:45 a.m., in Resident 15's room, oxygen was observed turned on while not in use, set to 2 liters per minute, and the nasal cannula tubing was observed touching the floor. During a concurrent observation and interview on 11/13/23 at 11:05 a.m., with LN 6, LN 6 stated Resident 15 uses oxygen as needed. LN 6 confirmed that oxygen was turned on and the nasal canula tubing was on the floor. LN 6 was observed asking Resident 15 if the oxygen was needed and Resident 15 said no. LN 6 was observed turning off the oxygen and placing the nasal canula in the black pouch. LN 6 stated, It should not touch the floor, germs and bacteria on the floor are introduced to his nose and cause illness, if it touched the floor, we need to change it. During an interview on 11/14/23 at 10:25 a.m., with the Infection Preventionist (IP), the IP stated, Nasal cannula should be placed in black pouch when not in use. When asked about the cannula touching the floor, the IP stated, Change it immediately and label it with date. It can cause respiratory infection, hypoxia. During an interview on 11/15/23 at 1:12 p.m., with the ADON, when asked about the expectation on the nasal cannula touching the floor, the ADON stated, We are going to change it right away. Supposed to be in the bag and the oxygen turned off. That's very germy. It might touch the floor if not in the pouch. During a review of the facility's P&P titled, Respiratory Therapy including Oxygen Labeling, dated 11/21, the P&P indicated, Infection Control Considerations Related to Oxygen Administration .4. Keep the oxygen cannula and tubing used PRN in infection control pouches when not in use .

Based on observation, interview, and record review, the facility failed to document the opening of an Emergency kit ([E-Kit], a limited supply of medications in the facility to use during an emergency or after-hours) for a census of 83 residents. This failure had the potential to delay the replacement of the E-Kit and contribute to decreased availability of medications in an emergency. Findings: During a concurrent observation and interview on 11/13/23, at 9:57 a.m., with the Assistant Director of Nursing (ADON) in the Medication Storage Room, E-Kit 13 was observed to have been opened. The ADON stated she did not know when the E-Kit 13 was opened and therefore did not know when the E-Kit 13 should have been replaced. The ADON confirmed the opening of the E-Kit 13 was not logged in the E-Kit log book. The ADON stated all medication bottles were present in the E-Kit but acknowledged the E-Kit should be replaced within 72 hours after opening. During a review of the facility's policy and procedure (P&P) titled, Emergency Kits, dated 12/22, the P&P indicated, .opened kits are replaced with sealed kits within 72 hours of opening.

Based on interview, record review and policy and procedure review, the facility failed to ensure one of three sampled residents (Resident 1) was free of accident hazards when Resident 1, who had an order to not be fed any food or water by mouth (NPO), was given a meal tray. This failure resulted in Resident 1 to choke evidenced by coughing, labored breathing, and low oxygen levels. He was subsequently transferred to the hospital and passed away. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and had a Gastrotomy Tube (G-Tube, a tube inserted through the stomach that brings nutrition, hydration, and medications). Review of Resident 1's Order Summary Report, revealed an order dated [DATE] for NPO diet. Review of Resident 1's Nutritional Risk Assessment (Admission/Annual)-V 3.0, dated [DATE], the assessment indicated, Resident is strict NPO-nutrition through G-tube related to dysphagia from throat cancer. During a review of Resident 1's Progress Notes (PNs), dated [DATE] at 11:12 a.m., the PNs indicated at 8:30 a.m. Resident 1 was accidently served a breakfast tray while on NPO status. Resident 1 was observed coughing while eating the foods on his tray. The food tray was immediately removed. While continuing to monitor resident's condition, resident noted to be coughing out thick yellow mucus, having labored breathing, desatting (low oxygen level) at 89% on 3.5 L (liters) oxygen, BP (blood pressure) ,d+[DATE], HR (heart rate) 103, RR (respiratory rate) 24. Lungs sounds diminished, whooshing sounds noted bil (bilateral, both lungs). Attending physician was notified of Resident 1's symptoms and an order was received to transfer Resident 1 to the hospital. Review of Resident 1's Hospitalist Admission History & Physical, dated [DATE], indicated, Chief Complaint: Cough and shortness of breath patient had an aspiration event today at the skilled nursing facility was sent in for choking. Patient was sent in by the local skilled facility because of a choking event. Patient does have cough and congestion . Under the section Assessment & Plan indicated Aspiration pneumonia (a lung infection that develops after you inhale food, liquid, or vomit into your lungs) of both lungs, unspecified aspiration pneumonia type, unspecified part of lung/acute hypoxic (absence of enough oxygen) respiratory failure . During a review of Resident 1's hospital Discharge Summary, dated [DATE] indicated, Discharge Diagnosis: Acute on chronic respiratory failure aspiration pneumonia. The Discharge Summary indicated, Patient was treated with antibiotics and diuretics (medicines that help reduce fluid buildup int the body). He did not improved (sic). Patient started requesting AIM (Advanced Illness Management-hospital based Palliative Care team) consultation .Patient was made DNR (Do Not Resuscitate). Subsequently to which patient has progressively gotten worse . Resident 1 expired on [DATE] at 2:38 p.m. During an interview on [DATE] at 9:48 a.m., with the Director of Nursing (DON), The DON stated Resident 1 was given a breakfast tray by accident by Certified Nursing Assistant (CNA) 1. A nurse was walking by and noticed Resident 1 was coughing while eating his breakfast and immediately removed the tray. The DON confirmed Resident 1 had a diet order of NPO. The DON stated an investigation was conducted and it was determined that Resident 1 was asking for food. CNA 1 proceeded to the kitchen to get Resident 1 a breakfast tray. The DON stated this is not the facility ' s protocol. If a resident doesn't have a meal tray, the CNA should have informed the nurse. The nurse is then to print out the diet order and bring the printed-out order to the kitchen. The DON stated nurses are to check meal trays before they are to be delivered to the residents. During a telephone interview on, [DATE] at 10:15 a.m., with CNA 1, she confirmed she worked the a.m. shift on [DATE]. CNA 1 stated she noticed Resident 1 did not get a tray. CNA 1 stated she then proceeded to the kitchen to get a meal tray for Resident 1. CNA 1 stated she received a regular diet, meal tray for Resident 1. She took the meal tray to Resident 1 and placed it within reach of Resident 1. CNA 1 confirmed, upon coming onto her shift, she had received report from the night CNA but was not told Resident 1 was NPO. CNA 1 also confirmed the a.m. LN did not inform her that Resident 1 was NPO. CNA 1 stated she was not aware of any facility practice that LNs check trays on the floor before CNAs start passing them to the residents. During a review of the facility's policy and procedure (P&P) titled, NPO Orders, revised [DATE], the P&P indicated, A resident's food tray shall be held as necessary to perform a test or treatment ordered by the Attending Physician. The Nursing staff will use the diet change notification form to notify Food Services staff when it is necessary to hold a resident's food tray, and also when the tray delivery can resume. During a review of the facility ' s P&P titled, Tray Identification, revised [DATE], the P&P indicated, Nursing staff shall check each food tray for the correct diet before serving the residents.

Based on interview and record review, the facility failed to ensure one resident (Resident 1) in a sample of three was free from physical abuse when a resident (Resident 2) with known aggressive behaviors walked over to Resident 1, grabbed for his arm and scratched him. This failure resulted in two skin tears on Resident 1's arm, which required treatment, and increased the risk of Resident 1 experiencing a decline in his emotional wellbeing. Findings: Review of an Admission Record indicated Resident 1 was admitted to the facility in December 2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's Admission Record indicated she was admitted to the facility in August 2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (an assessment tool) dated 3/20/20, indicated Resident 2 required supervision, defined as oversight, encouragement or cueing, when walking with a walker. Review of Resident 2's medical record revealed the following: A care plan for physically combative behavior, created on 1/22/20, indicated Resident 2 had a HX [history] of Recent Episodes Of Being Physically/Combative Abusive Such As: Striking Out, Grabbing at staff . The care plan's long-term goal indicated Resident 2 would not harm herself or others. The care plan had approaches, which included, Ensure distance in seating other residents around [Resident 2] .Observe whether the behavior endangers the resident and/or others. Intervene if necessary: Removing others from the surrounding Area .Remove resident from group activities when behavior is unacceptable . A physician order, dated 1/22/20, indicated, Monitor Episodes of Mood Disorder with behavioral issues: hitting, pinching, scratching .Every Shift . A physician order, dated 3/24/20, indicated, Merry Walker [a walker/chair combination ambulation device] .to aide in safe and independent mobility. A nursing progress note, dated 4/21/20, at 12:46 p.m., indicated, At apprx [approximately] 1000 [10 a.m.], [Resident 2] was walking in hallway in merry walker when she approached another resident [Resident 1] and grabbed his arm in attempt to scratch .[Resident 2] has been physically aggressive with staff with behaiovrs (sic) [behaviors] of hitting, pinching, scratching and cursing .[Resident 2] continues to be aggressive. A document titled, Behavior Monitoring Administration History, for April 2020, indicated nurses documented the number of episodes Resident 2 had behavioral issues of hitting, pinching, or scratching per shift. The record indicated Resident 2 had 38 episodes between 4/1/20 to 4/21/20, and 22 episodes from 4/22/20 to 4/30/20. Review of Resident 1's medical record revealed the following: A nursing note dated 4/21/20, at 12:44 p.m., indicated, At apprx 1000, [Resident 1] was sitting in wheelchair in middle of hallway when another resident [Resident 2] who was agitated, walked past him and grabbed his arm. [Resident 2] was attempting to scratch [Resident 1] .[Resident 1] sustained 2 skin tears to left forearm due to incident. PA [Physician Assistant] notified, cleanse w/ [with] NS [normal saline], pat dry and apply steri strips. Change prn [as needed] . During an interview with Licensed Nurse (LN) 1 on 5/21/21, at 2:10 p.m., LN 1 stated Resident 2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with LN 2 on 5/21/21, at 2:35 p.m., LN 2 stated she was the nurse on duty who responded to the altercation between Resident 1 and Resident 2 on 4/21/20, and stated she remembered Resident 1 got skin tears from the altercation. LN 2 stated Resident 2 wandered around independently throughout the facility and moved fast. LN 2 stated [Resident 2] would lock eyes on someone and would go after them to try to hurt them. LN 2 stated the staff tried to monitor her and divert her attention away from others to prevent her from hurting other residents. Review of a facility policy and procedure titled, Preventing Resident Abuse, dated 1/11, indicated, Our facility will not condone any form of resident abuse .The facility's goal is to achieve and maintain abuse-free environment.

Based on interview and record review, the facility failed to ensure one resident (Resident 1) in a sample of three was free from physical abuse when Resident 1's roommate (Resident 2) walked over to Resident 1's bed and hit him in the face. This failure resulted in physical injury to Resident 1 whereby he developed a red, swollen mark on his left cheek, and increased the risk of Resident 1 experiencing a decline in his emotional wellbeing. Findings: Review of the Admission Record indicated Resident 1 was admitted to the facility in the spring of 2019 with diagnoses, which included a stroke resulting in paralysis (inability to move) of his left arm and left leg. A Minimum Data Set (MDS, an assessment tool) dated 3/9/20, indicated Resident 1 required extensive assistance to move in bed, and to transfer from his bed to his wheelchair. Resident 2's Admission Record indicated he was admitted to the facility in the spring of 2020. A MDS dated [DATE], indicated Resident 2 required supervision, defined as oversight, encouragement or cueing, when moving in and out of bed, and walking with a walker. Review of Resident 1's medical record revealed the following: A nursing progress note dated 3/28/20, at 10:50 p.m., indicated Resident 1 and Resident 2 had an altercation. The note indicated Resident 1 stated Resident 2 punched him in his left eye, and the nurse noted slight puffiness under Resident 1's left eye. A document titled Event Report, dated 3/29/20, at 1:25 a.m., indicated Resident 1 was in an altercation with his roommate (Resident 2), and that he was injured during the altercation. The report indicated Resident 1's injury as a red [NAME] [a red, swollen mark left on flesh by a blow or pressure] left cheek. A nursing progress note dated 3/29/20, at 4:34 a.m., indicated, [Resident 1] has slight swelling to right [sic] cheek below right [sic] orbit [eye socket] with ice applied as tolerated by resident. A review of a facility provided document dated 3/29/20, included nursing documentation on observations, beliefs, and statements made by Resident 1 and Resident 2. The nurse's documentation indicated the nurse found Resident 1 and Resident 2 in their shared room. The document indicated that Resident 1 stated Resident 2 hit him on the left side of his face, and that Resident 2 initially denied hitting Resident 1 but then stated he did slap Resident 1. The nurse's documentation indicated the nurse noted a red [NAME] on Resident 1's left cheek. During an interview with Resident 1, on 3/29/21, at 12:25 p.m., Resident 1 stated he had a stroke over a year ago and could not walk because he was unable to move his left arm and leg. Resident 1 stated he remembered the altercation he had with Resident 2 on 3/28/20. Resident 1 stated Resident 2 said things to him that day that he did not like, so he called him an expletive name. Resident 1 stated Resident 2 walked over to his bed and punched him on his left cheek. During an interview with Licensed Nurse (LN) 1, on 3/29/21, at 1:15 p.m., LN 1 stated she was the nurse on duty when Resident 1 and Resident 2 had their altercation. LN 1 stated the roommates were not physically attacking each other when she entered the room, however, she found the two residents appeared amped up. LN 1 stated she observed a red mark on Resident 1's cheek. During a concurrent interview and document review with the facility administrator (ADM), on 4/6/21, at 3:10 p.m., the ADM reviewed the nursing documentation on the facility document dated 3/29/20. The ADM verified the document indicated the nurse noted a red [NAME] on Resident 1's left cheek. The ADM stated he considered a red [NAME] a physical injury. During an interview with Certified Nurse Assistant (CNA) 1, on 4/7/21, at 11:30 a.m., CNA 1 confirmed she was the CNA who reported the altercation between Resident 1 and Resident 2 to the nurse supervisor on 3/28/20. CNA 1 stated Resident 1 was bed-bound and only had the use of one arm, and Resident 2 walked independently with the use of a cane. CNA 1 stated, prior to the altercation, she was in the room getting Resident 1 ready for bed. Resident 2 was on his own side frequently interrupting the conversation between CNA 1 and Resident 1. CNA 1 told Resident 2 to wait his turn, to which Resident 2 replied, Resident 1 never knew when to be quiet. CNA 1 left the room to gather additional supplies. When she returned, she found the door closed and the light inside the room was off. CNA 1 stated, when she turned the light on, she saw the room in disarray; Resident 1's rolling side table was half flipped over with his items all over the bed and floor. CNA 1 stated Resident 1 had coffee spill over his chest area. CNA 1 stated she saw Resident 2 pacing the room on his toes and was bouncing like a boxer during a fight. CNA 1 stated Resident 1 looked roughed up and was wide-eyed. CNA 1 stated she noted a red mark appearing on Resident 1's cheek. CNA 1 stated she left the room to get the nurse supervisor. CNA 1 stated, on their return, the nurse supervisor did her assessment and investigation. CNA 1 stated, Resident 2 admitted to her and the nurse supervisor that he hit Resident 1 on the left side of his face. Review of a facility policy and procedure titled, Preventing Resident Abuse, dated 1/11, indicated, Our facility will not condone any form of resident abuse .The facility's goal is to achieve and maintain abuse-free environment.