**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one resident (Resident 26) out of a census of 137 was protected from abuse when Resident 26 slapped Resident 52 on the right side of her face.This failure had potential to result in physical injury for Resident 52.During a review of Resident 52's clinical record, the record indicated Resident 52 was admitted in April of 2025, with a diagnosis of Dementia (a decline in mental ability severe enough to interfere with daily life). A review of Resident 52's Medical Data Set (MDS, a federally mandated resident assessment tool), dated 6/4/25 indicated the resident had severe cognitive impairment. During a review of Resident 52's progress noted dated 8/16/25, the note indicated, . a CNA [Certified Nursing Assistant] looked up to see [Resident 26] slap [Resident 52] across the right side.During a review of Resident 26's clinical record, the record indicated Resident 26 was admitted in November of 2024, with a diagnosis of dementia. A review of Resident 26's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment. During a review of Resident 26's progress note dated 8/15/25, the note indicated, . [Resident 26] was standing in the room close to the outside door to the courtyard. Another resident [Resident 52] . was rattling to open it. A CNA looked up to see [Resident 26] slap [Resident 52] across the right side of her face.During a telephone interview 8/20/25 at 9:28 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 confirmed she was a witness to the altercation between Resident 26 and 52. CNA 2 stated, .At first, I had my back turned. I didn't see (Resident 26) go outside. (Resident 52) was rattling the door to get it open . and I turned around and I saw (Resident 26) slap (Resident 52) in an instant.During a telephone interview on 8/20/25 with Licensed Nurse 1 (LN 1), LN 1 stated . I was called in and [CNA 2] told me [Resident 52] was standing at the door outside . was rattling it and [Resident 26] was close by and when [Resident 52] was rattling the door in her chair [Resident 26] was standing there and he spontaneously slapped [Resident 52] across the face. LN 1 further stated Resident 26 did abuse Resident 52 and abuse was not tolerated in the facility. During an interview on 8/20/25 at 1:09 p.m. with Director of Nursing (DON), the DON confirmed Resident 26 did harm Resident 52 and residents in the facility should not be hitting or slapping each other. During a review of facility Policy and Procedure (P&P) titled Abuse. dated April 2025, the P&P indicated, .Each. resident has the right to be free from abuse. this includes. physical . Residents must not be subjected to abuse by anyone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a significant change in status assessment (SCSA- an assessment to reflect a major decline or improvement in the resident's status) was completed for one of 36 sampled residents (Resident 129) when Resident 129 was enrolled in a hospice program (compassionate care for people who are near the end of life provided within a health care facility). This failure increased the potential for plan of care not to be updated to meet the current needs for Resident 129. A review of the admission Record indicated Resident 129 was admitted [DATE] with diagnoses including frontotemporal neurocognitive disorder (group of brain disorder leading to significant changes in behavior, movement, language and personality) and major depressive disorder (persistent feeling of sadness and loss of interest in activities). A review of Resident 129's physician order revised 2/28/25 indicated, Terminal care via [name of hospice program] with prognosis of 6 month [sic] or less related to End Stage Alzheimer's Disease [a disease characterized by a progressive decline in mental abilities]. A review of Resident 129's 'Medical Director Certification of Terminal Illness' document indicated, . [Resident 129] is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. The Initial certification period was from 2/22/25 to 5/22/25. A concurrent interview and record review was conducted on 8/21/25 at 10:16 a.m. with the Minimum Data Set Coordinator (MDSC). The MDSC reviewed the physician's order and confirmed Resident 129 was admitted to hospice end of February and a SCSA was not completed. The MDSC stated she should have done a SCSA in March. In an interview on 8/22/25 at 11:32 a.m., the Director of Nursing (DON) stated if a resident was admitted to hospice a SCSA should be completed. A review of the facility's policy and procedure effective 8/1/18 and titled, Significant Change MDS indicated, Residents are assessed, using a comprehensive assessment process, in order to identify care needs .when significant change is identified .Significant Change in Status Assessment (SCSA) - a comprehensive assessment completed within 14 days of the identification of a status change . A SCSA is required when a resident enrolls in a hospice program . and remains in the facility .

Based on observation, interview and record review, the facility failed to ensure professional standards of care were followed for two of 36 sampled residents (Resident 116 and Resident 47), when:1. The nurse did not document an assessment of Resident 116's mid-upper arm for proper Peripherally Inserted Central Catheter (PICC) line management per physician order; and 2. The facility altered Resident 47's Insulin administration record. These failures had the potential to negatively affect Resident 116's and Resident 47's health and their ability to achieve their highest practical well-being due to not receiving treatment and services in a timely manner and inaccurate medical information. Findings A review of Resident 116’s medical record indicated Resident 116 was admitted to the facility in June of 2025 with diagnoses of Infection and Inflammatory reaction due to Internal Right Knee Prosthesis (a surgical procedure to implant an artificial body part) and Type Two Diabetes (a chronic disease where the body doesn’t produce enough insulin to maintain normal blood sugar levels). Resident 116’s Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 116 had no cognitive impairment. During an observation and interview on 8/19/25 at 11 a.m. with Resident 116, Resident 116 was observed to have a dressing, on her right upper arm. Resident 116 stated that she had a PICC line in her right arm. A review of Resident 116’s Physicians’ order dated 7/23/25 indicated an order to “…measure and document every evening shift [sic] Thursday…mid-upper arm…document circumference weekly…” During an interview and concurrent record review on 8/22/25 at 11:50 a.m. with Director of Nursing (DON), the DON confirmed that the physician’s order for Resident 116 was to “…measure and document every evening shift [sic] Thursday…mid-upper arm…document circumference weekly…”. The DON confirmed that the MAR/TAR (medication administration record/treatment administration record) for Resident 116 was missing a signature on 8/21/25. The DON verified that the box with a missing entry was where the nurse was to document that the mid-upper arm was measured. The DON stated her expectation of nurses for following physician orders and documentation was, I expect them to complete the task and sign off that they did it. The DON confirmed that missing a measurement of an arm with a PICC line could result in potential harm to the resident. During an interview and concurrent record review on 8/22/25 at 3 p.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed the current physician’s order for Resident 116 was to “…measure and document every evening shift [sic] Thursday…mid-upper arm…document circumference weekly…”. When LN 1 was asked what it meant if the MAR/TAR had a missing box under a date? LN 1 stated, “…If it is not signed, it is not done…”. When LN 1 was asked, what are the potential complications of not measuring a residents PICC line arm? LN 1 stated, “…You could have swelling [sic], which could mean that there is a dislodge of the catheter and leak of fluids into the surrounding tissues…”. LN 1 confirmed that missing a measurement of an arm with a PICC line could result in potential harm to the resident. A review of the facility’s Policy and Procedure (P&P) titled, “Peripherally Inserted Central Catheter (PICC) And Midline”, the P&P indicated, “…Upper arm circumference should be measured on admission and weekly to monitor for infiltration…” A review of Resident 47's admission Record indicated the facility admitted Resident 47 to the facility in 2022. Resident 47’s diagnoses included type I diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) with ketoacidosis (DKA, a life-threatening complication of DM when resident's blood sugar is high and the body does not have enough insulin and starts burning fat, which creates ketones (acids) leading to acid build up in the blood). A review of Resident 47’s clinical records contained a physician order to administer Tresiba (long-acting insulin used to manage high blood sugar), 16 units, (unit of measurement), subcutaneously (SQ, injection given in the fatty tissue, under the skin) once a day for DM. A review of Resident 47’s care plan dated 3/3/22 indicated the resident had diagnosis of diabetes mellitus. The care plan goal indicated the resident will have no complications related to diabetes. The nursing interventions included to monitor resident’s blood sugar and administer diabetes medications as ordered by physician. A review of the Medication Administration Record (MAR) for July 2025 indicated Resident 47 did not receive Tresiba insulin on July 22 and July 30. During concurrent interview and record review on 8/21/25 at 2:25 p.m., DON confirmed Resident 47 did not receive Insulin on 7/22/25 and 7/30/25 scheduled to be administered at 8 p.m. The DON searched Resident 47’s nursing progress notes and was unable to find any documentation why it was not administered. The DON validated that due to Resident 47’s history of ketoacidosis, the resident was at increased risk of high blood sugar which had the potential to affect the resident’s safety. A copy of Resident 47’s MAR for July was provided for Department on 8/22/25 at 9:37 a.m. The MAR showed that Licensed Nurse (LN 11) documented that Tresiba Insulin was administered to Resident 47 on 7/22/25 and 7/30/25. During a follow up interview with DON and Assistant of Director of Nursing (ADON) on 8/22/25 at 11 a.m., the DON reviewed Resident 47’s MAR for July and acknowledged that the MAR showed that the resident received Tresiba Insulin on 7/22/25 and 7/30/25 contrary to what was documented the day prior. The DON validated that Resident 47’s MAR for July previously indicated that on 7/22/25 and 7/30/25 the resident missed 2 doses of important medication. The DON acknowledged that “someone documented” that the insulin was administered on 7/22/25 and 7/30/25. The DON explained facility’s policy, “Document immediately after medication [was] administered. If documenting later, the progress note should follow up and indicate that medication was administered and not documented.” The ADON explained that when she was preparing to print Resident 47’s records per Department request, she noticed two blank spaces on 7/22/25 and 7/30/25 which indicated that insulin was not administered. The ADON stated she questioned LN 11 why the Insulin administration was not documented as given. ADON added further, “I pointed to empty spaces [on 7/22/25 and 7/30/25] and she [LN 11] must have documented” later. The DON stated that when the staff needed to revise or add missed documentation at later dates, there should be documentation in nursing progress notes explaining ‘late charting.’ The ADON searched Resident 47’s record and was unable to find late charting notes. The DON acknowledged that the facility did not follow the process of late documentation. During a phone interview with LN 11 on 8/22/25 at 12:50 p.m., LN 11 confirmed that she “corrected 7/22/25 and 7/30/25 Resident 47's Medication Administration Record. LN 11 explained, “I always administer Resident 47’s insulin, but sometimes I forget to document that it was given.” LN 11 added further, “When [ADON’s name] asked why the insulin administration was not documented, I went in and documented.” The LN 11 was asked the facility’s process for late documentation, and LN 11 initially stated, “I don’t know, I never miss charting.” LN 11 then added, “If I have to go in and document late charting, a late entry should be added.” LN 11 acknowledged that there was no late entry added in resident's progress notes on 8/21/25 when she charted that Resident 47’s insulin was administered on 7/22/25 and 7/30/25. A review of the facility’s ‘Documentation in Medical Record’ policy dated 4/28/25 indicated, “Each resident’s medical record shall contain an accurate representation of the actual experiences of the resident and include… complete, accurate, and timely documentation… documentation shall be completed at the time of service but no later than the shift in which… care service occurred… documentation should be timely and in chronological order . When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as “late entry.”

Based on interview and record review, the facility failed to ensure one of 36 sampled residents (Resident 47) received treatment and care in accordance with professional standards of practice, when the facility did not follow physician's orders for insulin (a medication that lowers high level of glucose in the blood) and glucose gel (sweet liquid containing sugar used to quickly raise blood sugar), and did not monitor blood sugar as directed by physician on multiple occasions when Resident 47's blood sugar dropped to critically low levels. These failures increased the risks for Resident 47 for possible complications of hypoglycemia (when the blood sugar is lower than normal) and hyperglycemia (high blood sugar), which could affect resident's health and safety. Findings:A review of Resident 47's admission Record indicated the facility admitted Resident 47 to the facility in 2022. Resident 47's diagnoses included type I diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) with diabetic ketoacidosis (DKA, a life-threatening complication of DM when the body does not have enough insulin and starts burning fat which creates ketones (acids) leading to acid build up in the blood). A review of Resident 47's clinical records contained the following physician orders:FSBS (finger stick blood sugar) TID (three times a day) for DM;Tresiba (long-acting insulin used to manage high blood sugar), inject 16 units (unit of measurement) subcutaneously (SQ, injection given in the fatty tissue, under the skin) once a day for DM and,If FSBS is below 60, give 15-30 grams (gm, unit of measurement) of Glucose gel orally. Repeat FSBS in 15 minutes. Daily as needed. A review of Resident 47's care plan dated 3/3/22 indicated the resident had diagnosis of diabetes mellitus. The care plan's goal indicated the resident will have no complications related to diabetes. The nursing interventions included to monitor resident's blood sugar, administer diabetes medications as ordered by physician, monitor and document for side effects and effectiveness. A review of the Medication Administration Record (MAR) for July 2025 indicated Resident 47 did not receive Tresiba insulin on July 22 and July 30. A review of Resident 47's MARs indicated the resident experienced blood glucose below 60 on the following dates:On 7/1/25 at 6 a.m., FSBS was 45; the resident received Glucose gel, but the resident's blood sugar was not rechecked 15 minutes later per physician order;On 7/27/25 at 6 a.m., FSBS was 41; the resident received treatment for low blood sugar, but the resident's blood sugar was not rechecked 15 minutes later per physician order;On 8/8/25 at 6 a.m., FSBS was 59 and the resident was not given Glucose gel or other treatments as directed by physician. There was no evidence the residents FSBS was rechecked until 4 p.m.;On 8/12/25 at midnight FSBS was 39; the resident received treatment for low blood sugar, the nurse documented ‘effective,' but the resident's blood sugar was not rechecked 15 minutes later per physician order; On 8/15/25 at 6 a.m., FSBS was 58; the resident refused treatment for low blood sugar. The nurse administered snack and juice. There was no documented evidence that Resident 47's blood sugar was rechecked 15 minutes after the snack or at a later time. - During a concurrent interview and record review, commencing on 8/21/25 at 2:25 p.m., the Director of Nursing (DON) explained the process when the resident experienced low blood sugar. The DON stated the expectation was to administer Glucose gel or Glucagon injection if resident is unable to swallow and recheck blood sugar 15 minutes after the treatment was administered. Upon reviewing Resident 47's MAR, the DON acknowledged that the resident did not receive Tresiba insulin on 7/22/25 at 8 p.m., and 7/30/25 at 8 p.m. The DON searched Resident 47's nursing progress notes and was unable to find any documentation why it was not administered. The DON validated that due to Resident 47's history of ketoacidosis, the resident was at increased risk of high blood sugar which had the potential to affect the resident's safety. During continued interview and records review on 8/21/25 at 2:25 p.m., the DON validated that Resident 47's blood sugar was not rechecked 15 minutes after the resident received treatment for low blood sugar on 7/1, 7/27, and 8/12/25, or when the resident refused treatment on 8/15/25.The DON confirmed that on 8/8/25 at 6 a.m., Resident 47's FSBS was 59, which indicated it was critically low and there was no documented evidence the resident received treatment for low blood sugar or was offered snack or juice. The DON validated there was no follow up monitoring for low blood sugar for 10 hours after the resident experienced critically low blood sugar. The DON stated the resident should have received treatment for BS of 59, snack and her blood sugar rechecked but it was not done. The DON stated the physician order for Resident 47's low blood sugar was not followed. A review of the ‘Insulin administration/Finger Stick Blood Sugars & Glucagon' policy dated 4/17/24 indicated, A Licensed nurse will perform the finger stick blood sugars (FSBS) and administer the appropriate dosage of insulin as ordered by the Physician. All residents who are diabetic will be monitored for signs and symptoms of Hyper/Hypoglycemia. The policy directed staff to draw insulin as ordered and verify with another licensed nurse. Administer the insulin .Record dose given and site of injection .Residents who are experiencing. signs of.hypoglycemia will continue to be monitored until the resident is stable. If the resident does not respond to treatment within 5-15 minutes, the Hall Nurse will reevaluate the resident's condition; notify the physician.and document this in the resident's clinical chart. A review of the facility's policy titled, Medication Administration, dated 4/17/24 indicated, Medications shall be administered as ordered by a licensed nurse upon the order of a physician/licensed independent practitioner. The person administering the medication is responsible for the accuracy and correctness of the drug administered . The licensed nurse shall chart the drug, time administered with each medication administration on the electronic MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that pain management was provided, consistent with professional standards of practice for one of 36 sampled residents (Resident 122), when the resident received inadequate pain management and, when non-pharmacological (non-medication) interventions were not used in conjunction with pain medication administration to manage pain. This failure placed Resident 122 at risk for unmanaged pain that had the potential to affect resident's sleep and diminish the residents' quality of life.Findings:A review of the admission Record indicated the facility admitted Resident 122 in the spring of 2025 with multiple diagnoses which included chronic pain and depression. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 4/14/25 indicated Resident 122 was cognitively intact and had no hallucinations or delusions. Resident 122's Pain Interview assessment dated [DATE] indicated the resident experienced pain or hurting.almost constantly and rated her pain as 7 out of 10 (a scale from zero (0) to ten (10), when zero represents no pain and ten being the worst pain possible). When the resident was asked during the assessment How much of the time the pain made it hard for you to sleep at night, the resident replied, Almost constantly. A review of the clinical record for Resident 122 revealed:- A physician order dated 4/9/25 for Resident 122 indicated, Pain assessment every shift, Score 1-10 [0= no pain, 1 to 2= least pain, 3 to 4=mild pain, 5 to 6= moderate pain, 7 to 8=severe pain, 9 to 10=horrible, worst ever experienced.- A physician order dated 4/9/25 indicated to administer Tylenol 325 mg (milligram, unit of measurement), 2 tablet every 4 hours as needed for headache and pain. - A physician order dated 7/18/25, indicated to administer Norco 5-325 (a strong narcotic pain medication containing 5 mg of hydrocodone and 325 mg of acetaminophen known as tylenol). The order directed, Give 1 tablet by mouth as needed for chronic pain BID [twice a day] prn [as needed]. A review of the Resident 122's care plan titled The resident is on pain medication, initiated on 6/27/25, indicated that the resident's goal was to be free of any discomfort. One of the care plan approaches indicated to administer pain medications as ordered by physician. A review of physician progress note dated 8/12/25, indicated, Patient was admitted to the hospital.since readmission continues to c/o [complain] of pain in shoulder and knee [sic] is on Norco which will be continued. During an observation on 8/19/25 at 9:59 a.m., Resident 122 was sitting in the wheelchair in her room. Resident 122 explained that she had concerns with her pain management and frequently had to wait for a few hours to receive pain medication. Resident 122 added that by the time the nurses administered her pain medications, the pain was out of control. Resident 122 explained that she had chronic back pain and she was assured by her physician that she can receive pain medications twice a day as needed. Resident 122 continued, Every time I ask for pain medication, they say, You have already had it. No point of arguing with them.They don't give me pain killers every 12 hours. Even I'm in pain, I have to wait.I'm lucky if I get it [pain medication] once in 24 hours. Resident 122 further stated that sometimes she had hard time sleeping because of the pain. Resident 122 stated her pain was 4 at present because she had Norco earlier this morning, but normally the pain was 7 or 8. During an observation and on 8/20/25 at 9:55 a.m., Resident 122 was sitting in the wheelchair in her room. Resident 122 appeared tense. Resident 122 explained that earlier that morning she slipped from her wheelchair when she bent down to pick something from the floor. Resident 112 added, Hurt my ankle, its sore.Nobody asked me if I need pain pill.When I asked last night, they told me ‘It's not time. Resident 122 stated the pain was 4 as long as she did not move her leg but worsened on movement. A review of Resident 122's clinical records, including Medication Administration Record (MAR) indicated that there was no pain assessment completed since resident's fall and the last time the resident was medicated for pain was on 8/19/25 at 4:04 a.m., over 24 hours ago. A review of Resident 122's MAR from 8/1/25 through 8/20/25, indicated nursing staff consistently documented every shift that the resident's pain was 0 out of 10, except on 8/17/25 pain was documented as 6 out of 10 and on 8/20/25 pain was 2 out of 10. In addition, Resident 122's record did not contain non-pharmacological pain interventions (any physical or psychological approaches that do not involve medication, such as massage, heat, cold therapy, relaxation) were offered to resident in conjunction with pain medications. During an interview and concurrent record review on 8/20/25 at 10:20 a.m., Licensed Nurse (LN 2) stated Resident 122 was alert and oriented and able to verbalize her needs. LN 2 stated she normally assessed Resident 122's pain once in the morning during medication administration. LN 2 explained that if the resident took pain medication, she was to be reassessed for effectiveness one to two hours later. LN 2 stated that Resident had chronic pain and had order for Tylenol to be administered every 4 hours as needed for pain and Norco 1 tablet as needed for pain twice a day, which meant every 12 hours. LN 2 stated that order for Tylenol and Norco did not indicate the numerical pain scale when the pain medication should be administered, but normally Tylenol was administered for mild pain and Norco for severe pain. LN 2 explained that if Resident 122 had severe pain and it have been less than 12 hours since the last time the resident received Norco, the resident has to wait.If resident complains of pain, we can offer Tylenol. During a concurrent interview and record review with Director of Nursing (DON) on 8/21/25, at 2:25 p.m., the DON validated that Resident 122 had diagnosis of chronic pain. The DON stated that the shift pain assessment should reflect the highest pain level for the day which would help to determine if pain medication was effective or not. The DON reviewed Resident 122's clinical record and was unable to find that non-pharmacological interventions were offered to the resident in conjunction with pain medications. The DON stated that waiting one to two hours to reassess if pain medication was effective was too long and added that nurses were to reassess the resident 30-45 minutes after pain medication was administered, document the effectiveness in the progress notes, and notify the physician if the pain was not relieved. The DON acknowledged that Resident 122's order for Tylenol and Norco did not have the numerical pain rating scale and needed to be clarified with physician. Upon further review of physician order for Norco, the DON stated that the order BID and as needed was not clear and should be clarified with physician. A review of the facility's ‘Pain Management' policy with the last revision date of 1/30/25 indicated, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Based on observation, interview, and record review, the facility failed to implement an efficient process to accurately document and secure emergency medications (E-Kit) for a census of 137.This failure had the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.Findings:During an inspection of the Station 2 Medication Storage Room on 8/20/25 at 4:13 p.m. with Licensed Nurse 10 (LN 10), the E-Kit containing insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was observed inside the medication refrigerator with a red tag (indicating the E-Kit had been opened by the facility). The E-Kit logs inside indicated one vial of Humalog (insulin lispro, a fast-acting insulin) 100units/mL (milliliters, a unit of measurement) was removed on 8/7/25, and one vial Lantus (insulin glargine, a long-acting insulin) 100units/ml was removed on 8/14/25. LN 10 confirmed that the E-kit was opened on 8/14/25 and was not replaced. LN 10 confirmed it was 6 days since the E-kit was opened and stated, .it takes longer for refrigerated ones [to get replaced] .During an interview on 8/22/25 at 2:15 p.m. with the Director of Nursing (DON), when pictures of the E-kit were shown, the DON confirmed the E-kit was opened and the last slip was 8/14/25 and stated, .The pharmacy should have sent it faster.Staff should have followed up on it.It should have been replaced timely. The DON stated it was important for the E-kit to get replaced timely because .we just need what need here and especially, it's for emergency.During a review of the facility's policy and procedure (P&P) titled Emergency Pharmacy Service and Emergency Kits, undated, the P&P indicated, .K. If exchanging kits, open kits are replaced with sealed kits within 72 hours of opening.

Based on interview and record review, the facility failed to ensure coordination of care between the hospice team (care designed to provide supportive care for physical, psychological, spiritual, and emotional needs to a terminally ill resident) and the facility for one of 36 sampled residents (Resident 133), when the resident's clinical records did not include hospice documents. This failure placed Residents 133 at risk for not receiving services necessary to promote comfort and quality of life. Findings:A review of ‘Inpatient Service Agreement' between the [name of the hospice agency] and facility, dated 11/16/2023 indicated the hospice and the facility will communicate with each other and document such communications to ensure that the needs of the patients are addressed and met 24 hours a day. The agreement policy indicated, The Hospice is providing the facility with a copy of the patient's plan of care [POC]. at the time of the patient's admission or as soon.as possible, and.specify the inpatient services to be furnished.The Hospice . patient's clinical record includes a record of all impatient services furnished.The FACILITY shall prepare and maintain medical records for each hospice patient.The medical record shall consist of progress notes and clinical notes describing all inpatient services.A review of the admission Record indicated the facility admitted Resident 133 in early 2025 with diagnoses which included dementia (decline in mental ability severe enough to interfere with daily functioning and life). A review of the physician order, dated 1/21/2025, indicated Resident 133 was admitted to the facility under hospice services with prognosis of 6 months or less related to dementia. A review of Resident 133's records, including paper chart located at the nursing station did not contain documents reflecting the care resident received from hospice agency. During a concurrent interview and record review on 8/19/25 at 12:15 p.m., Licensed Nurse (LN 3, a Nurse Coordinator) confirmed Resident 133 have been receiving hospice services since 1/21/25. LN 3 acknowledged that the special dedicated to hospice binder for Resident 133 had no hospice documents indicating coordination of care, except consent for hospice services. Upon reviewing Resident 133's clinical records, LN 3 confirmed Resident 133's clinical records contained no hospice POC, no visit schedule and no visit notes. LN 3 verified that hospice sheets with sign-in and visit log were blank. LN 3 stated, I don't understand why there are no [hospice] documents.Should be here under ‘Hospice' tab, but nothing here. LN 3 added, We don't know their [hospice staff] schedule or when they come, they just show up.When hospice nurses come, we discuss resident's care.Not sure about other staff who visits the resident. LN 3 was not able to explain the process of coordination of care between facility and hospice agency and stated the communication might not be documented. During an interview with LN 4 on 8/19/25 at 12:40 p.m., LN 4 stated she was not sure about visit schedule and what disciplines were assigned to resident receiving hospice services. LN 4 added that nurses usually visited hospice residents twice a week and they were checking with facility nurses when they came to visit. LN 4 reviewed Resident 133's chart and stated, We should have hospice records in paper chart or scanned into electronic chart, but I don't know why there are no hospice documents here.During a concurrent interview with the Director of Nursing (DON) and Assistant of Director of Nursing (ADON) on 8/21/25, commencing at 11:35 a.m., the DON stated there should be collaboration of resident's care between hospice and facility staff. The DON stated when residents received hospice services, the resident records should include a POC, a calendar showing hospice staff who were assigned to the resident, a log sheet for hospice staff to sign in to show the staff came in and visit notes where the staff document a summary of their visits. The DON stated these documents were important to ensure that Resident 133 received the necessary care and services consistent with hospice philosophy. The DON acknowledged that Resident 133's records and hospice binder did not contain Resident 133's Plan of Care and had none of the required documents. DON agreed that without communication notes from the hospice nurse, staff might not know the care needs of Resident 133 if there was improvement or decline. DON stated nursing supervisors were responsible for monitoring the hospice coordination of care and communication between hospice and facility staff regarding residents on hospice care.A review of the facility's ‘Hospice Services Facility Agreement' policy dated 5/29/25, indicated, It is the policy of this facility to provide.hospice services in order to protect a resident's right to a dignified existence, self-determination, and communication with.services inside and outside the facility. The policy explained that the facility will have a designated staff to be responsible for working with hospice representatives to coordinate care to the resident provided by facility and hospice staff.

Based on interview and record review, the facility failed to ensure the facility's Medical Director (MD) attended the Quality Assurance and Performance Improvement (QAPI, a program that helps healthcare facilities consistently evaluate and improve their services and improve the quality of life and quality of care for residents) committee meetings. This failure had the potential for the QAPI meetings to lack medical guidance for medical care concerns, lack quality care improvement activities, lack effective evaluation of the program resulting in negative outcomes and decline in quality of care for a census of 137 residents.During a concurrent interview and record review with the Administrator (ADM) and Director of Nursing (DON) on 8/22/25 at 2:10 p.m., the ADM stated that from January to May 2025 the facility held QAPI meetings monthly when they reviewed quality reports, identified the concerns with residents' care, discussed quality safety concerns, and ensured corrective actions were implemented. The ADM stated that the Medical Director (MD), who have been in the facility since January 2025, was a required member of the committee but he had not attended any of the QAPI meetings. A review of the QAPI Committee attendance sign-in sheet from 1/20/25 through 5/29/25 revealed the Medical Director's name was missing.The DON stated that the facility invited Medical Director to attend QAPI meetings, but every time they invited him, he declined stating he was too busy. The ADM added, We notify him verbally of all the issues encountered, prepare written report, but he never signed those reports acknowledging that he is aware of all the issues. The ADM further explained that the facility did not have the MD's designee to attend QAPI meetings in MD's absence. A review of the facility's Quality Assurance and Performance Improvement (QAPI) , implemented 4/28/2025 indicated, It is the policy of this facility to develop, implement, and maintain an effective.QAPI program.The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee.The QAA Committee shall be interdisciplinary and shall.consist at a minimum of.The Medical Director or his/her designee.

Based on observation, interview, and record review the facility failed to ensure the confidentiality of Identifiable information for a census of 137 residents, when residents' meal tickets with personal information were accessible to view by other residents and visitors.These failures decreased the facility's potential to protect residents' identifiable information.Findings:During an observation on 8/19/25 at 10:21 a.m. in the facility main dining room, the residents' breakfast trays being returned to kitchen were found unattended with meal tickets on them. Each meal ticket had resident's name, facility identification number, resident's colored photograph, room number, bed number and dining location in an easy to view status. Two people were observed entering the dining room.During a concurrent observation and interview on 8/19/25 at 10:30 a.m. with the Dietary Assistant 1 (DA 1), DA 1 was observed bringing residents' breakfast trays into kitchen and throwing meal tickets into a regular trash can while scraping the dishes. DA 1 stated that the trash bags were compacted at the compactor and then were throw away in a dumpster outside the kitchen.During an interview on 8/22/25 at 12:38 p.m. with the Registered Dietician (RD), the RD confirmed that the residents' meal tray tickets with residents' personal information were easily accessible to other residents and visitors. RD agreed disposing of the meal tickets to regular trash was not appropriate. RD stated the confidentiality of the residents' identifiable information was not protected.During a review of the facility's policy and procedure titled, HIPPA [Health Insurance Portability and Accountability Act - a federal law to protect the individually identifiable health information], revised on 4/17/2024, indicated, It is the policy of this facility to comply and protect resident information and to follow all HIPPA guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate assessments were completed for four of 36 sampled residents (Resident 9, Resident 98, Resident 129, and Resident 133) when: 1. Resident 9's Minimum Data Set (MDS- a federally mandated resident assessment tool) was incorrectly marked for invasive mechanical ventilator (a breathing machine connected to a tube inserted into the windpipe through the neck);2. Resident 98's MDS did not reflect the resident's terminal prognosis;3. Resident 129's MDS did not indicate resident was on hospice care; and, 4.Resident 133's MDS assessments were not consistent with resident's status. These failures increased the potential for residents not to receive consistent care.Findings: 1.A review of resident 9’s “admission Record,” dated 8/22/25, indicated Resident 9 was admitted to facility in January 2025 with the diagnoses including sleep apnea (a sleep disorder when breathing pauses repeatedly during sleep). Resident 9 had mental capacity to make own decisions. During a review of Resident 9’s “Order Summary Report,” dated 8/22/25, indicated that an order for C-Pap (a device that delivers a constant stream of pressurized air through a mask worn over the nose or mouth during sleep) was placed and initiated on 2/12/25, to be used at bedtime for sleep apnea. During a review of Resident 9’s “Minimum Data Set (a federal assessment tool), dated 6/9/25, indicated that Resident 9 had a special treatment via an invasive mechanical ventilator (a breathing machine connected to a tube inserted into the windpipe through the neck). During a concurrent observation and interview on 8/20/2025 at 4:17 p.m. with Resident 9, Resident 9 was observed sitting in a wheelchair and breathing normally. No invasive ventilator was applied. Resident 9 stated he never had a ventilator and only used a C-pap machine at bedtime for sleep apnea. During an interview on 8/20/25 at 4:20 p.m. with a Certified Nursing Assistant 10 (CNA 10), CNA 10 stated had not seen Resident 9 with an invasive ventilator. During an interview on 8/21/25 at 8:20 a.m. with a Licensed Nurse 7 (LN 7), LN 7 stated Resident 9 never had an invasive ventilator while at the facility. During a concurrent interview and record review on 8/21/25 at 1:20 p.m. with a MDS Coordinator (MDSC), Resident 9’s MDS record, dated 6/9/25 was reviewed. MDSC confirmed the special treatment of invasive mechanical ventilator was marked incorrectly which could have affected the care planned and provided to the Resident 9. During an interview on 8/22/25 at 1:45 p.m. with the Director of Nursing (DON), the DON expected staff to maintain the error-free assessment records. DON confirmed the inaccurate assessments could result in lack of care and impact on the quality of care for Resident 9. During a review of the facility’s policy and procedure (P&P) titled, “Conducting an Accurate Resident Assessment, revised on 6/5/24, the P&P indicated, “The purpose of this policy is to assure that all residents receive an accurate assessment … The appropriate, qualified health professional will correctly document .” 2. During a review of Resident 98’s admission records, the records indicated Resident 98 was admitted to the facility in February 2025 with diagnoses that included dementia a (progressive state of decline in mental abilities), psychotic disorder (disconnection from reality), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident 98’s MDS indicated Resident 98 had severe cognitive impairment. During a review of Resident 98’s Certification of Terminal Illness (CTI), dated 2/10/25, the CTI indicated Resident 98 was certified to be terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. During a review of Resident 98’s physician order, dated 2/10/25, the order indicated, “Terminal Care via [name of hospice program] with Prognosis of 6 month [sic] or less related to End Stage Dementia.” During a review of Resident 98’s MDS “Section J – Health Conditions,” dated 8/6/25, the MDS indicated “No” was coded for the question if Resident 98 had a condition or chronic disease that may result in a life expectancy of less than 6 months. During an interview on 8/21/25 at 11:54 a.m. with the MDSC, the MDSC confirmed Resident 98 was on hospice and stated “I messed up obviously with hospice…I am going to do a correction on her…I miscoded her on the significant change…I didn't do the prognosis…I think they need to have less than 6 months to live if they are in hospice…” The MDSC further stated, “Important so you know what's going on with patients.” During an interview on 8/22/25 at 9:55 a.m. with the DON, the DON stated, “MDS should be accurate because that is how we capture the details of our residents.” 3. A review of the admission Record indicated Resident 129 was admitted [DATE] with diagnoses including frontotemporal neurocognitive disorder (group of brain disorder leading to significant changes in behavior, movement, language and personality) and major depressive disorder (persistent feeling of sadness and loss of interest in activities). A review of Resident 129's physician order revised 2/28/25 indicated, Terminal care via [name of hospice program] with prognosis of 6 month [sic] or less related to End Stage Alzheimer's Disease [a disease characterized by a progressive decline in mental abilities]. A review of Resident 129's 'Medical Director Certification of Terminal Illness' document indicated, . [Resident 129] is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. The Initial certification period was from 2/22/25 to 5/22/25. A concurrent interview and record review was conducted on 8/21/25 at 10:26 a.m. with the MDSC. The MDSC reviewed Resident 129's MDS assessments dated 5/7/25 and 8/6/25. The MDSC confirmed both MDS assessments did not indicate Hospice care was provided to Resident 129 while a resident in the facility. The MDSC further confirmed the MDS dated [DATE] did not indicate Resident 129 had a life expectancy of less than 6 months. In an interview on 8/22/25 at 11:32 a.m. with the DON, the DON stated her expectation was for MDS assessments to be accurate and the assessment need to show the correct representation of the specific care provided to the resident. 4. A review of the admission Record indicated the facility admitted Resident 133 in early 2025 with diagnoses which included dementia, anxiety disorder (fear characterized by behavioral disturbances), and hypertension (high blood pressure). A review of the physician order, dated 1/21/2025, indicated Resident 133 was admitted to the facility under hospice services with prognosis of 6 months or less related to dementia with severe agitation. A review of Resident 133's MDS, Section J1400, dated 1/27/25, 4/16/25, and 7/16/25 indicated that the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. A review of Resident 133’s MDS assessment dated [DATE] and 4/16/25, Section O describing Special Treatments, Procedures and Programs offered to Resident 133, indicated the resident was on hospice care. Resident 133’s MDS assessment dated [DATE], Section O indicated Resident 133 was not on hospice care. During a concurrent interview and record review with the MDSC on 8/21/25 at 10:55 a.m., the MDSC stated that MDS assessments were to reflect an overall picture of the resident and the type of services, special procedures and programs each resident required. The MDSC acknowledged that Resident 133’s MDS assessments dated 1/27/25, 4/16/25, and 7/16/25 were not coded correctly, had conflicting information, and did not accurately reflect the resident’s condition and services the resident received. The MDSC explained that the MDS assessment was an instrument that helped the facility to have a proper plan of care for the resident and if any section were coded incorrectly, then it could affect the care planning process. The MDSC confirmed that because Resident 133’s sections J and O were not coded correctly, it potentially affected care planning and resulted in resident 133 not having a hospice care plan since 1/21/25. A review of the facility's policy and procedure effective 10/1/19 and titled, Conducting an Accurate Resident Assessment indicated, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of assessment, by staff qualified to assess relevant care areas .Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs .areas of decline.

Based on observation, interview, and record review, the facility failed to ensure:Medications and medical supplies were not available for residents' use past their expiration dates in three of three medication carts;Crash carts (storage of supplies needed in emergency situations) were checked regularly, and medical supplies were complete and were not past their expiration dates; andA medication was stored in the Resident Food Refrigerator at the memory unit.These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration dates, and the potential for malfunctioning equipment and delays during emergency situations for a census of 137.Findings: During a concurrent observation and interview on 8/20/25 at 3:02 p.m. with Licensed Nurse 8 (LN 8), an inspection of the facility's Memory Unit Medication Cart identified the following expired medications and medical supplies: One syringe Haloperidol (medication used to treat mental disorders) 1 mg (milligrams, a unit of measurement) – expired 8/18/25 One bottle Isopropyl alcohol (a clear, colorless liquid used to kill germs) 70% (percent, a unit of measurement) – expired 11/2024 One container Microkill One wipes (a disinfectant to kill germs)– expired 6/2023 One pack Maxorb II wound dressing (dressing that provides moist wound environment) – expired 7/2022 LN 8 confirmed the observation and stated, “It’s no good because of the reaction of the medication…there’s reason why there’s expiration date.” During a concurrent observation and interview on 8/21/25 at 10:06 a.m. with LN 5, an inspection of the Station 2 Medication Cart identified the following expired and discontinued medications and medical supplies: One bottle Antiseptic (a substance that kills or inhibits the growth of microorganisms) Skin Cleanser – expired: 6/1/25 One tube Extra Protective Cream – expired 10/2024 One tube Anti-itch cream 2% - expired 7/2025 One bottle Iodoform Packing Strip – expired 1/20/25 One bottle hydrogen peroxide (antiseptic) – expired 8/2022 Nine tablets Phenazopyridine (urinary pain relief medication) – expired 6/2025 LN 5 confirmed the observation and stated, “…important not to keep expired items in the cart so you don’t end up giving expired medication…” During a concurrent observation and interview on 8/21/25 at 10:29 a.m. with LN 7, an inspection of the Hallway 500 Medication Cart identified the following: One bottle hydrogen peroxide 3% - expired 12/2024 One bottle Skintegrity wound cleanser (used to treat and prevent minor skin irritations) – expired 1/11/25 One tube biofreeze menthol-pain relieving gel – expired 05/2025 One 30mL (milliliters, a unit of measurement) syringe – expired 6/2/23 One catheter stabilization device – expired 10/28/24 Two opened Petrolatum Dressing (used to maintain moist wound environment for effective wound healing) One unlabeled pill in medication cup inside narcotic box LN 7 confirmed the observation and stated the unlabeled pill was methadone (a controlled drug used to treat moderate to severe pain and to treat narcotic drug addiction) pulled out from the E-kit (emergency kit) that had to be wasted. LN 7 added petrolatum dressing should not be reused once opened. During an interview on 8/21/25 at 12:04 p.m. with the Infection Preventionist (IP), the IP stated, “…In the med cart, it should be randomly checked, expired meds should not be on the cart…There should be no expired meds and items in the cart…It has to be two nurses to sign the destruction, immediately…Important because narcotic counts are important, we want to avoid drug diversion…” During an interview on 8/22/25 at 9:16 a.m. with the Director of Nursing (DON), the DON stated, “There should not be any expired items in the med cart, possibly affect residents’ health.” During a review of the facility’s policy and procedure (P&P) titled “Medication Storage in the Facility,” dated 3/2018, the P&P indicated, “…M. Outdated, contaminated, or deteriorated medications…are removed from stock, disposed of according to procedures for medication disposal…” During a review of the facility’s P&P titled “Medication Destruction,” undated, the P&P indicated, “…G. All controlled drugs are placed in an approved waste container properly labeled as medication waste or pharmaceutical waste…” 2. During a concurrent observation and interview on 8/22/25 at 9:27 a.m. with the DON, an inspection of the Station 2 Crash Cart identified that the crash cart log was not checked for multiple days from May to August 2025. The DON stated, “Looks like they [staff] didn’t check it on those days.” The crash cart log indicated, “Crash cart will be checked every 24 hours and after each use. Replace any items that do not meet par.” The crash cart log further indicated that the cart should contain three containers of normal saline (a mixture of salt and water), but one container of normal saline and two containers of sterile water were observed inside the crash cart drawer. The DON stated, “Important to make sure everything is ready if there is an emergency…I think they messed up…” During a concurrent observation and interview on 8/22/25 at 9:40 a.m. with the DON, an inspection of the Station 1 Crash Cart identified that the crash cart log was not checked for multiple days from May to August 2025. The crash cart log further indicated that the cart should contain three containers of normal saline, but two containers of normal saline and one pack of sterile water were observed inside the crash cart drawer. The crash cart also contained a suction connection tubing that expired on 5/2011. The DON confirmed the observation and stated, “It could be damaged, it could be compromised…” During a review of the facility’s P&P titled “Crash Cart/E-carts,” dated 2/20/19, the P&P indicated, “…It is the policy of this facility to organize and maintain the emergency cart (E-cart) to ensure adequate needed equipment for CPR procedures…1. The nursing staff will ensure the equipment are stocked in the E-cart…3. The E-cart will be inventoried and restocked after each use and checked daily and documented by nursing staff or the pharmacy consultant…6. Once a month the E-cart should be opened and checked for outdated supplies. 7. E-cart checks should be documented on the lists maintained on the E-cart…” Findings: 3. During a concurrent observation and interview on 8/22/25 at 9:36 a.m. with a Certified Nursing Assistant 2 (CNA 2) in the memory unit, the residents’ food refrigerator was observed. A medication bottle was stored inside the refrigerator door compartment. CNA 2 confirmed that a bottle containing medication was stored inside the refrigerator meant to be storing only food for residents. During an interview on 8/22/25 at 9:50 a.m. with a Licensed Nurse 8 (LN 8), LN 8 confirmed a bottle of acidophilus probiotic (live microorganisms consumed for health benefits) was stored inside the resident food refrigerator. LN 8 stated medications stored in the same refrigerator with food posed a risk for cross contamination. During an interview on 8/22/25 at 1:45 p.m. with the Director of Nursing (DON), the DON stated staff should not be storing any medication in the food refrigerators. DON stated all medications that needed refrigeration should be stored in a secured medication refrigerator in the unit. During a review of the facility’s policy and procedure titled, “Medication Storage in the Facility, dated March 2018, indicated, “… Refrigerated medications are kept … separate from foods …”

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner for a census of 137 residents, when: 1. Expired, undated, unlabeled, spoiled, unsealed opened food items, and a dirty food tray were found in the walk-in refrigerator, walk-in freezer, and in the cooking area in the kitchen;2. The floor in the walk-in freezer was dirty;3. Cooking equipment and utensils were not clean;4. Undated and expired food items were stored in the resident food refrigerators in the three nursing units and temperature logs were inconsistent; 5. No written instructions were followed for cooking spinach; and 6. There were no air gaps for the plumbing system under the sinks and dishwashing machine in the kitchen.These failures had the potential to contaminate food in the kitchen and cause foodborne illnesses among residents. Findings:1. During a concurrent observation and interview on 8/19/25 at 8:45 a.m. with the Dietary Supervisor 1 (DS 1), the food items stored in the walk-in refrigerator, walk-in freezer, and cooking area were observed. DS 1 confirmed the following:- Spoiled, mushy, and brownish apples, an undated container of whipped cream stored in the walk-in refrigerator;- Opened and unsealed bags of sausages and bacon stored in the walk-in freezer;- Several food items with inconsistent and incomplete opening dates written on them. Some containers had day and year, others had month and day in the walk-in refrigerator and freezer;- An empty food tray with food fragments and a used fork in it stored with trays containing food in the walk-in refrigerator; and- Expired ground turmeric, basil leaves, and cooking wine stored in the cooking area in the kitchen.DS 1 stated the spoiled, expired, and undated food items were unsafe to be used. DS 1 expected food bags to be completely sealed, opening dates should be written as month/day/year, and dirty utensils were not to be stored in the refrigerator or freezer.2. During a concurrent observation and interview on 8/19/25 at 9:25 a.m. with DS 1, the floor in the walk-in freezer was observed. A layer of dark grime and garbage accumulated near the door. Several food fragments, a pudding cup, and coins were seen on the floor under the food racks. DS 1 confirmed the freezer floor was dirty. 3. During a concurrent observation and interview on 8/19/25 at 10:45 a.m. with DS 1, the cooking equipment and utensils were observed in the cooking area. A food blender had a sticky residue on it. Two non-stick pans had eroded interior surfaces. Two coffee pitchers had dark discoloration and cracks inside them. A wet cutting board and several cooking pans were stored wet on the ready to use racks. DS 1 confirmed the food blender, wet pans and wet cutting board were not sanitary. DS 1 agreed eroded non-stick pans and damaged coffee pitchers were unsafe for use and could cause food contamination. 4. Three refrigerators for residents' food were observed at the station 1, station 2, and memory unit in the facility. - During a concurrent observation and interview on 8/21/25 at 11:57 a.m. with Licensed Nurse 3 (LN 3), a resident food refrigerator at station 1 was observed. LN 3 confirmed two boxes of frozen food were expired on 7/22/25. LN 3 agreed the temperature log was not maintained for 8/21/25.- During a concurrent observation and interview on 8/21/25 at 12.09 p.m. with a Certified Nursing Assistant 9 (CNA 9), a resident food refrigerator at station 2 was observed. CNA 9 confirmed several unlabeled, undated food items were stored in it. CNA 9 agreed the temperature log was maintained a day in advance for 8/22/25.- During a concurrent observation and interview on 8/22/25 at 09:37 a.m. with CNA 2, a resident food refrigerator was observed at the memory unit. CNA 2 confirmed an undated ice cream container and a medication bottle were stored in it. CNA 2 agreed the temperature log was not maintained consistently and several days were missed. 5. During a concurrent observation, interview, and record review on 8/21/25 at 9:45 a.m. with the Head [NAME] (HC), twelve spinach bags were observed cooking in boiling water inside a big metal pot on the stove. HC described the frozen spinach inside the plastic bags boiled for one to one and half hours followed by removing it from the plastic bags and draining it. HC agreed the spinach recipe in the recipe book did not indicate boiling the spinach inside the plastic bags. HC stated there was no instructions on the spinach bags to be boiled inside the plastic bags. 6. During a concurrent observation and interview on 8/21/25 at 4:45 p.m. with the Maintenance Supervisor (MS), the drainage system was observed for the air gap to prevent the sewer back flow. MS confirmed there was no air gap in the kitchen drainage system. MS stated a drainage problem was fixed on 3/21/25 but no air gap was established.During an interview on 8/22/25 at 10;00 a.m. with DS 1, DS 1 expected staff to check the food items daily and remove the spoiled, expired, and undated food items. DS 1 stated all kitchen equipment and surfaces should be kept clean. DS 1 agreed the resident food refrigerators temperature logs had only provision to be maintained once a day. DS 1 confirmed there were no instructions to boil frozen spinach inside the plastic bags. DS 1 stated was not aware of no air gaps in the drainage system in the kitchen.During an interview on 8/22/25 at 12:38 p.m. with the Registered Dietician (RD), RD expected staff to have checked and removed the spoiled and expired foods regularly. RD agreed the kitchen equipment, utensils and floors should be cleaned daily. RD confirmed there were no written recommendations to cook spinach inside the plastic bags. RD stated all food items should be labelled consistently and refrigerators/freezers temperature logs should be maintained accurately twice a day. RD also stated wet pans and cutting board were a source of bacterial growth and food contamination which could cause food born illnesses among the residents. RD further stated a sewer back flow could cause closure of kitchen.During an interview on 8/22/25 at 1:37 p.m. with the Administrator (ADM), ADM confirmed issue with the airgaps from the kitchen sinks and dishwashing machine. ADM agreed the sewer back flow could contaminate the kitchen and interrupt the food services for the residents.During a review of the facility's policy and procedure (P&P) titled, Storing Produce, revised 12/2024, indicated, . Check boxes of fruit and vegetables for rotten, spoiled items. Throw away all spoiled items .During a review of the facility's policy and procedure (P&P) titled, Food for Residents from outside Sources, revised on 12/23/2024, indicated, food brought in from the outside the facility kitchen for residents' consumption will be monitored to prevent food borne illness . at nurse's station, labeled with the resident's name and date of storage. If opened must be sealed, dated with date opened, resident's name, and disposed of by the expiry date .During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 2023, indicated, Food shall be prepared by the methods that conserve nutritive value, flavor, and appearance. The facility will use approved recipes .During a review of the facility's policy and procedure titled, Station 1 and Station 2, revised on 4/24/24, indicated, Housekeeping staff will check the inside temperature of refrigerators and freezers . will record daily and initial the temperatures a.m. and p.m. shifts .During a review of the facility's policy and procedure titled, Dishwashing, dated 2023, indicated, . Dishes are to be air dried in the racks before stacking and storing .During a review of the facility's policy and procedure (P&P) titled, General Cleaning of Food and Nutritional Services Department, dated 2023, indicated, . Floors . must be scheduled for routine cleaning . must be moped at least once per day . Mop under and around equipment .During a review of the facility's policy and procedure (P&P) titled, Commercial Kitchen Air Gap, revised on 4/17/2024, indicated, The policy of the facility is to maintain a proper air gap to prevent backup and potential contamination of foods prep areas .

Based on observation, interview, and record review, the facility failed to ensure trash was stored in a sanitary manner for a census of 137 when, trash dumpsters were observed with open lids.This failure had the potential to create breeding ground for insects and rodents.Findings:During a concurrent observation and interview on 8/19/25 at 10:30 a.m. with the Head [NAME] (HC), a facility dumpster outside the kitchen backdoor was observed with the lid open. An additional trash container which had trash including used gloves, hairnet and a cigarette butt was found with no lid. The HC confirmed the lids were open. During an interview on 8/22/25 at 3:17 p.m. the Registered Dietitian (RD), RD agreed that open dumpsters and trash cans near the kitchen were sources to attract flies. RD stated flies could have entered the kitchen when the back door was opened. RD further stated flies could cause food contamination which could lead to food borne illnesses among the residents.During a review of the facility's policy and procedure titled, General Cleaning of Food and Nutritional Services Department, dated 2023, indicated, Garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and the lids are closed.

Based on observation, interview, and record review, the facility failed to maintain effective infection prevention and control measures to prevent the occurrence and spread of infections to residents, when: 1. The enhanced barrier precautions (EBP, infection control measures to prevent spread of infections) signage was not accurately assigned; 2. The nursing staff did not implement EBP for Resident 36;3. The nursing staff did not close the door of rooms on isolation precautions for COVID-19 positive residents;4. Blood Pressure (BP) cuff and BP machine were not disinfected with appropriate disinfectant;5. Resident 66's nebulizer (a machine that turns liquid medicine into a mist that can be easily inhaled) mask was not labeled and stored properly; and,6. Resident 98's humidifier (used to provide additional humidity to oxygen therapy) was left open when not in use and not replaced as ordered. These failures increased the potential to spread infections and cross contamination.1. An observation was conducted on 8/19/25 starting at 12:02 p.m., Resident 35's room had an EBP sign by the door. The Certified Nursing Assistant 3 (CNA 3) entered said room with a transfer device without a personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environment). In an interview on 8/19/25 at 12:22 p.m., CNA 3 stated he assisted resident in bed #1 [Resident 35] in the bathroom for an incontinence brief change. The CNA 3 further stated he used gloves when he changed Resident 35's brief. The CNA 3 added the EBP sign by the door was intended for the resident in bed #2 due to resident had a wound. A subsequent observation and interview with CNA 3 was conducted on 8/19/25 at 12:28 p.m. The CNA 3 looked at the EBP sign by the door, and he stated he should have worn a gown when he assisted resident to the toilet. In a concurrent observation and interview on 8/20/25 at 8:58 a.m., the Infection Preventionist (IP) wrote Bed #1 in the EBP sign by Resident 35's room. The IP stated the EBP sign was for Resident 35, resident had a wound that required a dressing. The IP further stated when staff are doing high contact care with the resident, staff should use gown and gloves, anytime staff perform transfer, shower and brief change. A review of Resident 35's clinical record did not indicate presence of wounds. In a follow up interview on 8/22/25 at 11:25 a.m., the IP stated she misplaced the EBP sign for Resident 35, the sign was for resident in bed #2 instead of Resident 35 in bed #1. 2. An observation was conducted on 8/20/25 at 9:45 a.m., CNA 3 and CNA 4 went inside Resident 36's with a transfer device. The door to resident's room had an EBP sign and Bed #2 (Resident 36) was handwritten on the sign. An interview was conducted on 8/20/25 at 9:53 a.m. with CNA 4. The CNA 4 stated CNA 3 and herself performed an incontinence brief change to Resident 36. The CNA 4 further stated CNA 3 and herself did not use a gown while caring for Resident 36. CNA 4 added she was not aware of the EBP sign posted on Resident 36's door. CNA 4 confirmed gown and gloves should be worn when changing Resident 36's brief. In an interview on 8/20/25 at 10:27 a.m., the IP stated the EBP sign was intended for Resident 36 due to colonized bacteria (presence of germs in the body without signs and symptoms of illness) and skin tear requiring dressing. A review of Resident 36's care plan initiated 4/1/24 indicated Enhanced barrier precautions in place for Infection Prevention and the intervention indicated, Staff will [NAME] proper PPE when giving high contact care. In an interview on 8/22/25 at 11:25 a.m., the Director of Nursing (DON) stated her expectation was for staff to clarify with the nurse if there was no specific resident indicated on the EBP sign. The DON further stated staff should be more careful when caring for residents on EBP because residents have a higher chance of contacting infection due to presence of wound, indwelling urinary catheter, or some sort of tube in the body. The DON added the staff are expected to use gown and gloves for high contact activity. A review of the facility's policy and procedure effective 7/2025 and titled, Enhanced Barrier Precautions indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs) .Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). High-contact resident activities include: .Transferring .Changing briefs or assisting with toileting .Wound care: any skin opening requiring a dressing . 3. During an observation on 8/22/25 at 9:26 a.m. in the 600 hall, the doors of two rooms were open. Both rooms had a sign on the door labeled “Special Droplet/Contact Precautions” that stated, “Keep door closed” During an interview and observation on 8/22/25 at 10:02 a.m. with CNA 5, CNA 5 confirmed that the 600 hall had positive Covid-19 residents in those two rooms. CNA 5 stated that the residents in the rooms were on isolation precautions due to Covid-19 and confirmed the doors of both rooms were left open. During an interview and observation on 8/22/25 at 10:12 a.m. with IP, the IP stated that there were five Covid-19 positive residents in Hall 600. The IP confirmed both rooms had two residents in each room that tested positive for Covid-19. The IP stated that the residents in the rooms were on isolation precautions due to Covid-19 and confirmed the doors of both rooms were left open. Per the IP, “The doors should be closed while on isolation to prevent the spread of Covid…they should have the doors closed since it is in our policy” During an interview and concurrent record review on 8/22/25 at 11:56 a.m. with the DON, the DON confirmed it was the facility’s policy to have doors closed for residents that were positive for Covid-19. The DON confirmed the Policy titled, “Covid-19 Response Plan”, is the policy the DON expects to be followed. The DON stated, “…expectation is that the staff follow the policy to prevent spread of Covid -19…” A review of the facility's Policy and Procedure (P&P) titled “Covid-19 Response Plan”, the P&P indicated in “…F…3. Implement airborne, droplet and contact precautions for all residents with suspected or confirmed Covid-19…Isolate the resident in their room, with the door closed…” 4. During a medication administration observation on 8/20/25 at 8:07 a.m. with LN 9, LN 9 was observed disinfecting the BP cuff and machine with hand sanitizer wipes after using it with a resident. LN 9 confirmed the observation and stated she used the hand sanitizer wipes “…because bleach wipes are too harsh for the equipment.” During an interview on 8/20/25 at 12:01 p.m. with LN 2, LN 2 stated, “I use the alcohol prep pad to disinfect the blood pressure cuffs…It is easier for me to use the alcohol prep pad…” LN 2 further stated that she should have used the proper disinfectant wipe. During an interview on 8/21/25 at 12:04 p.m. with the IP, the IP stated BP cuff and equipment should be disinfected after use and stated, “ .clean with alcohol-based cleaner with blue top…” The IP further stated alcohol-based cleaners are okay to use for disinfection and stated, “So they can use the hand sanitizer…I would prefer to use the sanitizer, they can use alcohol wipes as a last resort and not for convenience…” The IP added, “Proper disinfectant is going to clean certain bacteria and virus to reduce transmission of nosocomial infection [infection acquired in a healthcare facility].” During an interview on 8/22/25 at 9:55 a.m. with the DON, the DON stated, “They [staff] should be using micro-kill one for bp cuffs and medical equipment…” When asked if staff can use hand sanitizer wipes to disinfect BP cuff and equipment, the DON stated, “I don’t think so” and stated staff cannot use alcohol swabs either “for infection prevention.” During a review of the facility’s P&P titled “Cleaning and Disinfection of Resident-Care Equipment,” revised 4/17/24, the P&P indicated, “Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection…g. Use only EPA [Environment Protection Agency]-registered disinfectants with kill claims for the common organisms found in the facility…” 5. During a review of Resident 66’s admission records, the records indicated Resident 66 was admitted in January 2021 and readmitted in October 2023 with diagnosis that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing). Resident 66’s MDS indicated Resident 66 had severe cognitive impairment. During a review of Resident 66’s care plan, dated 2/6/24, the care plan indicated, “[Resident 66] has COPD…The resident will be free of s/sx [signs and symptoms] of respiratory infections…Give aerosol [tiny solid or liquid particles suspended in the air] or bronchodilators [relaxes the muscles in the airways to open them up] as ordered…” During a review of Resident 66’s physician order, dated 3/6/25, the order indicated, “Change nebulizer equipment every evening shift 1 days on and 2 days off…” During a review of Resident 66’s physician order, dated 3/13/25, the order indicated, “Ipratropium-Albuterol [inhaled medication to open the airways] Inhalation Solution…3 ml [milliliters, a unit of measurement] inhale orally [by mouth] via nebulizer two times a day for chronic congestion via nebulizer…” During a review of Resident 66’s Medication Administration Record (MAR) for August 2025, the MAR indicated Resident 66 received Ipratropium-Albuterol inhalation on 8/19/25 at 8 a.m. During an observation on 8/19/25 at 9:41 a.m. in Resident 66’s room, Resident 66’s nebulizer mask was observed on the bedside table connected to nebulizer, without label and not in a bag. During a concurrent observation and interview on 8/19/25 at 10:04 a.m. with LN 8 in Resident 66’s room, LN 8 stated Resident 66 received nebulization in the morning of 8/19/25 around 7:30 a.m. LN 8 confirmed Resident 66’s nebulizer mask was not labeled and stated, “…We just put it there on top of neb [nebulizer] machine…We are supposed to label it…So we will know when to change it…” During an interview on 8/21/25 at 12:04 p.m. with the IP, the IP stated, “…staff should store them [nebulizer mask] in a bag, changed weekly and date it .For infection prevention, it can grow bacteria if it falls on the floor…Important to prevent spread of bacteria keep the resident healthy…It can build up bacteria from the droplets overtime, we want to prevent infection…” During an interview on 8/22/25 at 9:55 a.m. with the DON, the DON stated, “…For neb mask, it should be labeled with the date to make sure it’s a new mask…” During a review of the facility’s P&P titled “Medical Gas and Oxygen Policy,” revised 2/20/19, the P&P indicated, “…All oxygen equipment will have the date of change and initials of the nurse…” 6. During a review of Resident 98’s admission records, the records indicated Resident 98 was admitted to the facility in February 2025 with diagnoses that included COPD and anemia (a condition where the body does not have enough healthy red blood cells). Resident 98’s MDS indicated Resident 98 had severe cognitive impairment. During a review of Resident 98’s physician order, dated 2/13/25, the order indicated, “Oxygen @[at]2L/min [liters/minute] via nasal cannula (oxygen tubing) as needed for shortness of breath q [every] shift prn [as needed].” During a review of Resident 98’s physician order, dated 2/17/25, the order indicated, “Change humidifier every night shift every Sat [Saturday].” During a review of Resident 98’s MAR for August 2025 the MAR indicated Resident 98’s humidifier was changed on 8/9/25. During an observation on 8/19/25 at 9:44 a.m. in Resident 98’s room, oxygen concentrator was observed at bedside, not in use, with opened humidifier in place, labeled “8/10.” During a concurrent observation and interview on 8/20/25 at 10:04 a.m. with LN 8 in Resident 98’s room, LN 8 confirmed the humidifier was opened and labeled on 8/10/25, and stated, “Humidifiers are changed by Noc [night] shift…Nurses sign it when they change it…usually, we change it once a week, we don’t throw it…” LN 8 further stated, “…once it [humidifier] is open and not going to use it, we throw it…resident can't use it because it is past one week…” During an interview on 8/21/25 at 12:04 p.m. with the IP, the IP stated, “Humidifiers should be dated as well and changed weekly and depends on the order…” During an interview on 8/22/25 at 9:55 a.m. with DON, the DON stated, “…for humidifiers, should be labeled and changed as ordered.” During a review of the facility’s P&P titled Medical Gas and Oxygen Policy, dated 2/20/19, the P&P indicated, “8. Humidifiers will be replaced 1x/week and prn…All equipment will have the date of change and initials of the nurse…”

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented for a census of 137 residents, when flies were observed in the kitchen. This failure decreased the facility's potential to maintain a pest-free environment in the kitchen that prevented food contamination.Findings: During a concurrent observation and interview on 8/19/25 at 10:45 a.m. with Dietary Supervisor 1 (DS 1), flies were observed in the kitchen. Flies were observed flying around and landing on kitchen counters, food processors, cooking utensils, dishes, and food. DS 1 confirmed the presence of flies in the kitchen and stated it posed a risk for food contamination.During a concurrent observation and interview on 8/19/25 at 11:55 a.m. with the Maintenance Supervisor (MS), MS confirmed the flies problem in the kitchen. MS stated the last pest control was conducted on 8/8/25 and agreed the issues were not resolved.During an interview on 8/19/25 at 3:40 p.m. with the Registered Dietitian (RD), the RD confirmed an infestation of flies in the kitchen. RD agreed flies could contaminate food and cause illness among residents. RD expected implementation of better pest control measures to eradicate flies from the kitchen.During an interview on 8/22/25 at 1:40 p.m. with the Director of Nursing (DON), the DON acknowledged the flies' issue in the kitchen. The DON stated facility had monthly pest control services and the last one was on 8/8/25. The DON expected the MS to contact the pest control vendor for additional and stronger pest control measures to eliminate flies from the kitchen.A review of the facility's policy and procedure titled, Pest, Rodents & Insect Policy, revised on 4/17/2024, indicated, Maintenance will ensure insects are not present in or around the premises . if found, maintenance will contact our outside vendor for additional treatments and/or solutions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards that were within the facility's control, when the facility did not provide supervision to prevent one of three residents sampled for elopement (to leave a health care facility without permission or authorization), from leaving the facility without staff awareness and wandered in their wheelchair toward a busy street. Staff had not noticed Resident 1 missing until a staff member saw him on the street in his wheelchair on her way to work.This failure had the potential to result in physical harm, getting ran over by a car, and exposure to the elements (weather) for all residents who wander and/or have the potential to elope. This could have serious negative impacts on their safety, physical and emotional well-being.During a review of the facility policy and procedure titled, Wandering/Elopement, dated 4/17/24, indicated, It is the policy of this facility to protect residents from wandering away from the facility and to begin an immediate search if resident is found missing.A review of Resident 1's medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included, Neurocognitive Disorder with Lewy Bodies (progressive brain disorder that leads to decline in thinking, reasoning, and independent function), Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), and Diabetes Mellitus (DM). A review of Resident 1's Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 05/07/2025, indicated Resident 1 rated 6/15, which equates to severe cognitive impairment. Resident 1 was not their own representative (RP), and did not make their own medical decisions, but is able to verbalize needs and preferences.During an interview on 7/3/25 at 09:30 am, with Kitchen Staff (KS) in their office, KS stated, I am aware of the incident where Resident 1 escaped. I found them halfway up the steep ramp close to a busy street in their wheelchair. I was headed to work; it was early and hard to see them. I returned them to unit 1 and was informed no staff was aware that they were gone. The charge nurse looked mortified because they had no idea Resident 1 was not in the building.During an interview on 7/3/25 at 11:00 am, with Licensed Nurse (LN) 4 at Nursing Station 1, LN 4 stated, I heard of the incident regarding Resident 1's elopement. Resident 1 was found by kitchen staff on the driveway ramp headed to the street.During a record review of the current resident assessment, Wandering Risk Scale (tool to determine the level of risk for a resident to potentially wander or elope), dated 4/29/25 at 12:58 am, indicated Resident 1 scored 11 which equates to being a High Risk for wandering/elopement.During a record review of Resident 1's, Progress Notes, N-Alert Charting, dated 5/5/25 at 5:45 am, indicated, Resident was found outside of building in wheelchair at top of driveway. Returned by kitchen staff member. No indication of any injury or harm resulting from adventure. Returned to [Station] Stn 1. without further incidents.During a concurrent interview and record review on 7/3/25 at 2:00 pm, with Director of Nursing (DON) and Administrator (Admin) in the facility conference room, Resident 1 Progress Notes and medical chart were reviewed. DON and Admin concurred and confirmed that Resident 1 was a confused resident that required supervision and permission to be outside the facility, regularly demonstrated active exit seeking behaviors, did exit the facility building on 5/5/25, was found in a wheelchair propelling it up the driveway incline to the street, staff was unaware of the resident's exit and location, and that this incident had a potential to have been a seriously dangerous and hazardous incident.

Based on interview and record review, the infection preventionist (IP) failed to report two potential infectious disease outbreaks withing 24 hours to the California Department of Public Health (CDPH), in accordance with the facility's Unusual Occrrence Reporting policy. This failure had the potential for infection to spread to residents, staff and visitors and negatively impact residents health and safety and delayed oversight by CDPH. Findings: A review of a facility policed titled, Unusual Occurrences, with a reviewed date of 4/17/2025, indicated, Unusual occurrences shall be reported to the Department of Health Services and/or the local Health officer. The administrator/designee shall report the following unusual occurrences to the Department of Health Services according to accepted National Standards. A review of a facility policy titled, Infection Prevention and Control Program, with a revision date of 12/2023, indicated, Outbreak management is a process that consists of . reporting the information to appropriate public health authorities . A review of a facility policy titled, Outbreak of Communicable Diseases, with a revision date of 9/2022, indicated, The administrator is responsible for communicating data about reportable diseases to the health department . A review of a report from the Infection Preventionist (IP) dated 4/11/2025, indicated that the gastrointestinal symptoms of five residents with nausea, vomiting and loose stool had an initial start date of 4/8/2025 and was reported to CDPH on 4/11/25. A review of a report from the IP dated 5/5/2025, indicated that the respiratory symptoms of three residents with fever, cough, and congestion had an initial start date of symptoms on 5/3/2025, and reported to CDPH on 5/5/25. During an interview on 5/22/2025 at 3:15 PM, the IP stated, 24 hours should be reported for unusual occurrences, which included outbreaks and suspected outbreaks. IP confirmed that she did report the gastrointestinal symptom outbreak to CDPH until 4/11/2025, which was three days late. IP also confirmed that the the respiratory outbreak was not reported to CDPH until 5/5/2025, which was two days late.

Based on interview and record review, the infection preventionist (IP) failed to report a flu and Respiratory Syncytial Virus (RSV – contagious virus that causes infections of the respiratory tract) outbreak in the facility in accordance to accepted national standards. This failure had the potential to cause a community wide outbreak for both RSV and Flu by potentially not preventing further transmission of the diseases. Findings: A review of a facility policy titled, Unusual Occurrences, with a reviewed date of 4/1/2024, indicated Administrator/designee shall report the following unusual occurrences within 8-24 hours to the Department of Health Services . Epidemic outbreaks of any disease, prevalence of communicable disease (an infection that can be transmitted from one person to another). During an interview on 3/11/2025 at 2:27 PM with IP, stated the fact that the outbreak occurred on a weekend was the problem since she does not work weekends and did not know she needed to report it. IP stated, I did miss a weekend, but I didn ' t report it in 24 hours. I am now aware I should ' ve reported it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and facility policy review, the facility failed to implement their Abuse policy and investigate an injury of unknown origin for one of three residents who were sampled for abuse (Resident 1), when Resident 1 was found to have a bruise on her left hip and the facility could not determine where the bruise came from, in order to rule out abuse. This failure had the potential for residents not to be protected against abuse in the facility, which could negatively impact their quality of life and physical, emotional and psychosocial well-being. Findings: A review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property; Prevention Of reviewed 4/17/24, indicated, D. Complaints, observations, suspicions, or reporting of incidents, falls, bruises and skin tears (of suspicious or unknown origin) will be investigated to rule out abuse. Occurrences, patterns, and trends will be assessed by administrative staff, licensed staff, and the interdisciplinary team to determine the corrective action based on the results of the investigation. Results will be reported to the Administrator .for further directions and action plans. F. All incidents of suspected or alleged abuse will be investigated by the assigned staff. The assigned staff will be informed of the nature of the incident and continue the investigation process. The investigation and report shall include: a) Date and time the incident took place. b) Circumstances surrounding the incident. c) Where the incident occurred. d) Names of witnesses and their account when applicable. e) Resident's/representative's account of incident. f) Employee's account of incident when applicable. g) Accounts of any other individuals involved. h) Recommendations for corrective action if applicable. i) Outcome of investigation; and j) Follow-up resolution or further action if necessary. 2. Suspicious falls and other incidents of unknown origin will be investigated to rule out abuse. During a record review of Resident 1's admission record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included frontotemporal neurocognitive disorder (group of brain disorders), tremors (involuntary, rhythmic shaking movements), and dementia (a decline in mental ability). A review of Resident 1's most recent Minimum Data Set (MDS, a standardized assessment tool), indicated that Resident 1 had memory, recall and decision making problems. During a review of Resident 1's clinical record, there was only one document that indicated that the facility had found a bruise on Resident 1. A Progress Notes Communication with Physician dated 3/14/25 at 3:14 pm, reflected that a nurse had reached out to Resident 1's Hospice provider (supports and manages symptoms and quality of life for people with terminal illnesses), to have an order to monitor a bruise on Resident 1's left iliac (hip) crest. Resident 1's clinical record contained no other documentation about how Resident 1's hip had been injured and bruised. During an interview and concurrent review of the facility's Abuse policy with Director of Nursing (DON) on 3/18/25 at 10:20 am, DON confirmed a bruise had been found on Resident 1s left hip and the injury was of unknown origin, as facility had not known how Resident 1 got the bruise. DON stated she was, pretty sure [Resident 1's hip bruise] might be from her brief [adult diaper] being too tight and then she shifts around in bed. DON confirmed there was no investigative report, documentation, reporting, investigation of the circumstances, witness accounts, resident's representative accounts, employee interviews, recommendations for corrective action, outcome of the investigation or follow-up that was done by the facility administration, as their Abuse policy specified. DON stated she could not remember which staff member first discovered Resident 1's bruise, or when it was discovered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) care plans were developed when: 1. A care plan was not developed when a bruise of unknown origin was found on Resident 1's left hip. 2. A care plan was not developed when Certified Nursing Assistant (CNA) A trimmed Resident 1's fingernails and caused lacerations (cuts) on two of her fingers with the nail clippers. These failures had the potential to result in Resident 1's needs not being identified, evaluated and reevaluated, and had the potential to contribute to unwanted pain and infection which could negatively impact her quality of life and ability to attain or maintain her highest practicable level of well-being. Findings: A review of the facility's policy titled, Wound Care (Other than Pressure Ulcers) dated 4/17/24, indicated, If a skin condition is identified, i.e. skin tear, bruise, laceration, abrasion, etc. the licensed nurse will: implement or update a care plan. 1. During a review of Resident 1's admission record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included frontotemporal neurocognitive disorder (group of brain disorders), tremors (involuntary, rhythmic shaking movements), and dementia (a decline in mental ability). During a review of Resident 1's clinical record a, Progress Notes Communication with Physician dated 3/14/25 at 3:14 pm, reflected that Resident 1 was found to have a bruise on her left hip that the facility could not determine how happened. A review of Resident 1's care plans on 3/18/25, reflected that no care plan had been developed for Resident 1's bruise to her left hip which identified the problem, goals, or interventions needed to resolve the problem. 2. During a record review of Resident 1's Progress Notes dated 3/13/25 at 7:00 pm, a nurse documented Resident 1 had lacerations on two fingers of her right hand. Progress Note indicated, One to 2nd right [pointer] finger and 4th [ring] finger. ADON [Assistant Director of Nursing] informed me that [CNA A] clipped the resident's fingers while trimming her nails. [CNA A] reported [Resident 1] was bleeding that was stopped with gauze and pressure. Progress Note indicated that Resident 1's lacerations were treated with normal saline, wrapped with gauze that was held in place with netting. During a record review of Resident 1's Care Plans on 3/18/25, there had been no care plan developed for Resident 1's lacerated fingers, which identified the problem, goals or interventions needed to resolve the problem. During an interview and concurrent review of Resident 1's care plans with Director of Nursing (DON) on 3/18/25 at 10:20 am, DON confirmed Resident 1 had a bruise on her right iliac crest (hip) and no care plan had been developed and should have been on 3/14/25, when the bruise was discovered. DON confirmed Resident 1 had no care plan for the lacerated fingers injury and one should have been developed on 3/13/25, when the injury occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure quality care was provided for one of three residents (Resident 1), who were sampled for quality of care when: 1. Certified Nursing Assistant (CNA) A trimmed Resident 1's fingernails and cut the skin and caused lacerations (cuts) on two fingers of her right hand with the nail clippers and the facility had not conducted corrective reeducation with CNA A, to prevent this from happening again. 2. Licensed Vocational Nurse (LN) B did not follow the wound care treatment directions for Resident 1's lacerated fingers, in accordance with what the physician ordered. These failures had the potential to cause Resident 1 unnecessary pain, discomfort and infection and have a negative impact on her quality of life and physical, emotional, and psychosocial well-being. Findings: During a record review of facility policy titled, Wound Care (Other than Pressure Ulcers) 4/17/24, indicated The licensed nurse will track effectiveness of treatments and call Medical Director (MD) for a change in treatment orders if the wound is not healing in a timely manner. 1. During a record review of Resident 1's admission record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included frontotemporal neurocognitive disorder (group of brain disorders), tremors (involuntary, rhythmic shaking movements), and dementia (a decline in mental ability). During a record review of Resident 1's most recent Minimum Data Set (MDS, a standardized assessment tool), indicated that Resident 1 was not able to make decisions on her own. During a record review of Resident 1's, Progress Notes dated 3/13/25 at 7:00 pm, a nurse documented that Resident 1 had lacerations to two fingers on her right hand. Progress note indicated, One to 2nd right [pointer] finger, and 4th [ring] finger. ADON [Assistant Director of Nursing] informed me that [CNA A] clipped the resident's fingers while trimming her nails. Progress note indicated CNA A reported bleeding was stopped with gauze and pressure. Nursing documentation reflected that Resident 1's wounds were treated with normal saline, wrapped with kerlix (gauze), and held in place with netting. During a record review of Resident 1's, Physician Orders dated 3/14/25 at 7:00 am, there was an order to, Cleanse laceration right 4th finger/right 2nd finger with normal saline and pat dry, apply Topical Antibiotic Ointment (TAO). Wrap fingers with kerlix [gauze] and hold in place with netting. Observe daily until healed. Every day shift until healed. During a record review of Resident 1's, Treatment Administration Record (TAR), dated March 2025, indicated Resident 1 had not received the treatment to the fingers on her right hand as the physician had ordered, on 3/14/25 and 3/18/25. During an observation on 3/18/25 at 9:14 am, Resident 1 was observed sleeping in her bed. Resident 1's right hand was in a hand splint. Resident 1's right hand fingers did not have any dressings over the two fingers that were lacerated. During an observation and concurrent interview with LN A on 3/18/25 at 11:31 am, Resident 1 was observed in her room sitting up in her wheelchair. LN A removed the hand splint from Resident 1's right hand and confirmed Resident 1's fingers were not wrapped in dressing, as specified in the physician's order. Resident 1 was observed to have a scab on the tip of the ring finger and no scab on the second (pointer) finger. 2. During an interview with ADON on 3/18/24 at 10:14 am, ADON confirmed that CNA A reported to her that he had cut Resident 1's two fingers when trimming her fingernails, and they were bleeding. ADON confirmed that the facility had not provided reeducation to CNA A, or any other CNAs, on how to safely trim resident fingernails, nor had an investigation been conducted into exactly what had happened. During an interview with Director of Nursing (DON) on 3/18/24 at 10:20 am, DON stated she was not sure if CNA A received any follow-up nail care corrective action or education. DON stated there was no active investigation into how or why Resident 1 incurred injuries during nail care that was provided by CNA A. During a concurrent interview with CNA A on 3/18/24 at 10:41 am, CNA A confirmed he had trimmed Resident 1's fingernails with clippers. CNA A stated Resident 1, jerked away from him and he cut Resident 1's skin and had noted that one finger was bleeding and added, I had no idea she was bleeding from two fingers. During an interview with Director of Staff Development (DSD) on 3/18/25 at 12:00 pm, DSD confirmed CNA A injured Resident 1 when he clipped her fingernails and cut her skin with the clippers. DSD stated she had not provided reeducation to CNA A, or any other CNAs, because incident occurred, Five days ago and today is my first day back. DSD indicated she needed to do some reeducation with the CNA staff. During an interview with LN B on 3/18/25 at 12:17 pm, LN B stated she last assessed Resident 1's finger lacerations, a couple days ago. LN B confirmed Resident 1's right hand lacerated fingers were not wrapped in dressing, as the physician ordered, at that time. LN B confirmed she had not followed Resident 1's physician ordered treatment and stated, because her fingers weren't bleeding and didn't appear infected. LN B stated, [Resident 1' fingers] would heal in a couple of days so wound care orders weren't necessary. LN B confirmed she had not followed the physcian's orders for Resident 1's wound treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor one out of three sampled residents (Resident 2) that were prescribed an antipsychotic medication (altered brain activity) when there was no monitor in place for staff to evaluate the response or effectiveness of Resident 2 ' s prescribed Haloperidol (Haldol, an antipsychotic) use. This failure could result in the unnecessary use of an antipsychotic medication and cause a decline in overall health status. Findings: A review of the facility ' s policy and procedure (P&P) titled, Care of Residents with Dementia and Care of Residents with Dementia Receiving an Antipsychotic Medication, revised 12/29/23, indicated, antipsychotic medications would be closely monitored for effectiveness. A review of Resident 2 ' s undated Admissions Record, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of dementia (memory loss) and severe major depressive disorder (a sad mood) with psychotic features (symptoms that affected the mind that included an inability to recognize what was real or what was not real and affected thought and behavior). Resident 2 was not her own responsible party and was dependent upon family to make all medical and financial decisions. A review of Resident 2 ' s Orders, dated 12/26/23, indicated the facility ' s physician ordered Haldol 0.5 milligrams (mg, unit of measure), one tablet by mouth two times a day for psychotic disorder due to extreme paranoia that caused extreme fear and distress. A review of Resident 2 ' s Orders, dated 1/4/24, indicated the physician increased Resident 2 ' s Haldol dose, from two tablets a day, to three tablets a day. A review of Resident 2 ' s Care Plan (a document that outlined care a resident received), dated 12/26/23, indicated Resident 2 used Haldol for behavior management and that facility staff would monitor Resident 2 for behaviors and symptoms of extreme paranoia that caused fear and distress. The Care Plan, indicated, facility staff would document per facility protocol. During a concurrent interview and record review on 4/3/24 at 1:50 pm, with Director of Nursing (DON), Resident 2 ' s Medication Administration Record (MAR), dated 12/27/23 through 4/3/24 was reviewed. DON stated, the facility physician and pharmacist utilized the data collected from the behavior monitor, located in the MAR, to determine the appropriate dose and effectiveness of antipsychotics that were ordered for residents. DON confirmed, Resident 2 had been prescribed Haldol on 12/26/23, confirmed there was no monitor in place that tracked Resident 2 ' s behaviors from 12/26/23 through 4/3/24, and stated there should have been.

Based on observation, interview, and record review, the facility failed to report an outbreak of scabies (tiny mites that crawled under the skin, caused itching, a rash, and was easily spread from person-to-person) to the California Department of Public Health (CDPH, worked to protect the public ' s health) when three residents and one staff member tested positive for scabies. This failure had the potential to cause further spread of scabies to other residents. Findings: A review of AFL 23-08 (All Facilities Letter (AFL), information regarding updated rules, provided to facilities, from CDPH), dated 1/18/23, indicated, the purpose of the AFL reminded facilities of the requirement to report outbreaks (more cases of a disease or infection than expected) to CDPH along with the local public health officer (public health, a resource to the community, that assisted facilities during an outbreak of disease or infection). A review of the undated policy titled, Outbreak Reporting, indicated, the facility would Report all suspected and confirmed outbreaks . to CDPH and the local public health officer. A review of the policy titled, Reporting Communicable Diseases, dated, 7/1/14, indicated, the facility ' s infection preventionist (IP, responsible to preventing the spread of infection and education) was responsible for reporting outbreaks to CDPH and the local public health officer. During an interview on 4/3/24 at 10:08 am, licensed nurse (LN) A stated, Resident 1 had a rash that spread all over Resident 1 ' s body and all 20 residents who lived in the facility ' s dementia (a disease the caused memory loss) unit were treated for scabies as a preventative measure. During a concurrent observation and interview on 4/3/24 at 10:22 am, located in the facility ' s dementia unit, a bag like container that contained personal protective equipment (gloves, isolation gown, shoe covers, worn by staff to prevent the spread of infection), hanging on Resident 1 ' s door, was observed. Certified nurse assistant (CNA) B stated, IP notified CNA B that Resident 1 was on isolation (separating someone from others to prevent spread of infection or disease) due to a rash. During a concurrent interview and record review on 4/3/24 at 11:11 am, with IP, the undated Index Case History and Contact Identification, (line listing, a document used to track and monitor outbreaks) was reviewed. IP stated, the Line Listing, indicated, Resident 3 was the first resident to be diagnosed with scabies on 3/11/24. IP stated, in total, there was one staff member and three residents that tested positive for scabies. IP stated two residents were being treated for scabies empirically (diagnosed by means of experience and not by means of test results). IP confirmed, IP did not report the scabies outbreak to CDPH and should have.

Based on observation, interview, and record review, the facility failed to publicly post the Nursing Hours Per Patient Day (NHPPD) sheets in a prominent place every day. This failure had the potential to prevent residents and visitors from having access to complete staffing information. Findings: During a concurrent interview and record review on 11/30/23 at 9:16 AM, with the Director of Nursing (DON), staffing sheets were hanging on a bulletin board in the hallway near the lobby. The sheets were titled, [Facility Name] Direct Care Staff, with a line below the title for the date. A table was divided into three sections, one each for the day shift, evening shift, and night shift. Four columns were titled, Registered Nurses (RNs); Licensed Vocational Nurses (LVNs); Unlicensed Nursing Staff; and Other Direct Care Staff, with the numerical information written in by hand for each shift. Beneath the table was the Resident Census number. When asked if those were the NHPPD sheets, DON thought they were, but was not sure. During an interview on 11/30/23 at 12:10 PM, the Staffing Coordinator stated they kept the NHPPD sheets and didn't post them and was never told to publicly post them.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. Food was not labeled in the walk-in refrigerator. 2. Food equipment was stored in an unclean area. 3. Food stored in Resident 41's room was not labeled and had expired. These failures had the potential to cause food borne illnesses in a medically vulnerable population. Findings: 1. During a review of facility's policy titled, Labeling and Dating of Foods, dated 2023, indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and use by date that follows the various storage guidelines. All prepared foods need to be covered, labeled, and dated. Leftovers will be covered, labeled, and dated. During the initial tour of the facility kitchen on 11/28/2023 at 9:15 am, with Registered Dietician (RD) and Food Service Supervisor (FSS), the following food items were observed not labeled or dated: a. A metal pan on the bottom shelf with thawing ground beef cubes. b. A previously opened container of cottage cheese. c. Two metal containers, one with sliced and one with diced tomatoes with clear plastic coverings. During an interview on 11/28/2023 at 9:15 am, the RD and FSS confirmed the ground beef cubes, container of cottage cheese, and metal containers of tomatoes should have been labeled and dated. 2. During a review of the facility policy and procedure titled, Sanitation, dated 2023, indicated all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and be free from breaks, corrosion, open seams, cracks, and chipped areas. During the initial tour of the facility kitchen on 11/28/2023 at 9:30 am, the RD, observed on the bottom shelf of the food prep area across from the stove, a large silver rectangular shaped shallow pan lined with a pan liner (thin paper like lining used for food preparation and cooking), with scattered brown particles on the pan liner that appeared unclean. Two large blenders upside down resting on their rims were stored on the paper liner that contained scattered brown particles and appeared unclean. During an interview on 11/28/2023 at 9:30 am, the RD, confirmed the blenders should not have been stored on the paper liner that contained scattered brown particles and appeared unclean. 3. During a review of the facility policy titled, Bringing In Food For A Resident, dated 2018, indicated food or beverages should be labeled and dated to monitor for food safety. Foods that are past the manufacturer's expiration date will be thrown away. Foods in unmarked or unlabeled containers will be marked with the current date and the resident's name. During a review of the facility policy titled, Food for Residents from Outside Sources, dated 2018, indicated non-perishable foods such as cookies, cake, crackers, etc. can be stored in the resident's room or at the nurse's station with the resident's name and date of storage. If opened, the food must be sealed, dated to the date opened, and disposed of by the best by date or 30 days, whichever comes first. During an observation and interview with Resident 41 on 11/29/2023 at 7:30 am, in Resident 41's room, observed a shelf containing a large clear Ziploc bag with 7 pieces of white bread. The Ziploc bag containing the bread was not labeled with the resident's name or date of storage. The shelf also contained a store-bought dessert in a hard clear plastic container with 5 square pieces left labeled, Brownies with Chocolate Fudge Icing and did not have the residents name or date of storage. The brownie container had a bright yellow expiration sticker on top of the container that indicated the brownies had expired 12 days ago, on 11/17/2023. Resident 41, indicated the bread was brought in by a family member about a week ago and the bread was probably bad and he could not remember when the brownies were brought in but they were too old to eat. During a concurrent observation and interview on 11/30/2023 at 7:20 am, with Certified Nursing Assistant (CNA) A in Resident 41's room, observed the unlabeled Ziploc bag containing the 7 pieces of white bread and the expired brownies in the clear plastic container with the bright yellow expiration date of 11/17/2023. CNA A stated the Ziploc bag and brownies should have been labeled with the resident's name and date of storage. CNA A confirmed the brownies were expired and should have been thrown away before the expiration date. During an interview on 11/30/2023 at 3:35 pm, with Licensed Nurse (LN) A, stated food brought in for residents should be labeled and dated when brought into the facility. LN A stated the licensed nurses, certified nursing assistants and housekeepers should monitor resident rooms for food items that are not labeled and dated or expired. During an interview on 11/30/2023 at 3:55 pm, with Director of Nursing (DON), stated when food was brought into the facility for residents, she expected staff to label it with the resident's name, room number and date. DON stated if the food had its own expiration date, the staff were expected to use that date to determine when the food was to be thrown out. DON confirmed bread in a Ziploc bag kept in a resident's room should be labeled with a name and date of storage. DON confirmed brownies kept in a resident's room with an expiration date of 11/17/2023, should have been thrown out on 11/17/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a concurrent observation, interview, and record review on 11/30/23 at 3 pm, with the IP and the Director of Nurses (DON), IP was observed to lick her fingers during a review on infection control practices, turn pages of documents with the dampened fingers, and then repeat the process of licking fingers and turning pages once again. IP and DON confirmed that was not a proper infection control practice. Based on observation, interview, and policy review, the facility failed to follow infection control standards for hand hygiene for three of seven sampled residents (Residents 58, 67 and 378) when: 1. A Licensed Nurse (LN) handled multiple meal trays and then handled a drinking straw without performing hand hygiene, for Resident 58. 2. A Certified Nursing Assistant (CNA) handled multiple meal trays and then handled a drinking straw without performing hand hygiene, for Resident 67. 3. A LN did not perform hand hygiene before or after she obtained a blood sample from Resident 378, and then cleaned medical equipment while wearing the same gloves used to obtain the blood sample. 4. The Infection Preventionist (IP) was observed to lick her fingers before turning pages of documents. These failures had the potential to spread germs which could have caused illness and threatened the residents' health and well-being. Findings: A review was made of a facility policy titled, Hand Hygiene & Donning Gloves, revised 2/13/19, which indicated it is the policy of the facility for all staff to perform proper hand hygiene per Centers for Disease Control and Prevention (CDC) guidelines and indicated that all staff will perform hand hygiene immediately before and after all resident care activities (performing finger stick), before any contact with food or water (opening meal tray items), and after contact with the patient care environment (room) to prevent transmission based infections (infection spread from a contaminated or dirty surface). According to the CDC, hand hygiene practices of using an alcohol-based hand rub or soap and water is indicated after contact with blood, body fluids, or contaminated surfaces. 1. During a med pass observation on 11/30/23 at 8:02 AM, LN D was observed assisting Resident 58 in her room with gloved hands. LN D was observed opening tray items, touching other surfaces in the room, and touching Resident 58's arm with gloved hands. When the resident asked for a straw, LN D left the room without removing gloves or performing hand hygiene. LN D walked through the hall with gloved hands and removed a straw from the clean supply on top of the station one med cart. LN D returned to Resident 58's room and resumed assisting the resident with the same gloved hands without performing hand hygiene. During an interview on 11/30/23 at 8:41 AM, LN D stated, the facility expectation is to perform hand hygiene before and after resident care. LN D explained gloves should be removed, and hand hygiene should be performed after handling items in a resident room, and confirmed this was not done during the 8:02 AM med pass with Resident 58 when it should have been. 2. Review of Resident 67's clinical record indicated they were admitted to the facility on [DATE]. Resident 67's diagnoses included Parkinsonism (a disorder of the central nervous system that affected movement, often including tremors), and macular degeneration (an eye disease that caused vision loss). During a concurrent observation and interview on 11/30/23 at 8:04 AM, in the Station One dining area, CNA B distributed resident breakfast trays while wearing gloves. CNA B removed the paper wrapper from a drinking straw and then touched the straw before placing it in Resident 67's juice glass. CNA B confirmed that they touched the straw after handling other breakfast trays while wearing the same pair of gloves without sanitizing their hands or changing gloves. 3. During a med pass observation on 11/30/23 at 11:48 AM, LN B gathered blood glucose monitoring (a test to measure the amount of sugar in the blood), supplies from the station 2 med cart without performing hand hygiene. LN B put gloves on without performing hand hygiene, left the station 2 med cart with gloved hands, walked through the hall to Resident 378's room, knocked on the door, entered the room, and performed a finger stick using a lancet (sharp item to poke through the skin and obtain a drop of blood for the glucose test), device with the same gloved hands. LN B soaked the end of a test strip with Resident 378's blood to obtain a blood glucose reading, gathered the used supplies, and left the room without removing gloves or performing hand hygiene. LN B walked through the hall, returned to station 2 med cart with the same gloved hands and placed the dirty glucometer on top of the med cart. During an interview on 11/30/23 at 11:52 AM, LN B stated, the facility expectation is to perform hand hygiene before and after resident care and confirmed that hand hygiene should have been performed before checking Resident 378's blood glucose, prior to exiting the room, and again after cleaning the glucose monitoring equipment. During an interview on 11/30/23 at 11:58 AM, LN C explained the facility expectation is to perform hand hygiene before and after providing resident care, and that if removing a dirty item from a resident room one hand only, may be partially gloved, with a clean glove to carry the dirty item until it is cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure their infection control program was properly maintained and/or implemented to reduce the spread of COVID-19 when Personal Protective Equipment (PPE, gloves, gowns, eye protection, and masks) was not consistently and correctly used by staff during resident care. These failures had the potential to contribute to the outbreak of COVID-19 at the facility. Findings: A review of the facility's most recent Covid -19 Policy/implemented with CDPH SNF IP (California Department of Public Health Skilled Nursing Facilities Infection Prevention) webinar (a live online video conference or presentation) frequently asked questions, revised on 5/13/2022, PPE and Face Masks per CDPH All Facility Letter(AFL) 20 – 74.1 (released on 7/22/2021) , indicated Eye Protection (face shields, goggles) and gowns were recommended for COVID Positive Residents (red area) and Symptomatic Suspected COVID, awaiting test results . A review of the guidance on the Center for Disease Control (CDC) website, titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic , updated on 9/23/2022, indicated Health Care Personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a The National Institute for Occupational Safety (NIOSH)-approved particulate respirator (a type of air-purifying respirators protects by filtering particles out of the air the user is breathing) with N95 filters (N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html A review of a document from CDPH Infection Prevention Webinars held on 10/26/2022 (The California Department of Public Health (CDPH)—with the California Association of Long Term Care Medicine (CALTCM), California Association of Health Facilities (CAHF), and Health Services Advisory Group (HSAG)—hosts a bi-weekly (2nd and 4th Wednesdays) webinar on infection prevention for long term care facilities to discuss any recent updates on Coronavirus Disease 2019 (COVID-19) and provide a venue for addressing questions. The webinars focus on infection prevention guidance for Skilled Nursing Facilities (SNFs)), titled California Department of Public Health, Center for Health Care Quality All Facilities Calls (AFC) Skilled Nursing Facilities Infection Prevention Call, October 26,2022 , the section of PPE Questions & Answers , Question -9: When Do HCP need to wear eye protection (face shields, googles)? indicated that, HCP need to wear eye protection when caring for COIVD-19 positive residents in isolation . During an observation at Hall 600 located at Station II on 11/21/2022 at 11:26 am, room [ROOM NUMBER], 603, 604 and 605 were occupied with one resident per room. Rooms 602, 604 and 605 had COVID CONFIRMED red signages posted outside the room. room [ROOM NUMBER] located at Hall 500 Station II contained one resident with COVID CONFIRMED red signage posted outside the room. During an observation and interview on 11/21/2022 at 11:30 am, Licensed Nurse (LN) 4 was seen without wearing eye protection while providing care to the resident who resided in room [ROOM NUMBER]. LN 4 confirmed that she was wearing her own eyeglasses and she did not wear any eye protection. During a concurrent observation and interview on 11/21/2022 at 12:02 pm, Certified Nursing Assisant (CNA) 5 was seen entering room [ROOM NUMBER] without eye protection and providing lunch service for the resident. CNA 5 confirmed that she should have worn an eye protection per the facility Covid policy, and she confirmed that there was no eye protection equipment inside the PPE supply cart outside of room [ROOM NUMBER]. She said, I felt bad, I would go and check all the PPE supply carts now . During an observation on 11/21/2022 at 12:07 pm, PPE supply cart/bags outside room [ROOM NUMBER], 604 and 605 were inspected and no eye protection equipment was found. During a concurrent observation and interview on 11/21/2022 at 12:08 pm, Speech Therapy (ST) was seen inside room [ROOM NUMBER] speaking to the resident. She confirmed that she was not wearing a gown, gloves, and eye protection. ST stated that she did not need to wear PPE because she was assessing the resident's cognition. During an interview on 11/21/2022 at 12:55 pm, with the Infection Preventionist (IP), she stated that while caring for Covid positive residents, gown, gloves and face shield were needed for full patient care. She said, when you were taking care of the resident directly, you do eye shield .I was not sure that they changed the rule .