Based on observation, interview and record review, the facility failed to follow its abuse prevention policy and procedures when one of one sampled resident (Resident 1) reported an incident of alleged physical abuse by staff, but the facility had no evidence it conducted an investigation nor reported the results of the investigation to the State Department of Health (the Department) within 5 working days. This failure had the potential to delay the Department ' s independent investigation of the incident. Findings: Review of Resident 1 ' s nurse's progress note, dated 10/29/2024 at 10:15 p.m., indicated, Resident [1] stated to the LN [licensed nurse] the CNA [certified nursing assistant] from last time [10/28/24] pulled on her arms and gave her a 2.5cm x 2 cm discoloration to her left hand near thumb . During a concurrent interview and record review on 2/12/25 at 3:20 p.m., with Medical Record Staff (Staff D), Resident 1's electronic medical record was reviewed. Staff D stated Resident 1's medical record contained a nurse's note dated 10/29/24 at 10:15 p.m. documenting the alleged abuse. Staff D also confirmed the medical record did not contain any additional nurse's notes nor IDT (interdisciplinary team of healthcare professionals including nursing, social workers, pharmacy, and dietary staff) notes addressing the alleged abuse incident or investigation of the incident. During a telephone interview on 2/13/25 at 2 p.m., AA stated she was unable to produce documentation of an IDT meeting, nor a 5-day investigation summary related to Resident 1 ' s alleged abuse incident. During a telephone interview on 2/14/25 at 10:15 a.m., AA stated when there is an allegation of abuse, the facility would interview all parties involved (including the family, resident, and staff), the incident would be discussed in IDT meetings, IDT meeting notes would be stored in a file of the in-house investigations, and social service staff would document investigation notes in the resident ' s medical record. AA confirmed the facility did not have any documentation related to an in-house investigation, nor IDT notes regarding the incident, nor any social service documentation related to the incident in Resident 1's medical record. AA added, the Administrative staff and the Director of Nursing were responsible for providing the 5-day investigation summary to the Department and confirmed the 5-day investigation summary should have been completed. Review of facility policy titled, Abuse and Neglect - Clinical Protocol, subtitled, Cause Identification, revised March 2022, the policy indicated, .1. The staff .will investigate alleged abuse and neglect to clarify what happened and identify possible causes . Review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, subtitled, Policy Interpretation and Implementation, revised April 2021, indicated, . 8. Identify and investigate all possible incidents of abuse . 9. Investigate and report any allegations within timeframes required by federal requirements .

Based on interview and record review the facility failed to perform annual performance reviews on two out of three sampled Certified Nursing Assistants (CNA). These failures had the potential for unlicensed nursing staff to not have their skills assessed under the performance review and not have necessary training addressed in the performance review. Findings: During a concurrent interview on 4/26/24 at 10:54 a.m., with Director of Nursing (DON) and Director of Staff Development (DSD) (by telephone), DSD was asked about the process for completing annual reviews for certified nursing assistants. DSD indicated the annual performance reviews were behind and agreed that Unlicensed Staff P and Unlicensed Staff Q had outstanding annual performance reviews. DSD indicated that on a three day a week schedule, there were things which were behind for the facility. DSD indicated the process would be to complete them within the month of the employee's hire date and the facility was working on the current year of 2024 and indicated 2023 was not complete with performance reviews for all unlicensed staff. During a review of Unlicensed Staff Q's, Human Resource File, dated 10/12/21, indicated to date of hire, Annual Performance Review was not observed for the year 2023. During a review of Unlicensed Staff P's, Human Resource File, dated 3/25/22, indicated to be date of hire, Annual Performance Review was not observed for the year 2023 or 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to appropriately diagnose and treat a growth on the left side of Resident 29's nose for one out of one sample residents (Resident 29). This failure had the potential to cause an infection and create discomfort for ongoing growth on Resident 29's face. Findings: During a review of Resident 29's, admission Record dated, 6/20/2022, indicated Resident 29's had a history of dementia (a general term for the impaired ability to remember, think or make decisions that interferes with doing everyday activities) and dry eye syndrome of bilateral lacrimal glands (lacrimal gland doesn't make enough tears, causing the eyes to become dry, sometimes caused by age). During an observation on 4/22/24 at 12:25 p.m., Resident 29 was observed lying in bed, asleep with a large growth on the left side of her nose with three streaks of dried blood on her cheek. During an interview on 4/22/24 at 3:29 pm. with Unlicensed Staff A, Unlicensed Staff A indicated Resident 29 had a tumor which had been consistently growing and staff were told to watch Resident 29 because she would scratch the growth causing it to bleed. During an interview on 4/22/24 at 4:02 p.m., with Licensed Staff B, Licensed Staff B indicated Resident 29 consistently picked at growth on the side of her nose and Licensed Staff B would use saline solution to clean the area and then re-apply a band aide to cover the growth. During a concurrent interview and record review on 4/24/24 at 4:06 p.m., with Social Services Director (SSD), SSD indicated part of the role was to arrange for transportation to medical appointment and care planning conferences. Resident 29's, Social Services Progress Note, dated 2/7/24, indicated Resident 29 had a plastic surgeon appointment, it was canceled without communication to the facility. SSD indicated, she was unaware of who made the appointment, but the transportation was arranged and when Resident 29 had arrived, it was determined the appointment was canceled. SSD indicated Resident 29's doctor had indicated Resident should be evaluated by dermatologist, but it was determined Resident 29 would not be further evaluated. Resident 29's, Care Plan Conference dated 3/12/24, indicated Resident 29's overall plan of care was evaluated. SSD indicated Resident 29's growth had started out small, looking like a mole and had progressed to the large growth on the left side of the nose. Resident 29's, Responsible Person (RP) had attended the conference by telephone and did not routinely visit Resident 29 in person. SSD indicated Resident 29's RP had not wanted any further diagnosis or treatment with the growth based upon Resident 29's age and the understanding that Resident 29 was not in any pain regarding the growth. SSD indicated Resident 29's RP had not seen how large the growth has gotten or the issue with Resident 29 scratching her nose, causing the growth to bleed. During an interview on 4/25/24 at 10:18 a.m., with Licensed Staff L, Licensed Staff L indicated Resident 29's growth has been getting larger, for example about four to five months ago, it was not as large as it was today. Licensed Staff L indicated that there was old blood type drainage observed around the growth and around the band aide which was visible beyond the band aide but was going to provide any treatment unless Resident 29 would pick at it causing further bleeding. Licensed Staff L indicated the plan was to continue replacing the band aide when soiled and not to pursue any further treatment. During a concurrent interview and record review on 4/25/24 at 2:17 p.m., with Licensed Staff N, Licensed Staff N indicated when Resident 29 was first admitted to the facility in 2022, Resident 29's RP had visited her two times a week and has been subsequently the visiting her less and less. Licensed Staff N indicated, Resident 29's growth on the left side of her nose started out looking like a mole and had has been subsequently growing and getting larger and larger approximately over the last year and a half. Licensed Staff N indicated the facility has not been monitoring the growth as there are no measurements with which to reference the starting size with current size. Licensed Staff N indicate Resident 29 with the coordination of the doctor and Resident 29's RP, there was a dermatology (branch of medicine dealing with the skin) appointment made and Resident 29 had attended, Licensed Staff N indicated at the appointment, Resident 29 had become combative and would not let the clinic staff assess the growth and since the appointment the doctor and RP had indicated there was no further treatment to pursue. Licensed Staff N indicated the growth on Resident 29's nose has grown toward the lower eye lid area. Licensed Staff N indicated the growth has been bleeding more and more when Resident 29 would pick at it. Licensed Staff N indicated Resident 29's RP has not seen the growth and not sure when the medical doctor or nurse practitioner had observed the vascularity or the continually bleeding when the growth was touched by Resident 29. Licensed Staff N indicated there were other treatment options potentially available to Resident 29 and confirmed that the Resident 29's RP was not aware of the current size and bleeding nature of the growth and the current treatment option would pose a potential for infection as whatever would be on Resident 29's fingers would gain access to an open wound when the growth was itched or scratched. The INTEGRETY SKIN ASSESSMENT, which were completed weekly, dated 4/15/24, 4/9/24, 4/8/24, 4/1/24 and 3/27/24 were reviewed and indicated Resident 29 had a skin tag indicated on the left side of her nose, with no changes and treatment to continue as indicated. Licensed Nurse N indicated the weekly skin assessments were not documenting the changing size and daily bleeding events of the growth on Resident 29's nose. The Integrity Skin Assessment dated 2/26/24, revealed a skin tear on the elbow but did not indicate a growth on Resident 29's nose and the assessment dated [DATE] did not indicate a growth on the nose either. Licensed Staff N indicated the health care team was not on the same page and per the documentation the accuracy of the monitoring of the skin growth was not reflected as to the current condition. Licensed Staff N indicated the risk to not addressing the growth on Resident 29's nose as a comprehensive health care team would increase the risk of infection and discomfort for Resident 29. During an on 4/26/24 at 11:19 a.m., Director of Nursing (DON), indicated regarding Resident 29's skin growth on the left side of her nose, the medical doctor had been contacted and Resident 29's fingernails needed to be care planned to keep finger nails short and her hands to need to be sanitized to reduce risk of infection. DON indicated, Resident 29's RP had been contacted and wanted to keep the plan of care as per the medical doctor. DON indicated there was a wound care doctor who made on site visits to the facility and Resident 29's growth on her nose would be evaluated to assess treatment options, since the band aide was not working that well. DON indicated she was not aware that the growth was increasing in size toward the lower eyelid of the left eye and that Resident 29's medical doctor would assess the growth on the nose. During a review of the facility's policy and procedure, titled Charting and Documentation, dated 7/17 indicated, c. Treatments or services performed .d Changes in the resident's condition; .f. progress toward or changes in the care plan goals and objectives .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . A review of the facility's policy and procedure titled, Skin and Wound Management, dated 3/20, indicated b. Once inspection of skin is completed document the findings on a facility- approved skin assessment tool .c. If a new skin alteration is noted a (pressure or non-pressure) form related to the type of alteration in skin . 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the RNA (restorative nursing assistant) program (assist the patient in performing tasks that restore or maintain physical function as directed by the established care plan) was being received per physician orders for one of 15 sample residents (Resident 33). This failure resulted in a disruption in treatment and had the potential for Resident 33 to have a decline in range of motion, strength and endurance, an increase in joint pain and depression, and an overall decrease in ADLs (Activities of Daily Living: activities related to personal care, which includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Findings: A review of Resident 33's admission Record, indicated Resident 33 was admitted to the facility on [DATE], with a diagnosis including cerebral infarction (stroke), major depression disorder, hemiplegia (paralysis on one side of the body), hearing loss, amongst others. A review of Resident 33's Physician Progress Note, dated 1/24/24, indicated Resident 33 had left hemiplegia, and the physician was adding Tylenol to Resident 33's medication list for joint pain. A review of Resident 33's ADL Function and Left-Hand Contracture Management care plan, Focus: decreased functional ability related to CVA (Cerebral Vascular Accident: stroke), decreased/limited ROM (Range of Motion)-left hand/wrist contracture; hemiplegia, initiated 12/19/22 and revision date, 4/5/23. The care plan Interventions/Tasks included: RNA - Transfer Training: from bed to wheelchair with extensive assist, revision on 7/26/23, and Passive Range of Motion (PROM) and stretching to bilateral upper extremities (arms) and Active Range of Motion (AROM) to bilateral lower extremities (legs) ten repetitions (reps) times two sets, revision date, 7/26/23. A review of Resident 33's Quarterly MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 3/22/24, indicated Resident 33 had a BIMS (Brief Interview of Mental Status) score of 12 (resident's mental understanding was moderately impaired), and indicated Resident 33 had functional limitations: impairment of one side: upper/lower extremities, one side. During a concurrent observation and interview on 4/22/24 at 10:33 a.m., Resident 33 stated he had left upper and lower extremity paralysis from a stroke, which occurred over a year ago. Resident 33 stated he was supposed to go to the gym twice a week, but promises were not kept all the time. Resident 33's left arm was elevated on a pad, bent at the elbow, while in his wheelchair. Resident 33 had no function of his left upper extremity because of a stroke. Resident 33 stated once he was assisted up from his wheelchair, he could take steps using the parallel bar. Resident 33 stated he felt his paralysis was getting better. A review of Resident 33's physician order, dated 7/20/23, indicated a request for the RNA Program to help maintain functional mobility and muscle strength 3x-5x/week for 90 days. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps times two, dated 7/1/202 - 8/30/2023, indicated Resident 33 received his ordered exercises on 8/13/23 and 8/17/23 for 15 minutes each day. Resident 33 received his ordered exercises from the RNA two times in a six-week period. Resident 33 should have been offered his exercises a minimal of 12 times in the six-week period. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps times two, dated 8/31/2023 - 10/29/203, indicated Resident 33 received his ordered exercises from the RNA on 9/22/23, 9/23/23, 10/1/23, and 10/14/23 for 15 minutes each day. Resident 33 refused his exercises on 10/27/23 and 10/28/23. Resident 33 received his ordered exercises from the RNA four times in an 8-week period. Resident 33 was offered his ordered exercises five times in an eight-week period. Resident 33 should have been offered his exercises from the RNA a minimal of 16 times in an 8-week period. A review of Resident 33's physician order, dated 10/20/23, indicated a request for RNA Program to help maintain functional mobility and muscle strength 3x-5x/week for 90 days. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps times two, dated 10/30/23 - 12/25/23, indicated Resident 33 received his ordered exercises on 11/11/23, 11/17/23, 12/22/23, and 12/23/23 for 15 minutes each day, 12/8/23 for 30 minutes, 12/25/23 for 45 minutes, refused on 11/25/23, and not available on 12/15/23 and 12/18/23. Resident 33 received his ordered exercises six times in an eight-week period. Resident 33 was offered his ordered exercises from the RNA seven times and not available two times. Resident 33 should have been offered his exercises from the RNA a minimal of 16 times in the eight-week period. A review of Resident 33's physician order, dated 1/20/24, indicated a request for RNA Program to help maintain functional mobility and muscle strength 3x-5x/week for 90 days. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps' times two, dated 12/26/23-2/20/24, indicated Resident 33 received his ordered exercises on 12/29/23, 1/12/24, 1/26/24 for 15 minutes each day, and he was not available on 12/28/23 and 1/28/24. Resident 33 received his ordered exercises from the RNA three times in an eight-week period. Resident 33 was offered his ordered exercises three times and not available one time. Resident 33 should have been offered his exercises from the RNA a minimal of 16 times in the eight-week period. A review of Resident 33's electronic medical record for the RNA task, PROM and stretching to bilateral upper extremities and AROM to bilateral lower extremities ten reps' times two, dated 2/21/24-4/20/24, indicated Resident 33 received his ordered exercises on 2/23/23, 3/9/23, 4/12/24 for 15 minutes each day and 4/20/24 for 30 minutes. Resident 33 received his ordered exercises from the RNA four times in an eight-week period. Resident 33 was offered his exercises from the RNA four times. Resident 33 should have been offered his exercises from the RNA a minimal of 16 times in the eight-week period. A review of Resident 33's electronic medical record for the RNA task, Transfer training: from bed to wheelchair with extensive assist, dated 8/31/23-10/28/23, 10/29/23-12-25/23, 12/26/23-2/22/24, and 2/23/24-4/23/24, indicated Resident 33 was offered and performed the Transfer Training exercise on 1/28/24 for five minutes, 4/20/24 for 30 minutes, refused on 10/27/24, and not available on 12/15/23 and 12/25/23. Resident 33 was offered the Transfer Training exercise three times in 33-weeks/eight-month time period. During an interview on 4/24/24 at 11:45 a.m., the Rehab Manager stated supposedly the DON was in charge of the RNA Program, but she has been overseeing the RNA Program for the past three years. The Rehab Manager stated she would initially evaluate the resident to see what exercises the resident would benefit from, then instruct the RNA by the RNA observing her perform the exercises with the resident and then by the RNA repeating the technique with the resident. The Rehab Manager stated it should be the residents' nurse who should oversee to make sure the residents they are assigned to and who are in the RNA program were receiving their physician ordered exercises. The Rehab Manager stated she made the exercise plan for the resident, had the physician approve and sign the plan, and she tried to meet with the RNA at least once a month to go over the resident's progress. During a concurrent interview and record review on 4/24/24 at 12:08 p.m., Unlicensed Staff O stated her RNA schedule was Monday, Wednesday, Friday, and Saturday. Unlicensed Staff O stated she was pulled to be a CNA (Certified Nursing Assistant) and assigned residents to care for on Monday, 4/22/24. Unlicensed Staff O stated she worked as an RNA twice a week and a CNA twice a week lately. Unlicensed Staff O stated there was another CNA who completed her RNA certification a few months ago but she has only shadowed (trained) with Unlicensed Staff O once because she was always placed on the CNA schedule. Unlicensed Staff O stated the RNA in training that one day was pulled because the CNA from the registry had to leave early. Unlicensed Staff O stated she had 19 residents in the RNA program. Unlicensed Staff O stated she tried to see the residents three days per week for 15 min but the residents should be seen three to five days a week for 15 to 30 min. Unlicensed Staff O stated if the residents refused their scheduled exercises she would document refused. Unlicensed Staff O stated Resident 33 has only been seen twice this month, 4/12/23 & 4/20/23 because the facility has been short staffed, so she was pulled from her duties as an RNA to fill a CNA spot. A review of Unlicensed Staff O's RNA resident assignment dated 4/22/24 (Monday), 4/23/24 (Wednesday), 4/26/24 (Friday) and 4/27/24 (Saturday), indicated Resident 33 was scheduled to be seen on Friday and Saturday for 15 minutes. Resident 33's physician ordered RNA Program plan indicated Resident 33 should have been seen by the RNA 3x-5x/week. During an interview on 4/25/24 at 10:03 a.m. the Director of Nursing (DON) stated the Rehab Manager was overseeing the RNA Program. The DON stated the facility had two RNAs, but it was pointed out to the DON the new RNA was pulled to the floor all but one day to fill a CNA spot because the facility was short staffed. The DON stated that was correct, the new RNA has been pulled to fill a CNA spot because the facility has been short staffed CNAs, but at least she was trained. During an interview on 4/25/24 at 3:27 p.m., Resident 33 was dressed and up in his wheelchair near his bed. Resident 33 stated he had not had RNA therapy today. Resident 33 stated he wanted to get stronger but felt like he was being forgotten about. The facility policy/procedure titled, Restorative Nursing Services, revised 7/2017, indicated: Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation: . 5. Restorative goals may include but are not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining, or strengthening his/her physiological and psychological resources; c. maintaining his/her dignity, independence, and self-esteem; and d. participating in the development and implementation of his/her plan of care . 8. Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs. The facility policy/procedure titled, Resident Mobility and Range of Motion, revised 7/2017, indicated: Policy Statement: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable . The facility job description titled, Restorative Nursing Assistant, undated, indicated: . Job Duties: oWorks with licensed therapy staff during active therapy period to take instruction on individual care of Elders. Follow through with individual Elders discharged from active Rehab Therapy to maintain abilities and improve endurance and independence through bed mobility, transfer skills, active ROM including splints as applicable, ambulation, assistance and instruction in AOL care. *Documents restorative treatments and actions by completing forms, reports, logs, and records. *Documents weekly progress reports for all participating Elders .

Based on observation and interview, the facility failed to follow a process of ensuring resident meals were served with the appropriate dietary consistency when one of two staff (Licensed Staff L) was observed reviewing the meal tray cards but not reviewing the covered food for accuracy prior to the meal being served to residents. Findings: During an observation on 4/22/24 at 12:34 p.m., with Licensed Staff L who was reviewing the resident meal tray cards and then reviewing the dietary order in the electronic medical record. Licensed Staff L was observed instructing the Certified Nursing Assistant (CNA) the appropriate texture for the tray, for example regular, pureed (food served with a pudding like texture, which is smooth and blended). Licensed Staff L was observed repeatedly checking the electronic medical record, waiting for the CNA staff to return and serve another tray. At one point, a CNA called out the resident's name and Licensed Staff L indicated the texture of the tray and CNA then delivered the tray to the resident. Licensed Staff L did not open the covered meals to view the dietary texture, only the meal tray cards were reviewed against the dietary orders in the electronic medical record. During an interview on 4/22/24 at 12:54 pm., with Licensed Staff L, Licensed Staff L indicated the process for checking meal trays prior to serving the residents was to review the dietary orders in the electronic medical record against the meal tray cards on each resident's tray prior to serving the resident. Licensed Staff L indicated the meals were not uncovered because it would mean the food might be touched. Licensed Staff L indicated he was new but had been working as a licensed staff member for a long time. Licensed Staff L agreed that the process of checking meal trays prior to serving the residents was common practice and not new to this particular facility. Licensed Staff L indicated the reason behind checking the trays was to ensure the consistency was appropriate and the resident would not choke on food which had not been prepared appropriately or aspirate (when food or liquid enters a persons airway and lungs). During a observation on 4/23/24 at 12:31 p.m., the lunch cart had been delivered and Unlicensed Staff Q was observed looking for licensed staff to check the trays. Unlicensed Staff Q indicated Licensed Staff L was at lunch and not available to check the lunch trays. A student was observed to walk up to the lunch cart and proceed to pull out a lunch tray and deliver to a resident. Unlicensed Staff Q was observed to deliver a lunch tray a resident. At 12:32 pm., Licensed Staff L was observed to be rushing onto the unit and indicating out loud that he was late for checking the trays and asked why Unlicensed Staff Q had not gone to get him. Unlicensed Staff Q did not respond to the question but gave a quizzical look. During an interview on 4/25/24 at 2:17 p.m., with Licensed Staff N, Licensed Staff N indicated as part of the role, there would be training with new licensed nurses but in terms of documentation, where and how to document. During an interview on 4/26/24 at 11:00 a.m., with Director of Nursing (DON), DON indicated the role of the licensed staff was to check the meal trays for appropriate consistency against the doctor order to ensure the meal card matched the consistency of the food being served. DON indicated when a new licensed staff person has been hired, there was no formal documentation regarding how to perform the task. DON was asked about the break/lunch schedule for licensed staff and DON indicated the licensed staff they do their own breaks/lunches. DON indicated she was not aware that meals were not being checked by licensed staff prior to being served to the residents and that licensed staff were not checking the consistency of the food being served for safety purposes. DON indicated the reason for the safety measure was to ensure the residents did not aspirate the meal due to inappropriate consistency being served. During a review of the facility's policy and procedure titled, Policy and Procedure, Tray Line Procedure, dated 2017 indicated, 6. Assigned Staff: a. When a cart is fully loaded the assigned staff delivers the cart to the nurses' station and announces the arrival of the cart.

Based on observation, interview and record review, the facility failed to ensure the safety, and functional environment in the kitchen when cracks and missing tiles on the kitchen floor were not repaired. This failure can cause trips and falls among the kitchen staff and cause dirt to build up on the floor attracting cockroaches and rodents. Findings: During initial tour of the kitchen on 4/22/24, at 9:20 AM, cracked tiled were noted on the floor in front of the entrance to the dry good storage. On continued observation on 4/22/24, at 10:06 AM, more cracks on the tiled floor and missing tiles were noted by the washing sinks, by the exit door to the back of the building, and by the entrance way to another dry good storage. During an interview on 4/23/24, at 10:09 AM, Certified Dietary Manager (DM) nodded in acknowledgement when told the cracks on the kitchen floor and missing tiles were findings of non-compliance to regulations. Review of the Food Code 2017 indicated: It is the standard of practice to ensure materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where FOOD ESTABLISHMENT operations are conducted.

Based on observation, interview and record review, the facility failed to ensure the sanitization, safety, and functional environment in the kitchen when the temperature of the final rinse of the dishwasher was not maintained to adequately sanitize dinnerware and cooking utensils. This failure can potentially result to food contamination and outbreak of foodborne illness among residents of the facility. Findings: During a concurrent observation and interview on 4/23/24, at 10:02 AM, the final rinse of the high temperature dishwasher was 150 degrees Fahrenheit. Dietary Aide E stated the dishwasher is not holding the final rinse temperature of 180 degrees Fahrenheit. During an interview on 4/24/24, at 5:19 PM, Dietary Aide F when asked about the final rinse temperature of the high temperature dishwasher stated, the dishwasher does not always go up to 180 degrees Fahrenheit at final rinse. Dietary Aide F stated he runs the dishwasher several times to reach 180 degrees Fahrenheit before he continues dishwashig. During an interview on 4/25/24, at 10:45 AM, Dietary Aide E confirmed she runs the dishwasher several times to check if the temperature goes to 180 degrees Fahrenheit. When asked what the final rinse temperature for the current batch of trays and cups, on the right of the washer was, Dietary Aide E stated, it was 150 degrees Fahrenheit. When asked what her course of action is given the dishwasher situation, Dietary Manager D (DM D) stated they will use disposable plates and utensils for lunch. DM D stated they are calling an on-call maintenance service to fix the final rinse booster heater of the dishwasher as their facility maintenance man could not come to fix it. During a review of records on 4/25/24, at 11:08 AM, the monthly Consultant Dietitian Report Card indicated, the dishwasher final rinse booster heater was broken in 1/24 and the dishwasher was not holding temperature. In 2/24, the report card indicated the final rinse booster heater was leaking and dishwasher was not holding temperature. In 3/24, the report card indicated the final rinse booster heater continued to leak and dishwasher was not holding temperature. A review of the undated document provided by the facility titled: Directions for Machine Dish Washing - High Temperature Machine indicated, under Rinse, Keep at 180 degrees Fahrenheit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 34's admission Record indicated Resident 34 was admitted to the facility on [DATE], with a diagnosis including congested heart failure (condition that develops when one's heart doesn't pump enough blood to meet the body's needs), pleural effusion (fluid builds in the space between the lung and the chest wall leading to shortness of breath), palliative care (specialized end-of life medical care for people living with a serious illness, such as heart failure, amongst others). A review of Resident 34's Order Summary Report, dated 4/26/24, indicated Resident 34 to be placed on oxygen (O2) at two liters (L) to five liters per minute via nasal cannula continuously to keep O2 saturation (the amount of oxygen circulating in one's blood) level greater than 90 percent, start date 1/22/24 and change O2 humidifier and nasal cannula every five days and as needed, start date 1/17/24. During an observation on 4/22/24 at 10:12 a.m., Resident 34 was on O2 at 2L/min per nasal cannula and had a humidifier, with adequate water level. The nasal cannula tubing and humidifier were not dated to show when they were last changed. A review of Resident 34's care plan indicated Resident 34 was admitted to Hospice (focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life), initiated 1/18/24. Focus was to apply O2 at two to five liters per minute via nasal cannula as needed for O2 saturation level 90% or greater. A review of Resident 34's Treatment Administration Record (TAR), dated 1/2024, 2/2024, 3/2024, and 4/2024, indicated Resident 34's O2 nasal cannula and humidifier were to be changed every five days and as need. The TARs indicated Resident 34's nasal cannula and humidifier was changed one time, 2/28/24. During an observation on 4/25/24 at 3:05 p.m., Resident 34 was resting comfortably in bed and positioned on her right side. Resident 34 was on O2 at 2L but Resident 34's nasal cannula tubing and humidifier were not labeled to indicate when they were last changed. During a concurrent interview and record review on 4/25/24 at 3:16 p.m., Licensed Staff N was asked to look at Resident 34's TARs to see when Resident 34's nasal cannula tubing and humidifier was last changed. Licensed Staff N stated the last time Resident 34's TAR was documented to indicate when Resident 34's nasal cannula tubing and humidifier was changed was 2/28/24 at 10 a.m. Licensed Staff N stated the night nurse was supposed to change the resident's O2 cannula tubing and humidifier weekly and it should be documented on the resident's TAR. Licensed Staff N stated any nurse from any shift could have changed the Resident 34's nasal cannula tubing and humidifier. Licensed Staff N stated if it was not documented it was not done. During an interview on 4/26/24 at 8:58 a.m., the Director of Nursing (DON) stated the night nurse was responsible for making sure the resident's nasal cannula tubing and humidifier was changed, which was scheduled every Wednesday. The DON did not realize Resident 34 had not had her nasal cannula tubing and humidifier changed since 2/28/24. The DON stated the IP (Infection Preventionist) should be overseeing if nasal cannula tubing/humidifiers were changed weekly. The DON stated it sounded like it was a documentation issue. It was pointed out to the DON Resident 34's nasal cannula tubing and humidifier was not labeled with a date to indicate when it was last changed. The IP stated she had not started the process of overseeing if the resident's nasal cannula tubing and humidifier was being changed weekly. The facility policy/procedure tiled, Oxygen Therapy, revised 10/2010, indicated: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . The facility job description titled, Infection Preventionist (IP), undated, indicated: Job Responsibility: Develop and maintain a system of care that promotes sound and scientific infection prevention principles and practices. Accountable for decreasing the incidence and transmission of infectious diseases. Through strategic planning, leads the team in the identification and implementation of infection prevention goals and objectives throughout the facility . The facility job description titled, Registered Nurse (RN), updated 12/30/23, indicated: Job Responsibilities: . RNs provide direct nursing care to residents in accordance with facility policy, physician's orders, and State/Federal regulations. RNs also help supervise the day-to-day nursing activities performed by Licensed Vocational/Practical Nurses and Certified Nursing Assistants (CNAs). Job Duties: . *Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary . * Operate and monitor medical equipment . The facility job description titled, Licensed Vocational Nurse (LVN), updated 12/29/23, indicated: Job Responsibilities: . LVNs provide direct nursing care to residents in accordance with facility policy, physician's orders, and State/Federal regulations . Job Duties: * Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary . *Operate and monitor medical equipment . Based on observation, interview and records review, the facility failed to: 1) ensure hand hygiene was practiced by six (6) of 15 sampled residents (Resident 3, Resident 16, Resident 9, Resident 22, Resident 1, Resident 24) before meals. This failure had the potential to cause the spread of infections to other residents and worsen their already compromised health or cause an outbreak; 2) conduct ongoing analysis of infection surveillance. This failure had the potential to result in the facility missing to identify trends in infection types and occurrence and not being able to detect where an infection came from or the presence of an increasing number of infection or an outbreak; 3) ensure physician's orders were being followed when one of 15 sampled residents (Resident 34), who was on oxygen, nasal cannula (a device that delivers extra oxygen through a tube and into your nose) and oxygen humidifier (plastic bottle filled with distilled water that adds moisture to the oxygen being delivered to prevent dryness of the nasal cavity) was not being changed weekly. This failure had potential for the plastic to deteriorate over time leading to tiny cracks and pores in the plastic tubing to occur. In these tiny cracks and pores, bacteria and mold could start to breed, and dirt, dust, and other small irritants, which could lead to lung infections. Findings: 1. During an observation on 4/22/24, at 12:17 PM, Licensed Staff C served Resident 16's meal tray in her room and asked Resident 16 if she would like to eat her lunch. Licensed Staff C did not offer to wash or wipe Resident 16's hands. During continued observation on 4/22/24, at 12:20 PM, Unlicensed Staff G served Resident 9's lunch tray in her room. Unlicensed Staff G was not heard or seen offering to wash or wipe Resident 9's hands. During subsequent observation on 4/22/24, at 12:43 PM, Licensed Staff C went into the room of Resident 22 to serve her meal tray. Licensed Staff C did not offer or remind Resident 22 to wash or wipe her hands before she left the room. Unlicensed Staff G then went into the to help Resident 22 remove the plastic covers over her food. Unlicensed Staff G did not offer or remind Resident 22 to wipe or wash her hands before eating. During an interview on 4/22/24, at 12:47 PM, Unlicensed Staff G when asked if she offered to wash or wipe the hands of her residents' when she served their meal trays stated she did not. During continued interview on 4/22/24, at 12:48 PM, when Unlicensed Staff G was told there were no moist wipes on Resident 22's meal tray, Unlicensed Staff G was surprised and stated there used to be moist wipes in residents' trays. Unlicensed Staff G confirmed there were no moist wipes on Resident 22's tray and stated, it is a good point to clean residents hands. During concurrent interview and observation on 4/22/24, at 12:50 PM, Licensed Staff C stated they use washcloths, but they have not offered to wash or wipe residents hands. Licensed Staff C then went to the linen closet and took some towels and handed them to Unlicensed Staff G. Unlicensed Staff G proceeded to wet the washcloths in the rest room of room [ROOM NUMBER] and wiped the hands of both residents in the room. During an observation and concurrent interview on 4/22/24, at 12:54 PM, Resident 1, who was eating lunch, was asked if facility staff had offered or reminder her to wash or wipe her hands prior to eating, stated staff who served her tray did not offer to wash or wipe her hands. During an interview on 4/22/24, at 1:06 PM, Resident 24 was on her way back to her room from the dining hall, where she ate, stated staff had not offered to wash or wipe her hands before eating. A review of the facility policy titled, Handwashing/Hand Hygiene taken from Nursing Services Policy and Procedure Manual for Long-term care 2001 Med-Pass. Revised 8/19, indicated, hand hygiene is the primary means to prevent the spread of infection and to use an alcohol-based hand rub containing 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water before and after assisting a resident with meals. The policy indicated residents, family members and/or visitors will be encouraged to practice hand hygiene using fact sheets, pamphlets, and/or other written materials. The policy did not indicate for staff to remind or offer hand hygiene to residents before eating their meals. 2. During a concurrent interview and records review on 4/25/24, at 02:16 PM, the facility Infection Preventionist (IP) stated she started working as IP in the facility 3 weeks ago. The IP stated had not seen the IP's folders except for the one on Antibiotic Stewardship. A review of the contents of the folder indicated there was documentation of facility residents on antibiotics for the months of 1/24 to 4/24. A blank page/template titled: Infection Prevention and Control Line Listing Surveillance Log was inserted among the pages and when asked about the completed pages for the previous months, the IP stated she did not have the surveillance documents. On 4/26/24, at 9:15 AM, the Surveillance log for the past 12 months was requested from the DON. During an interview on 4/26/24, at 9:40 AM, when asked where the IP documents were, the DON stated Infection control, surveillance and monitoring, and antibiotic stewardship documents could not be located because the office of the previous IP was at another location in the building and the IP documents could not be located or had been misplaced. Since the current IP's hiring, there were two IPs who had worked in the facility. The DON stated she had called one of the IPs to come to the office to help them locate the documents. A review of the facility Infection Prevention and Control Line Listing Surveillance Logs for the past 12 months indicated, surveillance logs from 8/23 to 4/24 were not completed. There was no documentation to indicate data analysis like plotting monthly infection rates, manual mapping of residents infection in the facility, etc., were done. A review of the facility policy titled: Infection prevention and control program from 2001 Med Pass Inc. revised 10/18 indicated, the infection prevention and control program (IPCP) was established and maintained to provide a safe environment to help prevent the development and transmission of communicable disease and infections. The policy further indicated the elements of IPCP consists of .surveillance, data analysis, outbreak management, etc. Surveillance tools are used for recognizing occurrences of infections, recording the number of infections, detecting outbreaks, and detecting unusual pathogens (microorganisms that can cause disease) with infection control implications. The information obtained from surveillance is compared with that from other facilities with acknowledge standards and used to assess the effectiveness of the infection prevention and control practices.

Based on interview and records review, the facility failed to consistently perform antibiotic stewardship. This failure had the potential to result to inappropriate or unnecessary antibiotic treatment, increase the risk of adverse events, development of antibiotic resistance, and worsen the already frail health condition of residents. Findings: During a concurrent interview and records review on 4/25/24, at 02:16 PM, the facility Infection Preventionist (IP) stated she had started working in the facility 3 weeks ago and had not seen the previous IP's folders except for the folder on Antibiotic Stewardship. A review of the contents of the folder indicated there were documentation on an antibiotic surveillance tracking form with residents' names who were treated with antibiotics for the months of 1/24 to 4/24 but none for the past months. During an interview on 4/26/24, at 9:40 AM, when asked where the IP documents were, the Director of Nursing (DON) stated Infection control, surveillance and monitoring, and antibiotic stewardship documents could not be located or may have been misplaced after the previous IPs left. The DON had called the previous IP to come to the facility to help locate the folders. A review of the Infection Prevention and Control Line Listing Surveillance Logs provided by the IP for the past 12 months indicated, there were no antibiotic surveillance tracking completed for the months from 8/23 to 12/23 as there were no line listing surveillance logs completed for the same months. During a concurrent review of the IP job description with the DON and interview of the IP on 4/26/24, at 9:53 AM, the job description of the IP indicated, the IP was responsible for the ASP (antibiotic stewardship program) in-servicing, tracking, reporting, and educating families, employees and physicians as needed. When asked if she had conducted in-services with staff on AS (Antibiotic Stewardship), the IP stated she had not. A review of the facility Antibiotic Stewardship (AS) policy updated 1/26/24 indicated the purpose of the antibiotic stewardship program was to monitor the use of antibiotic among the facility residents. The AS surveillance policy indicated, antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. As part of the antibiotic stewardship program (ASP), all clinical infections treated with antibiotics will undergo review by the IP, or designee.

Based on interview and record review the facility failed to send in their investigative report for one of one alleged abuse incident to the department, within 5 days from the incident. This failure to not finish the investigation and sending the report, could result in missed chance to improve the care and services provided by the facility and potentially avoid other instances of abuse and neglect. Findings: During a review of records on 9/12/23, the facilities Report of Suspected Dependent Adult/Elder Abuse dated 8/12/23 was reviewed. The report indicated an allegation of abuse by staff against a resident, occurring on 8/12/23. The 5-day investigation report was not available. The report had not been sent to the department. On 9/12/23 at 10 a.m., an on-site visit was conducted at the facility to investigate the allegation of abuse. During an interview on 9/12/23 at 10:15 a.m., Administrator stated he had investigated the incident, but indicated he had not formalized the report for the facilities records. Administrator stated he did not know he was required to send in an investigation report within 5 days to the department. Administrator stated he would need to finish the report and send it to department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of Notice of Discharge or Transfer to the representative of the Office of the State Long-Term Care (LTC) Ombudsman [a public advocate is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of rights] for four out of six residents: Resident 13, who was transferred to an acute care facility and Resident 43, 247, and 249, who were discharged to home. This failure had the potential for Resident 43, 247, and 249 being inappropriately discharged and Resident 13, 43, 247, and 249 not being provided an advocate who could inform them of their rights and options before being discharge to home or transferred to the acute care facility. Findings: A review of Resident 13's Nurse's Progress Notes, dated 1/7/23, indicated Resident 13 was transferred to the Emergency Department (ED) because Resident 13 had started spiking a temperature (99.8 degrees), CBC (complete blood count: used to diagnose and monitor numerous diseases) was abnormal, and had vomited large amount with food particles, on 1/7/23 at 3:32 p.m. A review of Resident 13's Emergency Department (ED) History and Physical, dated, 1/7/23, indicated Resident 13 was to be admitted to the acute care facility with the possibility of pneumonia. A review of Resident 13's Nurse's Progress Notes, dated 1/14/23, indicated Resident 13 returned to the facility on 1/14/23, at 6:40 p.m. During an interview on 1/18/23 at 3:00 p.m. when Social Services was asked if she notified the Ombudsman's office about Resident 13 being transferred to the acute care facility, Social Services state she informed Resident 13's Conservator about Resident 13 being hospitalized by e-mail. Social Services stated she never informed the Ombudsman's office about a resident being transferred to the hospital. Social Services stated her hire date was 7/2021 and she was never taught to notify the Ombudsman's office about a resident being transferred to the ED and admitted to the acute care facility if the resident's stay was more than 24 hours. Social Services stated she only notified the resident's responsible party. A review of Resident 247's Notice of Transfer and Discharge, dated 8/8/22, indicated Resident 247 was discharged to home on 8/8/22. Resident 247's admission Record, indicated Resident 247 was admitted on [DATE] and was discharged on 8/8/22 at 1:06 p.m. A review of the facility's fax notification to the Ombudsman's office of Resident 247's discharge to home, indicated the facility faxed the notification on 11/9/13 (date on document) at 2:10 p.m. per the Transmission Verification Report. The fax had a handwritten note indicating the Ombudsman's office was faxed the discharge notification at 12:45 p.m., but no date was noted. A review of Resident 249's Nurse's Progress Notes, dated 9/23/22, indicated Resident 249 was picked up by her daughter on 9/23/22 at 10:59 a.m., and discharged to home. Resident 249's Notice of Transfer and Discharge, dated 9/23/22, indicated Resident 249 was discharged to home on 9/23/22. A review of Resident 249's Discharge Summary, indicated per a written note, Social Services e-faxed the Ombudsman's office on 9/26/22 at 10:30 a.m. notifying the office of Resident 249's discharge, which took place on 9/23/22. During an interview on 1/18/23 at 3:00 p.m., Social Services stated when a resident was ready to be discharged , she would fax over the Discharge Notification to the Ombudsman's office once the nurse had gone over all discharge information with the resident and/or responsible party, all discharge paperwork was completed, and right before the resident left the facility. Social Services stated notifying the Ombudsman's office was the last step to the completion of the resident's discharge. When Social Services was asked what the Ombudsman's purpose was for coming to the facility, Social Services stated the Ombudsman advocated for the residents/spoke on the resident's behalf regarding a concern. When asked how the Ombudsman could advocate for the resident if the resident was upset about his/her discharge if the Ombudsman's office was notified minutes before the resident was discharged or after the fact, Social Services stated she was never trained to inform the Ombudsman's office as soon as the facility was aware of the resident's discharged . Social Services stated she was trained to notify the Ombudsman's office via way of fax of the resident's discharge after the resident or responsible party signed all the discharge paperwork and were about to leave the facility. Social Services stated if a resident was discharged over the weekend she would fax the discharge information to the Ombudsman's office on Monday, when she returned to work. During an interview on 1/19/23 at 10:24 a.m., when the Administrator was asked if the facility followed the facility policy/procedure (p/p) titled, Transfer or Discharge Notice, revised 12/2016, for reporting to the Ombudsman's Office a resident going to be discharge or transferred from the facility, which did not give a time frame of when to notify the Ombudsman's office or did the facility follow the AFL (All Facilities Letter) 17-27 under the HSC (Health and Safety Code) section 1439.6, indicating the facility should send a notice to the Ombudsman's office regarding a facility-initiated transfer or discharge at the same time the notice was provided to the resident or the resident's representative, the Administrator stated the facility needed to update their p/p titled, Transfer or Discharge Notice, because the policy did not indicate a timeframe of when to notify the Ombudsman's office. A review of Resident 43's Nurse's Progress Notes, dated 10/29/22, indicated Resident 43 was discharged on 10/29/22 at 10:26 a.m. A review of Resident 43's Notice of Transfer and Discharge, dated 10/29/22, indicated Resident 43 was discharge to his son's home on [DATE]. During an interview on 1/19/23 at 12:30 p.m., Social Services stated she was not working when Resident 43 was discharged on 10/29/22. Social Services stated the Ombudsman's office was not notified of Resident 43's discharge. The facility policy/procedure titled, Transfer or Discharge Notice, revised 12/2016, indicated: Policy Statement: Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge. Policy Interpretation and Implementation: .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman . A document titled All Facility Letter (17-27) Summary, dated 12/26/17, based on Health and Safety Code (HSC) section 1439.6, which indicated Long Term Care (LTC) facilities were to notify the local LTC Ombudsman at the same time notice is provided to the resident or resident's representatives when a facility-initiated transfer or discharge occurred. The facility must send a notice to the local Ombudsman for any transfer or discharge that is initiated by the facility, whether or not the resident agrees with the facility's decision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep residents' pneumonia vaccines up to date when residents were not offered the 23-valent pneumonia vaccine, as recommended by the Centers for Disease and Prevention (CDC). This failure could potentially leave vulnerable residents unprotected from preventable lung infections that can lead to hospitalization or death. Finding: During an interview on 1/13/23 at 2:33 p.m., the Director of Nursing (DON) stated the immunization program was usually overseen by the Infection Preventionist (IP), Director of Staff Development (DSD), and nursing. DON stated the program was a work in progress since they had not had stable IP coverage. DON stated she had been doing her best to keep up. DON stated IP and DSD were presently going through resident records and creating a spreadsheet of resident vaccinations. DON stated the system for tracking resident vaccinations to ensure they were current was overseen by MDS Nurse. When asked which guidance the facility policy followed for vaccinations, DON stated she did not know and would have to read the policy. DON stated it was the responsibility of the DON, the IP, and the administrator to follow the most recent guidance, but ultimately it was the IP's responsibility. DON stated that once IP was fully in her role, she would be ensuring the most recent guidance was implemented. During an interview on 1/13/23 at 3:40 p.m., DON nor IP knew that residents who had received the Prevnar 13 (pneumococcal/pneumonia vaccine) needed to receive a dose of the 23-valent Pneumococcal Polysaccharide Vaccine (PPSV23/Pneumovax 23). The DON and the IP stated none of the residents had received the PPSV23. During an interview on 1/17/23 at 10:10 a.m., when queried, IP stated that residents who were not up to date on their pneumonia vaccines could potentially have lessened immunity to pneumonia. IP stated the CDC recommended the 23-valent should be given a year after the first dose unless they had comorbidities that indicated they needed it sooner. During an interview on 1/18/23 at 1:05 p.m., MDS Nurse stated that in 2019 they were trying to get everyone up to date on their immunizations. MDS Nurse stated she just recently made a spread sheet for DON with the residents that needed to get updated on their immunizations. Review of the most recent MDS (minimum data set, an assessment tool) records for all 39 residents revealed the pneumonia vaccine status for 11 residents was coded as up to date, one was coded as not up to date with the reason left blank, the pneumonia vaccine status for 21 residents was coded as not given with the reason coded as offered and declined, the pneumonia vaccine status for two residents was coded as not eligible, and the pneumonia vaccine status for four residents was coded as not assessed. Per MDS Nurse interview on 1/18/23 at 1:05 p.m., Not assessed usually meant the documentation for the vaccine status had been requested but not provided by the time the assessment was submitted. Review of the electronic medical records for all 39 residents revealed under the Immunizations section that, of the 21 residents whose MDS was coded as offered and declined for the pneumonia vaccine, three residents had documentation that the Pneumovax-23 had been refused, six residents had documentation that the Prevnar-13 had been refused, and 12 residents had no documentation that a pneumonia vaccine had been refused. Of the 11 residents whose MDS was coded as up to date for the pneumonia vaccine, one resident had documentation that the Pneumovax-23 had been received, five residents had documentation that the Prevnar-13 had been received, three residents had no documentation of having received a pneumonia vaccine, and one resident had documentation that the Pneumovax-23 was refused. Review of facility policy Pneumococcal Vaccine, last revised 10/2019, revealed, Administration of the pneumococcal vaccines or revaccinations will be made in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Review of section References revealed an article from the CDC Morbidity and Mortality Weekly Report 63(37)titled, Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults >/= 65 years . The Centers for Disease Control and Prevention (CDC) recommendations, dated 4/1/22, for adults [AGE] years old and older, and adults 19 through [AGE] years old with certain underlying medical condition or other risk factors, indicated revaccination of PPSV23 at least one year after PCV13 (Pneumococcal conjugate vaccine) dose and at least five years after any PPSV23 dose (https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation Interview and Record Review: 1. The facility failed to ensure a comfortable environment when the facility did not maintain comfortable room temperature (standard room temperatures are to be from 68-81 degrees Fahrenheit) in 19 out of 24 rooms (Rm): (Rm 101, 102, 105, 106, 108, 109, 110, 112, 114, 115, 116, 117, 118, 120, 121, 123, 124, 125, and 126) when temperatures measured were from 60 to 67 degrees and multiple residents (Resident 14, Resident 17, Resident 23, Resident 26, Resident 40, and Resident 244) complained of being cold inside of their rooms. 2. The facility did not maintain comfortable resident room temperatures safely by using three space heaters in the west hallway, two space heaters in the east hallway, and a space heater in resident rooms: (Rm 101, 112, 114, 115, and 123), which had the potential of causing a fire resulting in injury or death. On 1/12/23 at 2:26 p.m., the Administrator was notified of substandard quality of care identified and the facility was on extended survey. Substandard quality of care means one or more deficiencies related to participation requirements under 483.25 Quality of Care. These failures had the potential to cause: a) Resident's susceptibility to loss of body heat and risk of hypothermia (medical emergency that occurs when your body lose heat faster than it can produce, causing dangerous low body temperature) or susceptibility to respiratory ailments and colds, b) immobility issues related to not wanting to get out of bed due to the cold, and c) negatively impact residents' comfort and homelike environment and potential for risk of fire, bodily injury (burns) and death. Findings: During concurrent observations and interviews on 1/17/23 at 10:35 a.m. to 10:49 a.m., the Maintenance Assistant went around to the residents' rooms checking the thermostat temperature reading. The Maintenance Assistant stated room temperatures normally range from 69 to 72 degrees F when he checks the room temperatures. The Maintenance Assistant stated he had an app on his phone to log room temperatures. The Maintenance Assistant would take a few resident room temperatures daily but had not taken any this morning. Observed three space heaters in the west hallway. The Maintenance Assistant stated the heater company was working on the boiler to the heater, so the heaters were turned off. Observed a space heater in RM [ROOM NUMBER] located in between bed A and B causing the electrical cord to be resting on the floor triggering a trip hazard. The thermostat in RM [ROOM NUMBER] read 63 degrees. Resident 14 stated she was freezing, absolutely freezing while up in her wheelchair layered in clothing, Rm 101's thermostat read 64 degrees. There was a space heater in the room, left of the door when walking into the room, The west hall thermostat read 63 degrees and there were three space heaters in the hallway, Rm 105 thermostat read 61degrees, Rm 114 thermostat read 61 degrees, Rm 123 thermostat read 61 degrees. Resident 40 stated she was chilly. She was layered with blankets. Rm 120 thermostat read 60 degrees, Rm 115 temperature measured 61 degrees per maintenance assistant using a surface thermometer (uses infrared laser technology to measure surface temperatures). Resident 39 was layered with blankets and was wearing a sweatshirt. The thermostat outside of the Director of Staff Development's office read 67 degrees, The Maintenance Assistant stated everything throughout facility was set at 68 degrees and each resident room had its own thermostat. The Maintenance Assistant stated those residents not cognitively able to adjust the room thermostat were set at 68 degrees. The Maintenance Assistant stated the heating company was working on the boiler for the heating system and he was not aware of any issues with the heater unit prior to today. During an interview on 1/17/23 at 11:35 a.m., the Administrator stated supposedly the heater went out last night (1/16/23). During an interview on 1/17/23 at 12:20 p.m., the Maintenance Supervisor stated the boiler to the heater system went out Sunday night (1/15/23) around 8 p.m., per his phone. The Maintenance Supervisor stated he had a phone app showing the water temperature of the boiler for the hydronic heater system was dropping. The Maintenance Supervisor stated a technician came out this morning and worked on the boiler. The Maintenance Supervisor stated he went to the facility right away on Sunday (1/15/23), to put out space heaters, six to eight around the facility. The Maintenance Supervisor stated the space heaters did not get scalding hot and there was no other alternative to keep residents warm. The Maintenance Supervisor stated the boiler for the facility baseboard heaters had to be turned off when the technician was working on the boiler this morning. The Maintenance Supervisor stated the valves to turn on the baseboard heater in RM [ROOM NUMBER], the beauty salon, and the Administrator's office were broken and needed to be replaced. The Maintenance Supervisor stated, normally the thermostats throughout the facility were set at 78 degrees and every resident room had its own thermostat, which the residents could regulate. The Maintenance Supervisor stated the temperature of the resident areas should be reading 78 degrees. The Maintenance Supervisor stated RM [ROOM NUMBER] baseboard heater had been broken since late 11/2023. The Maintenance Supervisor stated they never logged the room temperatures. During concurrent observations and interviews on 1/17/23 at 3:10 p.m. to 3:20 p.m., the Maintenance Assistant made rounds to check the temperatures of the resident areas: *Activities Room thermostat read 61 degrees, *Rm 116 thermostat read 61 degrees, *Space heater outside room [ROOM NUMBER] still on, *Rm 119 thermostat read degrees and baseboard heater was not on, Resident 26 stated it was cold last night, *Rm 123 thermostat read 69 degrees, *Rm 114 thermostat read 64 degrees. Space heater in RM [ROOM NUMBER] was off. The Maintenance Assistant stated he was supposed to be removing all space heaters. While make rounds with the Maintenance Assistant, observed the baseboard heater screens and coils looked dirty with lots of cobwebs. *Rm 112 thermostat read 66 degrees, *Observed baseboard heaters in the east hall were off, *West hall baseboard heater was off and space heater was on, and *Rm 101 thermostat read 67 degrees. During concurrent observations and interviews on 1/17/23 at 3:35 p.m. to 4:05 p.m., the Administrator made rounds to see if the resident baseboard heaters were working after boiler to hydronic heating system was worked on using a surface thermometer (infrared gun) and to check the resident room thermostat readings: *Rm 101 baseboard heater measured 67 degrees. There was no warmth to the floor heater, *Rm 102 baseboard heater measured 66 degrees. There was no warmth to the baseboard heater, *The west hall baseboard heater across from RM [ROOM NUMBER] and next to RM [ROOM NUMBER] was not on. *Rm 105 thermostat read 70 degrees, *Rm 106 baseboard heater measured at 91 degrees and the thermostat read 66 degrees, *Rm 107 baseboard heater measured 93 degrees and the thermostat read 68 degrees, *Rm 108 baseboard heater measured 96 degrees and thermostat read 66 degrees, *Rm 109 baseboard heater measured 66 degrees and thermostat read 66 degrees, *Rm 110 baseboard heater measured 92 degrees and thermostat read 66 degrees, *Rm 111 baseboard heater measured 95 to 98 degrees and thermostat read 68 degrees, *Rm 112 baseboard heater measured 103 degrees and thermostat read 66 degrees, *West hall baseboard heater left of RM [ROOM NUMBER] was not on, *North hall baseboard heater outside of RM [ROOM NUMBER] measured 87 degrees, *North hall baseboard heater next to Certified Nursing Assistant (CNA) work area where ice machine was located was not working, *Baseboard heater between shower rooms was not working, *Rm 126 baseboard heater measured 99 degrees and thermostat read 67 degrees, * East hallway baseboard heater across from RM [ROOM NUMBER] measured 91 degrees, * RM [ROOM NUMBER] baseboard heater measured 101 degrees and thermostat read 62 degrees, *Rm 123 baseboard heater measured 105 degrees, thermostat read 70 degrees, and space heater on near bedroom door, * RM [ROOM NUMBER] baseboard heater read 95 to 97 degrees and thermostat read 66 degrees, *Rm 121 baseboard heater 98 to 99 degrees and thermostat read 60 degrees, * RM [ROOM NUMBER] baseboard heater measured 90 degrees and thermostat read 69 degrees, * RM [ROOM NUMBER] baseboard heater measured at the low 70s and thermostat read 69 degrees, *Rm 120 baseboard heater not working, and thermostat read 64 degrees, * RM [ROOM NUMBER] baseboard heater measured 72 degrees and thermostat read 65 degrees, * RM [ROOM NUMBER] baseboard thermostat read 62 degrees. The Administrator stated the baseboard heater was not working, * RM [ROOM NUMBER] thermostat read 66 degrees. The Administrator stated the pipes to the baseboard heater should be hot to touch but were not. The baseboard heater was not working. * RM [ROOM NUMBER] baseboard heater measured 66 degrees. The Administrator stated no heat was coming out of the baseboard heater, * East hall baseboard heater next to RM [ROOM NUMBER] was not working, * East hall baseboard heater next to RM [ROOM NUMBER] measured 94 degrees. During an interview on 1/17/23 at 5:05 p.m., asked the Administrator for the invoice for the work done on the boiler for the hydronic heating system and for the servicing of the heating unit done last year. During an interview on 1/17/23 at 5:25 p.m., the HVAC (heating, ventilation, and air condition) Technician stated they were at the facility from 9 to 11 a.m. this morning. The HVAC Technician stated they found air pockets in the hydronic lines so the lines were purged (bleeding the lines on the water heater removes trapped air and the mineral deposits that can affect the water heater's ability to heat water). The HVAC Technician stated because the heater system was hydronic it would take 12 to 24 hours for the heated water to circulate throughout each resident room baseboard heater and for the resident rooms to warm up. The HVAC Technician stated the system was over [AGE] years old as were the pipes, but everything worked very well. The HVAC Technician stated trapped air caused an electronic glitch, but the system was running fine. The HVAC Technician stated to give it 12 to 24 hours to heat the entire facility. The HVAC Technician stated the facility maintenance was now bleeding (draining the water in the line to remove air pockets/bubbles) off the radiators in each resident baseboard heater because air must have gotten trapped in the lines. The HVAC Technician stated the air vents in the boiler room were working so he was not concerned the baseboard heaters would not work. During an interview on 1/17/23 at 5:30 p.m., the Administrator stated he and the Maintenance Assistant were opening the valve of each baseboard heater not working and letting water drip out into a bucket to get rid of air bubbles. He stated they were manually overriding the thermostat by turning the valve located on the baseboard heater. During a concurrent observation and interview on 1/18/23 at 8:40 a.m., the Maintenance Supervisor stated they were still working on some of the baseboard heaters, which were still not working. They were purging the line to each baseboard heater not working to remove the trapped air. The temperature outside was 37 degrees and the building felt very cold. The Maintenance Supervisor stated he was worried about air pockets getting trapped in the hydronic heating system when the HVAC technicians had to drain the boiler and reset the system. He hoped air had not gotten into the heater lines, but air was trapped somewhere in the lines. The Maintenance Supervisor stated they still were having issues with the resident baseboard heaters in the east hallway and most all hallway baseboard heaters. The baseboard heater coils looked very dirty; lots of cobwebs, dust, and cat hair. The Maintenance Supervisor agreed all baseboard heaters needed to be cleaned. During an observation on 1/18/23 at 9:10 a.m., the residents' thermostat readings: *Rm 101 thermostat read 64 degrees, * [NAME] hall baseboard heater across from RM [ROOM NUMBER] was being purged, *Rm 111 thermostat read 66 degrees. Resident 244, who was dressed and up in his wheelchair, stated he was cold especially when the door to his room was left open from the cold air coming from the hallway, *North hall baseboard heater nearest ice machine/CNA workstation was not working, *North baseboard heater between the two shower rooms was not working. *Rm 119 thermostat read 63 degrees, *Rm 120 thermostat read 61 degrees, *Rm 117 thermostat read 60 degrees, Resident 17 stated it had been cold all night, *Rm 118 thermostat read 63 degrees *Rm 116 thermostat read 60 degrees, *Rm 115 thermostat read 60 degrees, *East baseboard heater across from RM [ROOM NUMBER] was being purged. During an interview on 1/18/23 at 4:40 p.m., the Administrator was asked about the baseboard heaters not working in room [ROOM NUMBER], 102, 115, 116, 118, 120 and the hall baseboard heaters not working. The Administrator stated it still was a challenge, bleeding the lines was helping to get heat out of the baseboard heaters at first, and then the heaters stopped working. The Administrator stated the Maintenance Supervisor had called the HVAC Technician, who will be coming tomorrow to work on the heating system again. The Administrator was asked if he had reached out to HCAI (Department of Health Care Access and Information) in the meantime to get direction regarding keeping the residents warm such as approving the portable space heaters. The Administrator reached out to the City of Napa Fire Prevention Officer who approved the oil space heaters for the meantime but directed the Administrator to make sure to place the space heaters at least three feet from anything combustible. During a concurrent observation and interview on 1/18/23 at 5:05 p.m., the Administrator left a voice message to HCAI regarding the facility's broken hydronic heating system and the short-term use of portable space heaters as a corrective action to help keep residents warm. During a concurrent observation and interview on 1/18/23 at 5:30 p.m., the Administrator was placing portable space heaters throughout the hallways. He stated he would inform the staff to make sure residents did not get near the space heaters. During a concurrent observation and interview on 1/19/23 at 9:20 a.m., the Administrator stated the HVAC Technician was at the facility and working on the hydronic heater system. The Administrator stated HCAI had reached out to him and informed him how to ask for an emergency use of the space heaters because the heating system was not working properly. It felt very cold in the facility. Resident 14 was in the hallway huddled next to a space heater. She stated she was trying to get warm. During an interview on 1/19/23 at 2:20 p.m., the Administrator stated the HVAC Technician had just left. He had flushed the hydronic heating system, fixed air gaps, and increased the temperature of the boiler. The Administrator stated it should take about two to four hours to warm the facility. During a concurrent observation and interview on 1/19/23 at 2:40 p.m., the Maintenance Supervisor checked the room temperatures: *Rm 120 thermostat read 62 degrees, *Rm 118 thermostat read 61 degrees, *Rm 116 thermostat read 63 degrees, *Rm 115 thermostat read 63 degrees, *Activity Room wall by bookcase measured 64 degrees, *Rm 101 thermostat read 63 degrees, *Rm 102 thermostat read 62 degrees, *West baseboard heater across from RM [ROOM NUMBER] was not working. During an observation and concurrent interview on 1/20/23 at 2:50 p.m., Administrator checked resident room temperatures: *Rm 115 thermostat read 64 degrees, *Rm 116 thermostat read 62 degrees, *Rm 117 thermostat read 65 degrees, resident was wrapped in blankets around her shoulders and on her lap, had hooded sweatshirt on with the hood up, stated she was warm enough, *Rm 118 thermostat read 63 degrees, *Hallway by thermostat by RM [ROOM NUMBER], read 67 degrees, *Rm 120 thermostat read 66 degrees. During a concurrent observation and interview on 1/23/23 at 9:28 a.m., the Administrator stated a rental company had come over the weekend and hooked up an outside heater located outside of RM [ROOM NUMBER]'s sliding door connected to an accordion duct leading from the sliding door connected to a HEPA (high-efficiency particulate air) filter, located in the east hallway, outside of RM [ROOM NUMBER], which blew warm air into the hall to temporarily keep resident rooms warm. The thermostat temperature rounds with the Administrator: *Rm 124 thermostat read 68 degrees. Resident 108, who was up in her wheelchair, positioned at the foot of her bed, dressed, and looking at her I-pad, stated she was comfortable, * RM [ROOM NUMBER] thermostat read 67 degrees, *Rm 119 thermostat read 71 degrees. Resident 26 stated he has gotten used to the room temperature, *Rm118 thermostat read 63 degrees, *Rm 117 thermostat read 66 degrees, *Rm 115 thermostat read 62 degrees, *Rm 101 thermostat read 67 degrees, *Rm 102 thermostat read 66 degrees. Resident 244 stated she was cold. She had a down comforter on her. The Administrator stated if she left her door open the warm air would come into the room. Resident 244 stated she had her door closed because she did not want cats coming into her room. The Administrator stated he could have a scat mat (a training tool used to keep cats away from areas you wish) placed in the entrance of her door preventing the cats from wanting to enter her room. She agreed. * [NAME] hall thermostat across from RM [ROOM NUMBER] read 66 degrees, *Rm 103 thermostat read 69 degrees. During a phone conversation on 1/23/23 at 4:20 p.m., asked the Administrator to have someone check the resident room temperatures in the six problem rooms throughout the night (starting after dark) until surveyors returned in the morning. The Administrator agreed to have staff start at 6 p.m. and every two hours. During a concurrent interview and record review on 1/24/23 at 8:55 a.m., the Administrator provided the resident, Room Temperature Log taken on 1/23/23, starting at 6 p.m. through 1/24/23 at 8 a.m., which showed Rooms 101, 102, 115, 116, and 118 were still having temperatures ranging from 61 to 67 degrees. He stated there were still some low room temperatures. During observations on 1/24/23 at 9 a.m., the portable heating unit and HEPA filter was running. The thermostat readings in resident rooms: *Rm 101 thermostat read 67 degrees, *Rm 102 thermostat read 65 degrees * [NAME] hallway right of RM [ROOM NUMBER] thermostat read 68 degrees, *Rm 103 thermostat read 69 degrees, *Rm 107 thermostat read 72 degrees, *Rm 112 thermostat read 68 degrees. Resident 14, who was dressed, up in her wheelchair and propelling self, stated she was more comfortable, *North hall thermostat read 70 degrees, *Rm 123 thermostat read 74 degrees, *East hall thermostat read 69 degrees, *Rm 119 thermostat read 74 degrees, *Rm 116 thermostat read 64 degrees, *Rm 115 thermostat read 66 degrees. During an interview on 1/24/23 at 9:55 a.m., the Administrator and the Maintenance Supervisor were asked why the fan to the HEPA filter connected by duct tubing to the outside portable heater was so quiet. The Maintenance Supervisor stated there was a low to high dial on the fan. The Maintenance Supervisor stated the rental company delivered the portable heating unit on Saturday (1/21/23). The Maintenance Supervisor stated he was having to go frequently to get diesel fuel yesterday. At some point in the early morning the unit stopped producing heat and he did not know why. When informed the tape holding the duct to the HEPA filtration system was coming apart and the hot air was mainly blowing back into RM [ROOM NUMBER] (where the unit was set-up), the Administrator stated he would check on it. During an interview on 1/24/23 at 10:10 a.m., before leaving the facility, asked the Administrator and Maintenance Supervisor to make sure the room temperatures for resident rooms that were remaining below 68 degrees were logged every two hours starting at 6 p.m. until surveyors returned on 1/25/23. During a concurrent interview and record review on 1/25/23 at 8:35 a.m., the Administrator provided the resident Room Temperature Log taken on 1/24/23, starting at 6 p.m. through 1/25/23 at 8 a.m. He stated the temperatures looked good. Rooms 101, 102, 103, 117, 118, 119, and 120 room temperatures were within normal range (68 to 81 degrees). RM [ROOM NUMBER] had dropped to 66 degrees on 1/25/23 at 6 a.m. but went back up to 71 degrees at 8 a.m. During a concurrent observation and interview on 1/25/23 at 8:40 a.m., the residents in RM [ROOM NUMBER] had been moved to RM [ROOM NUMBER] and the temporary portable heating unit was set-up in RM [ROOM NUMBER]. Asked the Administrator for the invoices done by the HVAC Technician, HVAC company who serviced the heating system last year, and the rental company where the portable heating unit came from. During observations on 1/25/23 at 08:50 a.m., thermostat readings in resident rooms: *Rm 101 thermostat read 70 degrees, *Rm 102 thermostat read 68 degrees, *Rm 103: thermostat read 67 degrees. Thermostat was off, and resident stated he was comfortable. *West hall right of RM [ROOM NUMBER] thermostat read 69 degrees, *Rm 116 thermostat read 72 degrees, *East hallway thermostat read 72 degrees, *Rm 117 thermostat read 71 degrees, *Rm 118 - Resident busy *Rm 120 thermostat read 71 degrees, *Rm 119 thermostat read 75 degrees, *Rm 125, where residents were moved to from RM [ROOM NUMBER], thermostat read 72 degrees, *East hall left of RM [ROOM NUMBER] thermostat read 72 degrees. During an interview on 1/25/23 at 9:11 a.m., the Administrator stated the portable heating unit was moved from room [ROOM NUMBER] to room [ROOM NUMBER] yesterday and set-up around 1:30 p.m. The Administrator stated plastic was placed in the sliding door frame and a hole cut out for the duct to go through. The HEPA filters were in the hallway. One was hooked up to the heater unit and the other filtering the air. The Administrator stated the portable heating system was hooked up by the supplier on Saturday (1/21/23) at 12 p.m. The facility maintenance did the switch yesterday. On 12/25/23 at 9:49 a.m., the Surveyor requested copies of the HVAC repair invoices, the heating servicing invoice and the rental supplier invoice for the portable heater. The Administrator stated he would e-mail them when he received them. The Administrator understood the facility needed to get the hydronic heating system working in all resident livable areas, and he needed to be submit to HCAI as well as all temporary emergency authorization plans. A review of the Heating Service Invoice, dated 1/17/23, and e-mailed to surveyor on 1/26/23 at 9:02 a.m., indicated the hydronic heating system was serviced on 12/20/22. The technician found the hydronic boiler system was intermittently misfiring due to multiple issues. The burners and gas orifices (openings) were filled with debris. He cleaned the debris and found the pilot (light or burner) assembly was cracked which was causing a spark to round in the wrong direction. The facility policy and procedure titled, Quality of Life - Homelike Environment, revised 5/2017, indicated: Residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation: .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include . h. Comfortable and safe temperatures (68 degrees - 81 degrees) . The facility Maintenance Supervisor job description, undated, indicated: Purpose of Your Job Position: Assure that all systems and environments are clean, safe, and functional for the wellbeing of the residents as well as the employees. Job Function: Supervise all functions and all employees in the maintenance department (maintenance, housekeeping, laundry, and grounds) as well as perform all duties of Maintenance Mechanic . Working Conditions: Works on patient rooms, bathrooms, shower rooms, utility rooms, hallways, living room . Review of website localconditions.com, accessed on 1/26/23, revealed the following weather conditions at the location of the facility: On 1/19/23 the temperature was recorded as a low of 35° F and a high of 54° F, 1/20/23 low 34° F, high 55° F, 1/21/23 low 29° F, high 58° F, 1/22/23 low 37° F, high 57° F, 1/23/23 low 40° F, high 60° F, 1/24/23 low 34° F and high 60° F. 2. During an observation on 1/9/23 at 10:27 a.m., a space heater was noted in room [ROOM NUMBER] pushed against the wall between two nightstands. During an interview on 1/9/23 at 11:41 a.m., Resident 17 stated it was cold in her room at night. She stated she had a little heater the facility gave her, but someone took it, and she wanted it back. During an observation on 1/10/23 at 11:44 a.m., a space heater was noted in room [ROOM NUMBER] next to the bathroom door. During an interview on 1/11/23 at 3:09 p.m., Unlicensed Staff E stated he was caring for the residents in room [ROOM NUMBER]. Unlicensed Staff E stated the residents were using the space heater in their room a few days ago. Unlicensed Staff E verified it was the space heater by the wall between the nightstands. He stated it was placed in the middle of the room, and it was turned on in the late afternoon. During an interview on 1/13/23 at 11:04 a.m., when queried about the facility policy on use of space heaters, Maintenance Supervisor stated, We don't like using them. He stated the valves on three of the hydronic heaters needed to be repaired, and the space heaters were short term use only until he could get some time to fix them. During an interview on 1/17/23 at 12:15 p.m., Maintenance Supervisor stated that space heaters were in resident rooms because the residents were complaining of being cold. When asked if the hydronic heater was broken in room [ROOM NUMBER], Maintenance Supervisor stated he did not recall, and he would have to check. When asked about his knowledge of the life safety code pertaining to space heaters, Maintenance Supervisor stated he knew using space heaters in nursing homes was not ideal, but he chose to prioritize the residents' comfort over that (the safety code). During an observation on 1/17/23 at 3:08 p.m., three space heaters were noted in the west hallway, two space heaters in the east hallway, and a space heater was noted in resident rooms 101, 112, 114, 115, and 123. Review of facility policy titled, Electrical Safety for Residents, last revised 1/2011, revealed, Portable space heaters are not permitted in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain safe water temperatures when the water temperatures in eight of 14 residents' bathroom sinks were too hot, one over 130 degrees Fahrenheit (° F). This failure could potentially result in vulnerable residents getting scalded or burned from hot water. Findings: During an observation on 1/9/23 at 10:27 a.m., the water from the faucet in the bathroom between rooms [ROOM NUMBERS] felt very hot to the touch. During an observation on 1/9/23 at 11:11 a.m., the water from the faucet in the bathroom between rooms [ROOM NUMBERS] felt very hot to the touch. During an interview on 1/9/23 at 11:41 a.m., Resident 17 stated that one of the two showers had fluctuating water temperatures that were so uncomfortable she refused to use that shower. During an observation on 1/9/23 at 3 p.m., the water from the faucet in one of the front public restrooms was scalding hot. During an observation on 1/9/23 at 3:41 p.m., Maintenance Supervisor checked the temperature of the water from the faucet in the bathroom between rooms [ROOM NUMBERS]. The thermometer read 124.9° F. Maintenance Supervisor stated the water was supposed to be less than 120 degrees. During an interview on 1/9/23 at 3:51 p.m., Unlicensed Staff B stated when she washed her hands in a resident's bathroom, she would turn on the cold and hot together otherwise the hot water would be too hot to touch/wash her hands. During an observation on 1/9/23 at 3:58 p.m., Maintenance Supervisor checked the temperature of the water from the faucet in the bathroom for room [ROOM NUMBER]. The thermometer read 134.4° F. During a concurrent observation and interview on 1/9/23 at 4:09 p.m., Licensed Staff A stated she had a high tolerance for the hot water, but if she was washing her hands in a resident's bathroom, the hot water would be a little too hot if she did not turn on the cold water with the hot water. Licensed Staff A was asked to wash her hands in the bathroom shared by the residents in RM [ROOM NUMBER] and RM [ROOM NUMBER] just using the hot water. Licensed Staff A stated the hot water was too hot and she was not able to tolerate the hot water alone. Licensed Staff A stated her hands were turning red. During an observation and concurrent interview on 1/9/23 at 4:18 p.m., in the boiler room, the temperature gauge on the pipe that Maintenance Supervisor stated was running from the mixing valve to the residents' bathrooms read 123° F. Maintenance Supervisor made some adjustments to the boiler and ran hot water through hoses onto the ground outside the boiler room. When queried, Maintenance Supervisor stated the water pipe that runs to the residents' bathrooms has a monitor that sends him an alert on his phone if the water temperature gets too high. He stated he did weekly spot checks on the water temperature in the residents' bathrooms, but he did not document the temperatures. During observations on 1/9/23 at 4:45 p.m. when running the hot water in Room (Rm) 101's bathroom, within 30 seconds, the hot water was too hot to touch. *Rm 102's bathroom hot water was too hot to touch within 10 seconds. *Rm 104 and RM [ROOM NUMBER] shared bathroom hot water was too hot to touch. *Rm 107 and RM [ROOM NUMBER] shared bathroom hot water was too hot to touch. *Rm 108 and RM [ROOM NUMBER] shared bathroom hot water was too hot to touch. During a group interview on 1/10/23 at 10:11 a.m., an anonymous resident stated the larger of the two showers had big fluctuations in water temperature. During an interview on 1/10/23 at 11:33 a.m., Maintenance Supervisor stated he had consulted with a plumber who stated the mixing valve was probably sticking due to its age and recommended replacing the whole unit. Maintenance Supervisor stated a new mixing valve had been ordered over-night delivery. Review of facility policy Water Temperatures, Safety of, last revised 12/2009, revealed, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120° F. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. Review of the American Burn Association's Scald Injury Prevention Educator's Guide, not dated, (accessed at website https://dds.dc.gov/sites/default/files/dc/sites/dds/publication/attachments/ABA%20Scald%20Injury%20Prevention%20Educator%27s%20Guide.pdf on 1/25/23) revealed, Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. The guide further indicated that hot water can cause third degree burns at 140° F after five seconds and at 133° F after fifteen seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to install call lights that could be accessed by a resident lying on the floor in the bathroom or shower room. This could potentially result in a resident falling to the floor and unable to signal to staff that they need immediate assistance. Finding: During observations on 1/9/23 between 3:41 p.m. and 4:30 p.m., all resident bathrooms and showers were noted to have call lights with a red button and no cord or other device to activate the call system from the floor. During an observation on 1/9/23 at 4:45 p.m., room [ROOM NUMBER]'s bathroom call light was located on the wall right of the sink. If a resident fell to the floor while in the bathroom, the resident would not be able to reach the call light to call for assistance. During a concurrent observation and interview on 1/12/23 at 10:15 a.m., the large shower room had shower equipment and other equipment that prevented one from being able to reach the shower call light without moving the equipment. The shower call light was out of reach from the shower area and could not be reached if a resident was on the floor. When the Maintenance Assistant was asked how a resident would be able to reach the call light if the resident fell to the floor, he stated, Good question; don't know. The Maintenance Assistant stated the piled-up equipment in the large shower room was always like this. During an observation and concurrent interview on 1/13/23 at 11:04 a.m., in the bathroom between room [ROOM NUMBER] and 166, Maintenance Supervisor verified there was no way to activate the call system if a resident was on the bathroom floor. Maintenance Supervisor stated he was not aware bathroom and shower call systems should be accessible to residents on the floor. Maintenance Supervisor verified that all 14 resident bathrooms and the showers had the same call button as the one in the bathroom for rooms [ROOM NUMBERS]. During an interview on 1/13/23 at 12:05 p.m., when Licensed Staff C was asked how a resident could reach a bathroom call light from the floor, Licensed Staff C stated the residents were assisted to the bathroom. When Licensed Staff C was asked what about an independent resident who went to the bathroom on their own and fell to the floor while in the bathroom. Could the resident reach the call light from the floor? Licensed Staff C stated it would depend on where the resident fell in the bathroom, but probably not. During a concurrent observation and interview on 1/13/23 at 12:10 p.m., in the bathroom shared by the residents in room [ROOM NUMBER]/126, Unlicensed Staff D was asked if a resident fell to floor in the bathroom, could the resident reach the call light (push button on wall left of toilet) from the floor. Unlicensed Staff D stated the resident would need to be near the call light to be able to push the button on the wall left of the toilet. Unlicensed Staff D stated all residents are assisted with their shower. The shower call light was more for the Certified Nursing Assistant needing assistance with a resident. A policy for call light accessibility was requested. Per Administrator, the facility did not have such a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 4 was free from physical restraint when the facility applied physical restraints to Resident 4 without a physician's order, and without attempting less restrictive interventions first to prevent falls. This failure had the potential to cause injuries such as entrapment, feelings of imprisonment and agitation to Resident 4. Findings: Resident 4 was admitted to the facility on [DATE] with Medical Diagnoses including Dementia (General term for a decline in mental ability severe enough to interfere with daily life), Alzheimer's Disease (The most common cause of dementia) and Anxiety disorder, according to the facility Face Sheet. During an observation on 7/9/19 at 11:26 a.m., Resident 4 was observed in bed with full side rails in the up position on both sides of her bed. These were side rails that went from the foot of the bed, to the headboard. Resident 4 was verbal, but unable to answer questions, as she appeared very confused. Resident 4 did not seem to be able to release the side rails herself. The side rails did not allow Resident 4 to get out of bed. During an interview on 7/9/19 at 11:28 a.m., Licensed Nurse J, Resident 4's assigned nurse, stated that the reason for having both full side rails up was because sometimes Resident 4 could not be redirected and could get very hyper. Licensed Nurse J also stated that Resident 4 seemed confused, and while sometimes she was able to use the call light, other times she was not able to do so. During a record review on 7/9/19 at 2:15 p.m., no physician's order for full side rails was found in Resident 4's Medical Record. During an interview on 7/11/19 at 10:20 a.m., Unlicensed Staff M, Resident 4's assigned nursing assistant, stated that Resident 4 was able to stand up from bed with assistance. Unlicensed Staff M also stated that Resident 4 had the ability to roll over and reposition herself in bed. Unlicensed Staff M stated that Resident 4 could move her upper and lower extremities well and had attempted to get out of bed in the past. Unlicensed Staff M stated that when Resident 4 was in her wheelchair, she could wheel herself around. Unlicensed Staff M stated that facility staff was not allowed to leave both full side rails up when Resident 4 was in bed. During an interview on 7/11/19 11:50 a.m., the DON (Director of Nursing) stated that the facility used side rails only when the residents requested them. During a concurrent observation and interview on 7/15/19 at 3:17 p.m., Resident 4 was again observed in bed, with both full side rails in the up position. Licensed Nurse I, Resident 4's assigned nurse for the evening shift, stated that Resident 4 now had an order for both (full) side rails up when in bed. When asked what other interventions they had attempted to keep her from falling from bed, Licensed Nurse I stated that they performed frequent checks on Resident 4, put her bed in the lowest position, and provided a mat by Resident 4's bedside, but Resident 4 continued to attempt to get out of bed. Licensed Nurse I stated that Resident 4 could not make her needs known as she was very confused. During a record review on 7/15/19 at 4:15 p.m., it was noted that Resident 4 did not have Nursing Care Plans that mentioned the use of full side rails to prevent falls. A Nursing Plan of Care initiated on 3/30/19 for falls, had only the following interventions, Instruct on the use of the call light .Place bed in low position .re-explain how to use the call light frequently. During the interview with Licensed Nurse J on 7/9/19 at 11:28 a.m., she stated that Resident 4 sometimes could not use the call light. Licensed Nurse I stated on 7/15/19 at 3:17 p.m. that Resident 4 could not make her needs known. During concurrent interview and record review on 7/15/19 at 3:20 p.m., Licensed Nurse J presented a physician's order for full side rails. The order, documented on 7/15/19 at 11:30 a.m., indicated, May use full side rails for positioning & safety. The order did not indicate what medical symptom it was intending to treat. The order did not specify the period of time for the use of the restraint. When asked about the order's discontinuation date, Licensed Nurse J indicated not been aware that that the order for full side rails had to be re-evaluated often. The facility policy titled, Proper Use of Side Rails, last revised in October of 2010, indicated, Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed) .Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. The facility's policy titled, Use of Restraints, last revised in December of 2007 indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, of for the prevention of falls .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed .Restraints shall only be sued upon the written order of a physician .The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom: and c. The type of restraint, and period of time for the use of the restraint .Orders for restraints will not be enforced for longer than twelve (12) hours unless the resident's condition requires continued treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a baseline care plan for one resident (Resident 143) within 48 hours of admission which had the potiental to result in Resident 143 not receiving necessary care for her medical conditions. Findings: During a record review on 7/9/19, at 10:06 a.m., the Electronic Medical Record (EMR) for Resident 143 indicated she was admitted to the facility on [DATE]. The Orders section indicated, resident is able/unable to understand and sign admission contract and participate in plan of care due to dx [diagnosis], with no indication if resident 143 was able or not able. The Orders section further indicated, nurses review by blank date blank, indicating no nurse had reviewed the record. The Care Plan section indicated, no care plan had been created for Resident 143. The section was blank. During a record review on 7/9/19, at 10:47 a.m., the physical chart for Resident 143 was reviewed. The Care Plan tab indicated, no care plan in chart. A review of the other sections in the physical chart indicated no care plan anywhere in the physical chart. During an interview with the Minimum Data Set (MDS) assessment Nurse, on 7/9/19, at 4:56 p.m., she stated she received notification over the weekend that Resident 143 was admitted . The MDS Nurse stated today was her first day back to work and the state was here. She stated she had not had time to get any of her MDS (part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs. After the assessment Care Area Triggers populate to list concerns to be Care Planed.) work done. The facility policy and procedure titled Care Plan - Baseline, dated 12/16, indicated, a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that oxygen therapy was administered using the right oxygen delivery device and within professional standards of practice for one of one sampled residents (Resident 93). This failure had the potential to cause respiratory distress and excessive rebreathing of carbon dioxide (A colorless, odorless gas produced by burning carbon and organic compounds and by respiration) which could lead to carbon dioxide poisoning. Findings: Resident 93 was admitted to the facility on [DATE] with Medical Diagnoses including Fracture of the Lower End of the Right Femur (A bone in the human leg extending from the pelvis to the knee) according to the facility Face Sheet. A Nursing Plan of Care initiated on 7/3/19 for Resident 93 indicated, Altered respiratory status/Difficulty Breathing r/t (related to) Anxiety. During an observation on 7/9/19 at 9:29 a.m., Resident 93 was observed using supplemental oxygen at three liters per minute through a nasal cannula (A device consisting of a lightweight tube used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) from an oxygen concentrator (A medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen). During an observation on 7/12/19 at 10:07 a.m., Resident 93 was observed in bed with a face mask (A device used to administer oxygen, shaped to fit snugly over the mouth and nose and secured in place with a strap or held with the hand) on her chest. Resident 93's eyes were closed. The oxygen concentrator was still on, at a flow rate of three liters per minute, connected to the face mask tubing laying on Resident 93's chest. During an interview on 7/12/19 at 10:10 a.m., Licensed Nurse J, Resident 93's assigned nurse, stated that Resident 93 kept taking off the face mask herself. Licensed Nurse J stated that the morning of 7/12/19, Resident 93's SpO2 (blood oxygen concentration) was found to be in the 80's (Normal pulse oximeter readings usually range from 95-100%), at three liters per minute via nasal cannula. Licensed Nurse J decided to get a face mask for Resident 93. Licensed Nurse J stated that with the face mask on, at a flow rate of three liters per minute, Resident 93's oxygen saturation increased to 95%. Licensed Nurse J stated that she decided to leave Resident 93 with the face mask on, at a flow rate of three liters per minute. During an interview on 7/15/19 at 11:58 a.m., the DSD (Director of Staff Development) stated that she did not think the facility went over with staff what type of oxygen delivery systems were used depending on the flow of oxygen that the residents required, but thought that at a flow rate of three liters per minute a nasal cannula should be used. The DSD stated that a face mask was used for flow rates of five liters per minute or above. Licensed Nurse J's annual Nurse Orientation Checklist dated 1/29/19 indicated that the subjects, Oxygen Concentrators/Tanks/Supplies .Oxygen Administration via nasal cannula .Oxygen Administration via nonrebreather mask were reviewed by Licensed Nurse J, and she was able to demonstrate appropriate skills in regards to the reviewed subjects, as evidenced by the instructor's initials. The educational nursing book titled, Clinical Nursing Skills, Seventh Edition by S. S., D. D. and B. M. published in 2008 indicated, Simple Face Mask .This equipment requires fairly high oxygen flow to prevent rebreathing of carbon dioxide . Flow: 8-12 L (Liters). The educational nursing book titled, Kosier & Erb's FUNDAMENTALS of Nursing, 8th edition, published in 2008 indicated, [The nasal cannula] delivers a relatively low concentration of oxygen at flow rates of 2 to 6 L per minute .The simple face mask delivers oxygen concentrations from 40% to 60% at liter flows of 5 to 8 L per minute. The facility policy titled, Oxygen Administration last revised in October of 2010, indicated, Review the physician's orders or facility protocol for oxygen administration .Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter) .Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.

Based on observation, interview, and record review, the facility failed to ensure residents were provided diets as ordered by physician for the lunch meal on 7/11/19. This failure could have caused worsening of the residents' medical conditions. Findings: During a review of the Daily Cook's Menu, on 7/11/19, at 12:10 p.m., the menu indicated residents with a Heart Healthy Diet were going to be served turkey with Dijon honey. During tray line observation, on 7/11/19, at 12:20 p.m., heart healthy diet was called out, resident was served turkey ham with brown sugar glaze. During tray line observation, on 7/11/19, at 12:23 p.m., heart healthy diet was called out, resident was served turkey ham with brown sugar glaze. During tray line observation, on 7/11/19, at 12:35 p.m., heart healthy diet was called out, resident was served turkey ham with brown sugar glaze. During an interview with the Dietary Manager (DM) on 7/11/19, at 3:57 p.m., she reviewed daily cook menu and stated, no, we did not make the turkey. The DM confirmed the Heart Healthy diet was not followed as prescribed.

4) During an observation on 07/11/19, at 1:03 p.m., unknown maintenance staff was on a ladder at the foot of Resident 5's bed. The staff member was removing the privacy curtain. Resident 5 was being assisted with lunch by Unlicensed Staff E. During a request for facility policies and procedures on 7/15/19, at 6 p.m., the Director of Nursing wrote, We do not perform housekeeping during meal times. There was no policy Based on observation, interview and record review, the facility failed to ensure that residents' rights were protected when: 1) Staff was observed in the upstanding position, looking down at one resident while assisting him with his meal, 2) Two staff were observed standing over two residents when assisting with their meal, 3) Staff was observed speaking a language other than English in the hallways of the facility making one resident uncomfortable, and; and 4) Privacy curtains were removed for one resident, during a meal. These findings had the potential to cause feelings of frustration, loss of dignity and helplessness to the residents of the facility. Findings: 1) During an observation on 7/10/19 at 8:40 a.m., Unlicensed Staff N was observed assisting Resident 36 with breakfast, in bed. Unlicensed Staff N was standing while feeding Resident 36, looking down at the resident during the process. Unlicensed Staff N's head was observed approximately two feet higher than Resident 36's head. During an interview on 7/10/19 at 4:06 p.m., Unlicensed Staff N confirmed he was standing while assisting Resident 36 with his meal. He stated that he had the resident's bed raised while feeding him. Unlicensed Staff N stated that sometimes they used chairs when assisting residents with meals but he preferred to stand up. Unlicensed Staff N confirmed that he was not at eye level with the resident, and stated he could have had the bed higher. During an interview on 7/15/19 at 11:58 a.m., the DSD (Director of Staff Development) stated that caregivers were expected to be at eye level with residents when assisting them with their meals. She stated that if standing, care givers had to raise the bed so they were at eye level with the residents. 2) During a meal observation on 7/09/19, at 12:52 p.m., Unlicensed Staff S was standing over Resident 143 while assisting with the lunchtime meal. During a meal observation on 7/09/19, at 12:53 p.m., Licensed Nurse D was standing over Resident 14 while assisting with the lunchtime meal. 3) Based on the facility's Matrix provided on 7/9/19 by the Administrator and residents' Medical Records, the primary language for the majority of the residents in the facility was English. During an observation on 7/11/19 at 2:35 p.m., three housekeeping staff were heard and observed having a loud conversation among themselves in Spanish in the west wing of facility (right next to residents' rooms). During a second observation on 7/15/19 at 9:35 a.m., housekeeping staff were heard speaking Spanish among themselves in the south wing of the facility. During an interview on 7/12/19 at 3:15 p.m., Resident 18 stated that she often heard housekeeping staff speaking Spanish in the hallways. Resident 18 stated not being certain if it bothered her, but confirmed she could not understand it. Resident 18's BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in residents in Medicare or Medicaid certified nursing homes) score dated 5/13/19 was 14, which indicated her cognition was intact. During an interview on 7/12/19 at 3:48 p.m., Resident 26 stated that housekeeping staff was often overheard speaking Spanish. She stated that it bothered because she could not understand what they were saying. During an interview on 7/12/19 at 3:59 p.m., Licensed Nurse O stated that Resident 26 could make her needs known and could tell when something was bothering her. During an interview on 7/15/19 at 9:56 a.m., Resident 11 stated that she frequently heard staff speaking Spanish from her room. She stated that it did not bother her but that it happened often. Resident 11's MDS (U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated 4/19/19, indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in residents in Medicare or Medicaid certified nursing homes) score was 15, which indicated her cognition was intact. During an interview on 7/15/19 at 9:46 a.m., with Housekeeper K, Housekeeper P and Housekeeper Q, they stated that one of the facility's rules was to speak only English in resident areas. They stated that they were allowed to speak Spanish with residents who spoke only Spanish. In residents' rooms and hallways, they were not allowed to speak a language other than English. They stated that they had private areas, away from residents where they were allowed to speak Spanish. During an interview on 7/15/19 at 11:58 a.m., the DSD stated that in resident areas, it was required that staff speak only English, including in the facility's hallways.

Based on observation, interview, and record review, the facility failed to promote the resident's right to make choices regarding food from outside sources which had the potential for residents to feel institutionalized when not allowed to enjoy their food of preference. Findings: During an observation at Nurse Station 1, on 7/10/19, at 2:20 p.m., there was no resident refrigerator in the medication room or at the nurse's station. During an interview with Licensed Nurse A (LN A), on 7/12/19, at 2:35 p.m., she stated as far as she knew, the facility did not accept food from home. During an interview with Certified Nurse Assistant E (CNA E), on 7/12/19, at 2:55 p.m., she stated if someone brought food from home she would have to check with the resident's nurse. CNA E stated if the nurse was ok with the food, then yes, the resident could eat it. CNA E confirmed food left in the resident's room had to be thrown out. During an interview with Licensed Nurse J, on 7/12/19, at 3:04 p.m., she stated as long as the food was safe and met the requirements of the prescribed diet order, she would want to promote resident's eating with their family. When asked what she would do if there was leftover food, Licensed Nurse J stated unfortunately, the facility did not have a place to store and reheat resident's leftovers. During an interview with the Director of Nursing (DON), on 7/12/19, at 3:18 p.m., she stated in order to allow outside food, she expected nurses to check the resident's diet order. The DON stated the facility would not keep leftovers. She stated the only space in the facility would be the front utility room, where a staff refrigerator and microwave were located. The DON stated she could allow a resident to put food in there if it were a special occasion, but it would be a recipe for disaster. The DON confirmed the facility did not provide a space to store or reheat food brought in from outside the facility. The Facility policy and procedure titled, Food from Outside Sources, dated 1/1/17, indicated residents had the right to accept food brought in from outside sources. The procedure section indicated: To allow residents to have treats or their 'own kind' of food brought in from outside sources . 1. Do take food to the charge nurse before giving it to the resident, especially those on controlled diets, such as diabetic and low sodium, ect. 3. Don't leave any food in residents' rooms, as it attracts pests. 4. Don't give food to any other resident such as room-mate unless you check with the nursing department. They might be on a special diet! 5. Residents have the right to choose to accept food from visitors, family, friends, or other gurests. 6b. Ensure that if they are assisting visitors with re-heating or other preparation activities, that the community staff use safe food handling practices and encourage visitors and residents who are contributing to food preparation in the community to use these safe practices as well.

Based on interview and record review, the facility failed to provide two of three sampled residents (Resident 14 and Resident 99), Notice of Medicare Non-Coverage forms, which had the potential to result in residents being billed for services without notice. Findings: During a review of the Beneficiary Notice Worksheet, received 7/12/19, the facility had 27 residents discharge from a Medicare covered part A stay in the past six months, with benefit days remaining. Of the 27 residents, six chose to stay in the facility. Three residents were selected at random to review facility compliance with notification. During a review of the Beneficiary Protection Notification Review for Resident 14, received on 7/15/19, at 4:45 p.m., the form indicated resident was leaving the facility immediately following the last covered skilled day. The document further indicated no Notice of Medicare Non-Coverage was provided to Resident 14. During a review of the Beneficiary Protection Notification Review for Resident 99, received on 7/15/19, at 4:45 p.m., the form indicated resident was leaving the facility immediately following the last covered skilled day. The document further indicated no Notice of Medicare Non-Coverage was provided to Resident 99. During an interview with the Administrator and Social Service Director (SSD), on 7/15/19, at 5 p.m., they confirmed that the facility did use both the Skilled Nursing Facility Advanced Beneficiary Notice and the Notice of Medicare Non-Coverage. The SSD confirmed that for Resident 14 and 99 only the Advanced Beneficiary Notice was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide therapy services as ordered by the physician to seven of eleven residents (Resident 15, Resident 30, Resident 29, Resident 6, Resident 22, Resident 11, and Resident 24) of the facility. This failure could have caused decline in functional mobility, inability to perform activities of daily living (ADLs) and longer facility stays for residents. Findings: Resident 15 Resident 15 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease (Gradual loss of kidney function), according to the facility Face Sheet. Resident 15's MDS (U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated 5/1/19, indicated that she required supervision while walking in her room and out in the corridor. Resident 15's physicians' orders active as of 6/14/19 indicated, RNA (Restorative Nursing Assistant-a type of nursing assistant trained to help nurses in restoring mobility to patients) Services-Ambulation. Routine 5 x week/90 days (Five times per week for ninety days). During an interview on 7/12/19 at 10:13 a.m., Unlicensed Staff F stated she was the only RNA working for the facility. Restorative nursing notes documented by Unlicensed Staff F from 6/15/19-7/13/19 indicated that Resident 15 was offered RNA services only nine times, out of twenty days that were ordered by the physician (Five times per week for four weeks which equaled twenty times) during the time frame from 6/15/19-7/13/19. During an interview on 7/12/19 at 11:47 a.m., Resident 15 stated that she ambulated with Unlicensed Staff F only when Unlicensed Staff F had time, which was less than three times per week on some weeks. Resident 15 stated that Unlicensed Staff F was pulled to work with residents on the floor as a regular nursing assistant. Resident 15 stated that she had a walker and could ambulate by herself with the walker, but facility staff had instructed her not to walk without assistance for safety reasons. Resident 30 Resident 30 was admitted to the facility on [DATE] with Medical Diagnoses including Hemiplegia (Paralysis of one side of the body) and Hemiparesis (Weakness of one side of the body) following cerebral infarction (brain lesion), according to the facility Face Sheet. Her MDS dated [DATE], indicated her BIMS (brief interview for mental status) score was 11, which indicated her cognition was moderately impaired. Resident 30's Nursing Plan of Care on decreased functional ability initiated on 5/15/19, indicated, RNA to ambulate with FWW (Front wheel walker) 3-5 x/wk (Times per week) as tolerated. Physicians' orders active as of 6/14/19 indicated, RNA services for ambulation 5x (Five times) a week for 90 days. Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 30 was offered RNA therapy services only nine times, out of twenty that were ordered by the physician from 6/15/19-7/13/19 (Five times per week for four weeks which equaled twenty times). During an interview on 7/12/19 at 11:50 a.m., Resident 30 stated that she only ambulated with Unlicensed Staff F at an average of three times per week maximum, but often less than three times per week. Resident 30 stated she would like to get therapy as much as possible because she did not want to lose her abilities. Resident 30 indicated she would like therapy everyday if possible and stated, It makes a tremendous difference. Resident 29 Resident 29 was admitted to the facility on [DATE] with Medical Diagnoses including Muscle Weakness and Repeated Falls, according to the facility Face Sheet. Resident 29's MDS dated [DATE], indicated that he required supervision while walking in his room and out on the corridor. Physicians' orders active as of 6/14/19 indicated, RNA 5x weekly for 90 days. Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 29 was offered RNA therapy services only nine times, out of twenty that were ordered by the physician from 6/15/19-7/13/19 (Five times per week for four weeks which equaled twenty times). Resident 6 Resident 6 was admitted to the facility on [DATE] with Medical Diagnoses including Heart Failure (A chronic, progressive condition in which the heart muscle is unable to pump enough blood through the heart to meet the body's needs for blood and oxygen), according to the facility Face Sheet. Resident 6's MDS dated [DATE], indicated that she required supervision while walking in her room and out in the corridor. Resident 6's Nursing Plan of Care on decreased functional ability initiated on 11/16/18, indicated, RNA services to ambulate 5x/week /90 days. Resident 6's Physicians' orders active as of 6/14/19 indicated, RNA services to ambulate 5 x/week/90 days. Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 6 was offered RNA therapy services only nine times, out of twenty that were ordered by the physician from 6/15/19-7/13/19 (Five times per week for four weeks which equaled twenty times). Resident 22 Resident 22 was admitted to the facility on [DATE] with Medical Diagnoses including Weakness and Restless Leg Syndrome (A condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), according to the facility Face Sheet. Resident 22's MDS dated [DATE] indicated that she required supervision with transfers, and had not been observed walking in her room. Physicians' orders active as of 6/14/19 indicated, RNA services for ambulation and therapy 3x/week x 90 days (Three times per week for ninety days). Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 6 was offered RNA therapy services only nine times, out of twelve that were ordered by the physician from 6/15/19-7/13/19 (three times per week for four weeks, which equaled twelve times). Resident 11 Resident 11 was admitted to the facility on [DATE] with Medical Diagnoses including Postpolio syndrome (A cluster of potentially disabling symptoms that appear decades after the initial polio illness-a disease that causes severe nerve injury) and Paraplegia (A form of paralysis in which function is substantially impeded from the waist down), according to the facility Face Sheet. Resident 11's MDS dated [DATE], indicated her BIMS score was 15, which indicated her cognition was intact. Resident 11's MDS also indicated that she required extensive assistance with bed mobility and total dependence for transfers. Resident 11's Nursing Plan of Care on decreased functional ability initiated on 11/5/18, indicated, RNA Services-therapeutic exercise & ROM (Range of Motion). Routine 5 x week/90 days. Physicians' orders active as of 6/14/19 indicated, RNA Services-therapeutic exercise & ROM (Range of Motion). Routine 5 x week/90 days (Five times per week for ninety days). Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 11 was offered RNA therapy services only nine times, out of twenty that were ordered by the physician from 6/15/19-7/13/19 (Five times per week for four weeks which equaled twenty times). During an interview on 7/12/19 at 12:23 p.m., Resident 11 stated that she was usually provided RNA therapy services three times per week, but sometimes only received therapy twice per week because Unlicensed Staff F got pulled to work as a nursing assistant on the floor. Resident 11 stated that it was beneficial for her to have RNA therapy services three times per week. Resident 24 Resident 24 was admitted to the facility on [DATE] with Medical Diagnoses including Morbid Obesity, Unsteadiness on Feet and History of Falling, according to the facility Face Sheet. Resident 24's MDS dated [DATE], indicated his BIMS score was 13, which indicated his cognition was intact. Resident 24's MDS also indicated that he required extensive assistance with bed mobility, transfers and walking in the room. During an interview on 7/09/19 at 3:18 p.m., Resident 24 stated that he did not receive enough RNA therapy and that staff walked with him only once per week. Resident 24 stated that the facility did not have enough employees to offer RNA therapy services to the residents. Resident 24 stated that he planned to discharge home but was concerned that he was not getting enough ambulation therapy. According to Resident 24, Unlicensed Staff F, who offered RNA therapy services, told him that she had to work on the floor, therefore she could not offer services more often. Resident 24's Nursing Plan of Care on decreased functional mobility initiated on 6/14/19, indicated, RNA 3x/week (three times per week). Resident 24's physicians' orders active as of 6/14/19 indicated, RNA for therapeutic exercise 3-5 x/week, as tolerated. RNA ambulation documentation from 6/15/19 to 7/6/19, indicated that Resident 24 was offered RNA therapy services only one time the week of 6/23/19-6/29/19, when Resident 24 had orders to receive RNA therapy services three to five times per week. During an interview on 7/15/19 at 3:35, Resident 24 stated feeling affected by not having his RNA therapies done as ordered. When asked if he felt that he was getting weaker, Resident 24 stated that he was. Resident 24 also stated he wanted to go home, and had been in the facility for two years without being able to get strong enough to be discharged home as a result of the lack of therapy. Documents titled, [Facility] DAILY GROUP ASSIGNMENT provided by Administrator on 7/15/19 at 11:00 a.m., indicated that in July of 2019, Unlicensed Staff F (The only RNA [Restorative Nursing Assistant] in the facility), was removed from her assignment as an RNA therapist, to work as a nursing assistant on the floor taking a regular nursing assistant assignment five out of six shifts from 7/1/19-7/13/19. Records from June of 2019, indicated Unlicensed Staff F was pulled to work as a nursing assistant on the floor three out of ten shifts. During an interview on 7/15/19 at 4:10 p.m., the DON (Director of Nursing) confirmed that Unlicensed Staff F was removed from her regular assignment as an RNA therapist to work on the floor as a nursing assistant on some days, but stated that when this occurred, Occupational Therapist B took over and completed Unlicensed Staff F's therapy tasks. During three separate interviews on 7/15/19 from 4:07 to 4:09 p.m., Resident 11, Resident 15 and Resident 24 stated that only Unlicensed Staff F assisted them with their RNA exercises, and denied being assisted by any other staff member for those activities. Documents provided by a representative from Medical Records on 7/15/19 at 4:15 p.m., indicated that there was no documentation for Resident 15 written by Occupational Therapist B for the month of July, 2019. In June of 2019, the documentation by Occupational Therapist B indicated that Resident 15 participated in bilateral upper extremity exercises and not on ambulation, which was the RNA's assigned task. There was no indication that Occupational Therapist B assisted Resident 15 with the ordered RNA therapy services for June and July of 2019. There was no June/July (2019) documentation written by Occupational Therapist B for Resident 11 or Resident 24. There was no indication that Occupational Therapist B assisted Resident 11 or Resident 24 with the RNA therapy services ordered for June and July of 2019. During an interview on 7/12/19 at 10:13 a.m., Unlicensed Staff F stated that she was the only RNA working for the facility and providing RNA therapy services. Unlicensed Staff F stated that she provided RNA therapy services to twelve residents in the facility, including Resident 15, Resident 30, Resident 29, Resident 6, and Resident 22, Resident 11 and Resident 24. Unlicensed Staff F stated that she worked at the facility four eight-hour shifts per week. Given her work schedule, Unlicensed Staff F could not complete therapy services to residents that had RNA orders five times per week, since she only worked four days per week. During an interview on 7/12/19 at 10:13 a.m., Unlicensed Staff F confirmed providing RNA therapy services less than three times per week to several residents of the facility because she was assigned to work as a nursing assistant on the floor. Unlicensed Staff F stated that the DSD (Director of Staff Development) created the work schedules, many of which indicated that she was removed from her assignment as an RNA therapist to work as a nursing assistant on the floor with a regular resident assignment. Unlicensed Staff F stated that if allowed to work only as an RNA she would have time to complete her therapy assignments, but on the days when she worked as a regular nursing assistant, she could not provide RNA services because, It is too much. Unlicensed Staff F stated that the facility was short staffed and needed more certified nursing assistants. Unlicensed Staff F stated that management knew that she was constantly being pulled to work as a nursing assistant on the floor, and that there were weeks where she had to work as a nursing assistant two to three shifts out of four. During an interview on 07/15/19 at 2:32 p.m. with the Administrator and DON (Director of Nursing), they confirmed knowing about this issue, and stated that they were actively trying to hire certified nursing assistants and restorative nursing assistants. The facility policy titled, Scheduling Therapy Services last revised in July of 2013, indicated, Therapy Services shall be scheduled in accordance with the resident's treatment plan .The therapist shall interview the resident and consult with the Attending Physician as to the type of treatment to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, inteview, and record review, the facility failed to ensure 2 out of 12 sampled residents (Resident 10 and 143), received quality of treatments and care when: 1. Resident 10, with a diagnosis of heart failure, was not provided the medical device required to shock her heart back into a functioning rhythm, which had the potential to result in death, 2. Resident 10's medical device was discontinued without assessing the need for the device, which had the potential to result in death, 3. Resident 10, with a diagnosis of congestive heart failure, was not weighed daily as ordered for 31 out of 99 opportunities, and did not inform the doctor of the change, which had the potential for delay in treatment during an exacerbation of her medical condition. 4. Two residents (Resident 10, and 143) were not given medication as ordered by a physician, which had the potential to exacerbate their medical conditions. Findings: 1. During a review of the clinical record for Resident 10, she was admitted to the facility on [DATE], with active diagnosis of heart failure, valve insufficiency, left bundle-branch block, heart disease of the coronary artery, and end stage kidney disease dependent on renal dialysis (The process of removing waste products and excess fluid from the body). During a review of the Electronic Medical Record for Resident 10, the Orders section indicated, [brand] life vest wearable defibrillator (wearable cardioverter defibrillator (WCD), a treatment option for patients at risk of sudden cardiac death (SCD) that offers advanced protection and monitoring as well as improved quality of life) wear 24 hours a day, 7 days a week, with a battery change at 11 a.m. dated 4/17/19, revised 4/24/19. During a review of the physical chart for Resident 10, the Physician's Orders tab indicated, a fax was sent from the facility to the physician on 4/18/19. The fax indicated Resident 10 had been wearing the [brand] life vest at the facility she was residing in prior to admission to the facility. The fax indicated that a nurse was requesting an order to continue to use the medical device. The document indicated the physician agreed to continue the order with a signature and the date of 4/23/19. The order was noted to be carried out by Licensed Nurse O on 4/24/19 at 12:44 a.m. Attached to the document was a Facsimile Transmittal Sheet from [Name] Care Center sent to the facility on 4/18/19. The Notes section indicated, regarding Resident 10 and the [brand] life vest orders, call for additional information. During a review of the clinical record for Resident 10, the Medication Administration Record indicated, every day at 11 a.m. there was an order to change the battery on a [brand] vest). The record indicated that the battery was not changed because the vest was not in use since admission. During an interview with Licensed Nurse D (LN D), on 7/15/19, at 9:52 a.m., she confirmed she was the nurse for Resident 10. LN D stated the vest came with the resident when she transferred from another facility, then someone came and picked up the vest. When asked if a replacement had ever been ordered LN D stated it had not. When asked if the vest was still an active order, LN D stated, I need to call the doctor for an order to discontinue the vest. LN D reviewed the record and confirmed there was no documentation that the doctor had been informed Resident 10 was not wearing the vest. When asked if there was any assessment data or reports from the doctor showing Resident 10 no longer needed the vest, LN D stated there was not in the record, she would have to call the doctor. No facility policy or procedure was provided to indicate what to do in cases where required medical equipment is not available to provide to a resident as ordered by a physician. 2. During an observation, on 7/15/19, at 10:29 a.m., observed LN D transcribing an order. She stated The Nurse Practitioner wrote an order to discontinue the use of the vest. When asked if there was an assessment or lab or rational to the order LN D confirmed there was not. During an interview with The Nurse Practitioner (NP) on 7/15/19, at 10:36 a.m., she confirmed she wrote an order to discontinue Resident 10's vest. When asked what was the rationale for the order, the NP stated, because the vest was not available in the facility. The NP confirmed she had not spoken or seen Resident 10. When asked how she knew the resident did not need the vest, the NP stated well, it's not here. During an interview with Resident 10 on 7/15/19, at 10: 56 a.m., she confirmed she had not worn the vest on for several months. During an interview with The Administrator and the Director of Nursing (DON), on 7/15/19, at 2 p.m., The DON stated there should be a rationale for discontinuing a treatment or service for a resident. When asked what was the expectation when an order was discounted, she stated an assessment of the resident, pertinent diagnostic findings, and resident health status, as needed should be reviewed. During a review of the clinical record for Resident 10 on 7/15/19, 3:58 p.m., there was no change to the order to discontinue the medical device. The record further indicated there was no indication, or reason provided as a rationale for discontinuation. No facility policy or procedure was provided to indicate what was required when there was a discontinuation of treatment or service. 3. During a review of the clinical record for Resident 10, the Orders section indicated, daily weights were ordered. The order further indicated to call the doctor if the resident had a weight change of three pounds in one day or five pounds in a week. During a review of the clinical record for Resident 10, The Vitals section indicated, there were no daily weights documented for 31 days out of the 99 days the resident had been in the facility. During a review of the clinical record for Resident 10 on 7/11/19, at 9:06 a.m., the vitals section indicated, the last recorded weight was on 7/8/19. The change in weight from 7/7/19 to 7/8/19 was 4.4 pounds. No indication in the EMR that the doctor was made aware. The facility policy and procedure titled, Change in a Resident's Condition or Status, revised 5/17, indicated the facility shall promptly notify the resident, and his or her Attending Physician, of the change. The policy further indicated, except in medical emergencies notifications will be made within 24 hours of the change. During an interview with the Medical Records Director on 7/15/19, at 4 p.m., she reviewed the physical chart and EMR for resident 10. She confirmed multiple daily weights were missing from the record. The Medical Records Director was unable to locate any documentation that the doctor was made aware when there was a weight change that required notification. 4. During a record review, on 7/9/19, at 10:06 a.m., the Electronic Medical Record (EMR) for Resident 143 indicated she was admitted to the facility on [DATE]. The orders section indicated, systane soln 0.4-0.3 instill 1 drop 4 times a day for dry eyes. The orders section further indicated, timolol maleate soln 0.5% instill one dose in both eyes two times a day for primary open -angle glaucoma. Both eye drops had the status of awaiting delivery. Progress Notes section indicated on 7/7/19 and 7/8/19, staff called the pharmacy to check on the status of the eye drops being delivered. On 7/8/19 a note further indicated the DON was going to purchase one of the eye drops due to the fact that it was not a prescription medication. During a review of the clinical record for Resident 143 on 7/9/19, the Medication Administration Record indicated, the over the counter eye drop was documented as unavailable. During a review of the clinical record for Resident 10, the Orders section indicated, Nephplex RX (a vitamin tablet formulated to be tolerated by people with kidney failure) tablet give 1 tablet by mouth every day. The ordered date was 4/17/19. The supply note from pharmacy dated received 7/9/19, indicated it will not be filled because it was rejected error 601. During an interview with the Medical Records Director on 7/15/19, at 4 p.m., she reviewed the physical chart and EMR for resident 10. She confirmed multiple dates the Medication Administration Record indicated the medication was not given. During a review of the clinical record for Resident 10, the Progress Notes Section, a Nurse Note indicated, on 7/9/19 at 5:10 p.m., spoke to representative at the pharmacy, Nephplex RX will be delivered at 9 p.m. A similar note was dated 7/8/19, with a delivery expected at 9 p.m. that day.

Based on observation, interview, and record review, the facility failed to provide ongoing assessment of one resident's condition (Resident 10) before and after dialysis treatments received at a certified dialysis facility. This failure had the potential for Resident 10's change of condition before or after dialysis not being monitored or treated appropriately. Findings: During an observation on 7/12/19, at 11 a.m., Resident 10 was assisted onto a gurney by two ambulance staff members and wheeled outside of the facility. No paperwork or file was observed. During an interview with Licensed Nurse O (LN O), she stated she was the regular evening nurse for Resident 10. LN O stated Resident 10 returned from dialysis around 5:30 p.m., 3 days a week. LN O stated when Resident 10 got back to the facility, the nurse would take the resident's blood sugar and a full set of vital signs. LN O stated direct care staff would get the resident changed and ready for dinner. When asked if any information got passed verbally from [brand] dialysis clinic, LN O stated no, and not that she was aware of. During an interview with The Medical Records Director on 7/15/19, at 10:10 a.m., she confirmed there was no documentation from [brand] dialysis clinic in Resident 10's physical chart. The Medical Records Director was able to provide various progress notes from the electronic medical record that had various statements about the resident's status related to dialysis. She confirmed the notes were not consistent, and did not specifically address the dialysis treatment. During an interview with Resident 10 on 7/15/19, at 11 a.m., she confirmed there was no information she transported back and forth, to and from dialysis and the facility During an interview with the Director of Staff Development (DSD) on 7/15/19, at 12:10 p.m., she stated she was responsible for ensuring the direct care staff knew how to care for the residents. The DSD also stated the nurse would monitor for bleeding and check the dressing. The DSD confirmed she had not worked with nurses on competencies needed to care for a resident requiring dialysis. The DSD confirmed the facility did not get any information from [brand] dialysis clinic about the treatment or how the resident tolerated the treatment. During a review of the contract between the facility and the dialysis clinic, dated 10/4/02, indicated the facility would be responsible for creating a policy and procedure for resident care. The contract indicated the policy would include interchange of information useful and necessary for the care of the resident. The facility policy and procedure titled, Hemodialysis Access Care, dated 9/10, the Documentation section indicated, the nurse should document every shift. The policy further indicated the documentation should record if dialysis was done, any part of the report from the dialysis nurse post treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staff when: 1) RNA (Restorative Nursing Assistant- a type of nursing assistant trained to help nurses in restoring mobility to patients) therapy services were not provided as ordered for seven of eleven residents (Resident 15, Resident 30, Resident 29, Resident 6, Resident 22, Resident 11, and Resident 24) over an extended period of time, and; 2) Call lights were not answered timely. This could have caused decline in functional mobility and inability to meet the residents' care needs within a reasonable time frame. Cross reference F676 for RNA Therapy Services Findings: 1) RNA Therapy Services Resident 15 Resident 15 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease (Gradual loss of kidney function), according to the facility Face Sheet. Resident 15's MDS (U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated 5/1/19, indicated that she required supervision while walking in her room and out in the corridor. Resident 15's physicians' orders active as of 6/14/19 indicated, RNA (Restorative Nursing Assistant-a type of nursing assistant trained to help nurses in restoring mobility to patients) Services-Ambulation. Routine 5 x week/90 days (Five times per week for ninety days). During an interview on 7/12/19 at 10:13 a.m., Unlicensed Staff F stated she was the only RNA working for the facility. Restorative nursing notes documented by Unlicensed Staff F from 6/15/19-7/13/19 indicated that Resident 15 was offered RNA services only nine times, out of twenty days that were ordered by the physician (Five times per week for four weeks which equaled twenty times) during the time frame from 6/15/19-7/13/19. During an interview on 7/12/19 at 11:47 a.m., Resident 15 stated that she ambulated with Unlicensed Staff F only when Unlicensed Staff F had time, which was less than three times per week on some weeks. Resident 15 stated that Unlicensed Staff F was pulled to work with residents on the floor as a regular nursing assistant. Resident 15 stated that she had a walker and could ambulate by herself with the walker, but facility staff had instructed her not to walk without assistance for safety reasons. Resident 30 Resident 30 was admitted to the facility on [DATE] with Medical Diagnoses including Hemiplegia (Paralysis of one side of the body) and Hemiparesis (Weakness of one side of the body) following cerebral infarction (brain lesion), according to the facility Face Sheet. Her MDS dated [DATE], indicated her BIMS (brief interview for mental status) score was 11, which indicated her cognition was moderately impaired. Resident 30's Nursing Plan of Care on decreased functional ability initiated on 5/15/19, indicated, RNA to ambulate with FWW (Front wheel walker) 3-5 x/wk (Times per week) as tolerated. Physicians' orders active as of 6/14/19 indicated, RNA services for ambulation 5x (Five times) a week for 90 days. Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 30 was offered RNA therapy services only nine times, out of twenty that were ordered by the physician from 6/15/19-7/13/19 (Five times per week for four weeks which equaled twenty times). During an interview on 7/12/19 at 11:50 a.m., Resident 30 stated that she only ambulated with Unlicensed Staff F at an average of three times per week maximum, but often less than three times per week. Resident 30 stated she would like to get therapy as much as possible because she did not want to lose her abilities. Resident 30 indicated she would like therapy everyday if possible and stated, It makes a tremendous difference. Resident 29 Resident 29 was admitted to the facility on [DATE] with Medical Diagnoses including Muscle Weakness and Repeated Falls, according to the facility Face Sheet. Resident 29's MDS dated [DATE], indicated that he required supervision while walking in his room and out on the corridor. Physicians' orders active as of 6/14/19 indicated, RNA 5x weekly for 90 days. Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 29 was offered RNA therapy services only nine times, out of twenty that were ordered by the physician from 6/15/19-7/13/19 (Five times per week for four weeks which equaled twenty times). Resident 6 Resident 6 was admitted to the facility on [DATE] with Medical Diagnoses including Heart Failure (A chronic, progressive condition in which the heart muscle is unable to pump enough blood through the heart to meet the body's needs for blood and oxygen), according to the facility Face Sheet. Resident 6's MDS dated [DATE], indicated that she required supervision while walking in her room and out in the corridor. Resident 6's Nursing Plan of Care on decreased functional ability initiated on 11/16/18, indicated, RNA services to ambulate 5x/week /90 days. Resident 6's Physicians' orders active as of 6/14/19 indicated, RNA services to ambulate 5 x/week/90 days. Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 6 was offered RNA therapy services only nine times, out of twenty that were ordered by the physician from 6/15/19-7/13/19 (Five times per week for four weeks which equaled twenty times). Resident 22 Resident 22 was admitted to the facility on [DATE] with Medical Diagnoses including Weakness and Restless Leg Syndrome (A condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), according to the facility Face Sheet. Resident 22's MDS dated [DATE] indicated that she required supervision with transfers, and had not been observed walking in her room. Physicians' orders active as of 6/14/19 indicated, RNA services for ambulation and therapy 3x/week x 90 days (Three times per week for ninety days). Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 6 was offered RNA therapy services only nine times, out of twelve that were ordered by the physician from 6/15/19-7/13/19 (three times per week for four weeks, which equaled twelve times). Resident 11 Resident 11 was admitted to the facility on [DATE] with Medical Diagnoses including Postpolio syndrome (A cluster of potentially disabling symptoms that appear decades after the initial polio illness-a disease that causes severe nerve injury) and Paraplegia (A form of paralysis in which function is substantially impeded from the waist down), according to the facility Face Sheet. Resident 11's MDS dated [DATE], indicated her BIMS score was 15, which indicated her cognition was intact. Resident 11's MDS also indicated that she required extensive assistance with bed mobility and total dependence for transfers. Resident 11's Nursing Plan of Care on decreased functional ability initiated on 11/5/18, indicated, RNA Services-therapeutic exercise & ROM (Range of Motion). Routine 5 x week/90 days. Physicians' orders active as of 6/14/19 indicated, RNA Services-therapeutic exercise & ROM (Range of Motion). Routine 5 x week/90 days (Five times per week for ninety days). Restorative nursing notes documented by Unlicensed Staff F from 6/15/19 to 7/13/19, indicated that Resident 11 was offered RNA therapy services only nine times, out of twenty that were ordered by the physician from 6/15/19-7/13/19 (Five times per week for four weeks which equaled twenty times). During an interview on 7/12/19 at 12:23 p.m., Resident 11 stated that she was usually provided RNA therapy services three times per week, but sometimes only received therapy twice per week because Unlicensed Staff F got pulled to work as a nursing assistant on the floor. Resident 11 stated that it was beneficial for her to have RNA therapy services three times per week. Resident 24 Resident 24 was admitted to the facility on [DATE] with Medical Diagnoses including Morbid Obesity, Unsteadiness on Feet and History of Falling, according to the facility Face Sheet. Resident 24's MDS dated [DATE], indicated his BIMS score was 13, which indicated his cognition was intact. Resident 24's MDS also indicated that he required extensive assistance with bed mobility, transfers and walking in the room. During an interview on 7/09/19 at 3:18 p.m., Resident 24 stated that he did not receive enough RNA therapy and that staff walked with him only once per week. Resident 24 stated that the facility did not have enough employees to offer RNA therapy services to the residents. Resident 24 stated that he planned to discharge home but was concerned that he was not getting enough ambulation therapy. According to Resident 24, Unlicensed Staff F, who offered RNA therapy services, told him that she had to work on the floor, therefore she could not offer services more often. Resident 24's Nursing Plan of Care on decreased functional mobility initiated on 6/14/19, indicated, RNA 3x/week (three times per week). Resident 24's physicians' orders active as of 6/14/19 indicated, RNA for therapeutic exercise 3-5 x/week, as tolerated. RNA ambulation documentation from 6/15/19 to 7/6/19, indicated that Resident 24 was offered RNA therapy services only one time the week of 6/23/19-6/29/19, when Resident 24 had orders to receive RNA therapy services three to five times per week. During an interview on 7/15/19 at 3:35, Resident 24 stated feeling affected by not having his RNA therapies done as ordered. When asked if he felt that he was getting weaker, Resident 24 stated that he was. Resident 24 also stated he wanted to go home, and had been in the facility for two years without being able to get strong enough to be discharged home as a result of the lack of therapy. Documents titled, [Facility] DAILY GROUP ASSIGNMENT provided by Administrator on 7/15/19 at 11:00 a.m., indicated that in July of 2019, Unlicensed Staff F (The only RNA [Restorative Nursing Assistant] in the facility), was removed from her assignment as an RNA therapist, to work as a nursing assistant on the floor taking a regular nursing assistant assignment five out of six shifts from 7/1/19-7/13/19. Records from June of 2019, indicated Unlicensed Staff F was pulled to work as a nursing assistant on the floor three out of ten shifts. During an interview on 7/15/19 at 4:10 p.m., the DON (Director of Nursing) confirmed that Unlicensed Staff F was removed from her regular assignment as an RNA therapist to work on the floor as a nursing assistant on some days, but stated that when this occurred, Occupational Therapist B took over and completed Unlicensed Staff F's therapy tasks. During three separate interviews on 7/15/19 from 4:07 to 4:09 p.m., Resident 11, Resident 15 and Resident 24 stated that only Unlicensed Staff F assisted them with their RNA exercises, and denied being assisted by any other staff member for those activities. Documents provided by a representative from Medical Records on 7/15/19 at 4:15 p.m., indicated that there was no documentation for Resident 15 written by Occupational Therapist B for the month of July, 2019. In June of 2019, the documentation by Occupational Therapist B indicated that Resident 15 participated in bilateral upper extremity exercises and not on ambulation, which was the RNA's assigned task. There was no indication that Occupational Therapist B assisted Resident 15 with the ordered RNA therapy services for June and July of 2019. There was no June/July (2019) documentation written by Occupational Therapist B for Resident 11 or Resident 24. There was no indication that Occupational Therapist B assisted Resident 11 or Resident 24 with the RNA therapy services ordered for June and July of 2019. During an interview on 7/12/19 at 10:13 a.m., Unlicensed Staff F stated that she was the only RNA working for the facility and providing RNA therapy services. Unlicensed Staff F stated that she provided RNA therapy services to twelve residents in the facility, including Resident 15, Resident 30, Resident 29, Resident 6, and Resident 22, Resident 11 and Resident 24. Unlicensed Staff F stated that she worked at the facility four eight-hour shifts per week. Given her work schedule, Unlicensed Staff F could not complete therapy services to residents that had RNA orders five times per week, since she only worked four days per week. During an interview on 7/12/19 at 10:13 a.m., Unlicensed Staff F confirmed providing RNA therapy services less than three times per week to several residents of the facility because she was assigned to work as a nursing assistant on the floor. Unlicensed Staff F stated that the DSD (Director of Staff Development) created the work schedules, many of which indicated that she was removed from her assignment as an RNA therapist to work as a nursing assistant on the floor with a regular resident assignment. Unlicensed Staff F stated that if allowed to work only as an RNA she would have time to complete her therapy assignments, but on the days when she worked as a regular nursing assistant, she could not provide RNA services because, It is too much. Unlicensed Staff F stated that the facility was short staffed and needed more certified nursing assistants. Unlicensed Staff F stated that management knew that she was constantly being pulled to work as a nursing assistant on the floor, and that there were weeks where she had to work as a nursing assistant two to three shifts out of four. During an interview on 07/15/19 at 2:32 p.m. with the Administrator and DON (Director of Nursing), they confirmed knowing about this issue, and stated that they were actively trying to hire certified nursing assistants and restorative nursing assistants. The facility policy titled, Scheduling Therapy Services last revised in July of 2013, indicated, Therapy Services shall be scheduled in accordance with the resident's treatment plan .The therapist shall interview the resident and consult with the Attending Physician as to the type of treatment to be administered. 2) Call lights During an interview on 7/9/19 at 9:10 a.m., Resident 11 stated that call lights took up to twenty minutes to be answered. She also stated that the evening shift was the worst in regards to answering the call light timely. Resident 11's MDS dated [DATE], indicated her BIMS (brief interview for mental status) score was 15, which indicated her cognition was intact. During an interview on 7/9/19 at 9:50 a.m., Resident 30 stated that sometimes the call light took from ten to fifteen minutes to be answered, especially during change of shift. Resident 30's MDS dated [DATE], indicated her BIMS score was 11, which indicated her cognition was moderately impaired. During an observation and interview on 7/09/19 at 3:04 p.m., Resident 23 was observed pressing her call light. Her facial expressions indicated concerns. Resident 23 stated that she had been pressing the call light for a long time and needed to urinate. From the time she was first observed pressing the call light to the time it was answered by a staff member, five minutes passed. During an interview on 7/11/19 at 3:34 p.m., Resident 23 stated that on 7/9/19 she had to wait more than ten minutes for somebody to answer her call light. Resident 23 stated that sometimes it took staff an awful long time to answer the call lights. Resident 23 stated that she could not tell what time it was worst, but sometimes she could not hold her urine and urinated all over herself while waiting for her call light to be answered. Resident 23's MDS dated [DATE], indicated that she required extensive assistance with toilet use. During an interview on 7/15/19 at 9:15 a.m., the Administrator stated that the facility did not have a policy on call light use. During a phone interview on 7/15/19 at 11:58 a.m., the DSD (Director of Staff Development) stated that staff was expected to answer the call lights within seven minutes. The DSD stated that she had not done any audits to make sure the call lights were being answered timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that a Licensed Nurse had the competencies and skill sets necessary to care for residents' needs as identified through residents' assessments when Licensed Nurse J: 1) Used the wrong supplemental oxygen delivery system for one resident, 2) Obtained and carried out an order from the physician for bedrail use for one resident, without a date for the discontinuation of the order, and; 3) Sanitized her hands in between direct contact with residents, with disinfecting wipes not intended for skin use. This had the potential to place the safety of residents at risk, and decrease the possibility of attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident. Findings: 1) Resident 93 was admitted to the facility on [DATE] with Medical Diagnoses including Fracture of the Lower End of the Right Femur (A bone in the human leg extending from the pelvis to the knee) according to the facility Face Sheet. A Nursing Plan of Care initiated on 7/3/19 for Resident 93 indicated, Altered respiratory status/Difficulty Breathing r/t (related to) Anxiety. During an observation on 7/9/19 at 9:29 a.m., Resident 93 was observed using supplemental oxygen at three liters per minute through a nasal cannula (A device consisting of a lightweight tube used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) from an oxygen concentrator (A medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen). During an observation on 7/12/19 at 10:07 a.m., Resident 93 was observed in bed with a face mask (A device used to administer oxygen, shaped to fit snugly over the mouth and nose and secured in place with a strap or held with the hand) on her chest. Resident 93's eyes were closed. The oxygen concentrator was still on, at a flow rate of three liters per minute, connected to the face mask tubing laying on Resident 93's chest. During an interview on 7/12/19 at 10:10 a.m., Licensed Nurse J, Resident 93's assigned nurse, stated that Resident 93 kept taking off the face mask herself. Licensed Nurse J stated that the morning of 7/12/19 Resident 93's SpO2 (blood oxygen concentration) was found to be in the 80's (Normal pulse oximeter readings usually range from 95 to 100 percent), at three liters per minute via nasal cannula. Licensed Nurse J stated that she decided to get a face mask for Resident 93. Licensed Nurse J stated that with the face mask, at a flow rate of three liters per minute, Resident 93's oxygen saturation increased to 95%. Licensed Nurse J stated that she decided to leave Resident 93 with the face mask on, at a flow rate of three liters per minute. During an interview on 7/15/19 at 11:58 a.m., the DSD (Director of Staff Development) stated that she did not think the facility went over with staff what type of oxygen delivery systems were used depending on the flow of oxygen that the residents required, but thought that at a flow rate of three liters per minute a nasal cannula should be used. The DSD stated that a face mask was used for flow rates of five liters per minute or above. Licensed Nurse J's annual Nurse Orientation Checklist dated 1/29/19 indicated that the subjects, Oxygen Concentrators/Tanks/Supplies .Oxygen Administration via nasal cannula .Oxygen Administration via nonrebreather mask were reviewed by Licensed Nurse J, and she was able to demonstrate appropriate skills in regards to the reviewed subjects, as evidenced by the instructor's initials. The educational nursing book titled, Clinical Nursing Skills, Seventh Edition by S. S., D. D. and B. M. published in 2008 indicated, Simple Face Mask .This equipment requires fairly high oxygen flow to prevent rebreathing of carbon dioxide . Flow: 8-12 L (Liters). The educational nursing book titled, Kosier & Erb's FUNDAMENTALS of Nursing, 8th edition, published in 2008 indicated, [The nasal cannula] delivers a relatively low concentration of oxygen at flow rates of 2 to 6 L per minute .The simple face mask delivers oxygen concentrations from 40% to 60% at liter flows of 5 to 8 L per minute. The facility policy titled, Oxygen Administration last revised in October of 2010, indicated, Review the physician's orders or facility protocol for oxygen administration .Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter) .Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. 2) Resident 4 was admitted to the facility on [DATE] with Medical Diagnoses including Dementia (General term for a decline in mental ability severe enough to interfere with daily life), Alzheimer's Disease (The most common cause of dementia) and Anxiety disorder, according to the facility Face Sheet. During an observation on 7/9/19 at 11:26 a.m., Resident 4 was observed in bed with full side rails in the up position on both sides of her bed. These were side rails that went from the foot of the bed, to the headboard. Resident 4 was verbal, but unable to answer questions, as she appeared very confused. Resident 4 did not seem to be able to release the side rails herself. The side rails did not allow Resident 4 to get out of bed. During an interview on 7/9/19 at 11:28 a.m., Licensed Nurse J, Resident 4's assigned nurse, stated that the reason for having both full side rails up was because sometimes Resident 4 could not be redirected and could get very, hyper. Licensed Nurse J also stated that Resident 4 seemed confused, and while sometimes she was able to use the call light, other times she was not able to do so. During record review on 7/9/19 at 2:15 p.m., no physician order for full side rails was found in Resident 4's Medical Record. During a concurrent observation and interview on 7/15/19 at 3:17 p.m. Resident 4 was again observed in bed, with both full side rails in the up position. Licensed Nurse I, Resident 4's assigned nurse, stated that Resident 4 now had an order for both (full) side rails up when in bed. During concurrent interview and record review on 7/15/19 at 3:20 p.m., Licensed Nurse J presented a physician's order for full side rails. The order, documented on 7/15/19 at 11:30 a.m., indicated, May use full side rails for positioning & safety. The order did not indicate what medical symptom it was intending to treat. The order did not specify the period of time for the use of the restraint. When asked about the order's discontinuation date, Licensed Nurse J stated she had not been aware that that the order for full side rails had to be re-evaluated often. A document titled, ANNUAL Nurse Orientation Checklist-2019) dated 1/29/19, indicated Licensed Nurse J received training and was able to demonstrate skills on, Safety/Falls/Fall report/Prevention .resident Centered Care. The facility policy titled, Proper Use of Side Rails, last revised in October of 2010, indicated, Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed) .Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. The facility's policy titled, Use of Restraints, last revised in December of 2007 indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, of for the prevention of falls .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed .Restraints shall only be sued upon the written order of a physician .The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom: and c. The type of restraint, and period of time for the use of the restraint .Orders for restraints will not be enforced for longer than twelve (12) hours unless the resident's condition requires continued treatment. 3) During an observation on 7/10/19 at 9:23 a.m., Licensed Nurse J was observed disinfecting her hands between residents, during medication administration, with germicidal disposable clothes intended for disinfecting medical equipment. The bottle of germicidal disposable clothes indicated, NOT FOR SKIN USE. The bottle had a red top which differentiated it from other disinfecting wipes. During a phone interview on 7/12/19 at 11:02 a.m., Customer Care Representative L (Employed by the company that created the Germicidal Disposable Clothes that the facility used) stated that the wipes indicated (which Licensed Nurse J used to disinfect her hands between residents) were not for hand use and were for use on hard surfaces such as medical equipment. During an interview on 7/12/19 at 11:55 a.m., the DON (Director of Nursing) stated that the germicidal disposable clothes with the red top were not for hand use, but staff was allowed to use other wipes (in containers with blue tops) to sanitize their hands. During a phone interview on 7/15/19 at 11:58 a.m., the DSD (Director of Staff Development) stated that hand hygiene was frequently discussed with staff. The DSD stated that the disinfecting wipes in containers with blue tops were for resident use only, and not for staff. The DSD also stated that the wipes with red tops (Germicidal disinfecting clothes) were not to be used for hand hygiene by staff, and were only intended to disinfect equipment. During a second observation on 7/12/19 at 10:07 a.m., Licensed Nurse J was again observed using the germicidal disposable clothes which came in containers with red tops, to sanitize her hands between residents during medication administration. A document titled, ANNUAL Nurse Orientation Checklist-2019) dated 1/29/19, indicated Licensed Nurse J received training and was able to demonstrate skills on handwashing. The facility policy titled, Handwashing/Hand Hygiene last revised in April of 2012, indicated, Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact . If hands are not visibly soiled, use an alcohol-based rub containing 60-95% ethanol or isopropanol for all the following situations: a. before and after direct contact with residents .The wearing of artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities, and is prohibited among those caring for severely ill or immunocompromised residents. The policy did not indicate that sanitizing wipes (of any kind) were allowed to be used by staff for hand hygiene.

Based on observation, interview, and record review, the facility failed to ensure 1 out of 12 sampled residents (Resident 5), who was diagnosed with dementia, received the appropriate care and treatment to maintain their highest practicable physical, mental, and psychosocial well-being. Findings: During an observation on 7/9/19, at 11:17 a.m., Resident 5 was in bed with her left leg exposed and hanging off the bed. Resident 5 had propped herself up on her elbow. Resident 5 had her other arm stretched outward. Resident 5 was flapping the hand of her extended arm and repeatedly called out help me, please, somebody help me! at 11:19 a.m. House Keeper Q (HK Q) was cleaning the baseboards in front of Resident 5's room. At 11:19 a.m. HK Q saw Resident 5. In response to the Resident 5's plea help me! HK Q responded hi sweetie. An unknown Certified Nursing Assistant walked by Resident 5's room and ignored the repeated pleas help me! An unknown staff member in scrubs walked by Resident 5's room and ignored, somebody help me at 1120 a.m. HK Q was still cleaning baseboards and floorboards within ear shot of Resident 5. At 11:21 a.m. the yelling got louder, please, please help me. the latch the latch i dont want to anymore. i am so sorry mommy. At 11:22 a.m., Certified Nursing Assistant S (CNA S) walked past the doorway and ignored Resident 5, she entered a different resident's room. No sounds were coming from the room; the call light was not on. At 11:27 a.m., CNA S was in the doorway of the other room and looked at Resident 5's doorway. CNA S observed a state surveyor typing directly outside the doorway. At 11:30 a.m., CNA S walked into Resident 5's doorway and spoke to Resident 5, what's wrong? why are you crying? Resident 5 responded, I lost my baby CNA S stated, can I cover you? I just need you to rest ok? don't cry CNA S pulled Resident 5's privacy curtain around the bed, blocking Resident 5's view to the hallway. AT 11:33 a.m. CNA 5 stated, see you later and exited the room. At 11:34 Resident 5 called out again, can you help me please! CNA S responded from the hallway, later, and walked down the hallway. CNA S walked around the corner, past Licensed Nurse C, and entered a room labeled utility. During a review of the clinical record for Resident 5, the clinical record indicated she had active diagnoses of: Senile Degeneration of the Brain, Unspecified Dementia with Behavioral Disturbance, Anxiety Disorder, Degenerative Disease of Nervous System, Adult Failure to Thrive, and Restlessness and Agitation. Resident 5 was receiving Hospice care in addendum to the care she received at the facility. During a review of the clinical record for Resident 5, the Dashboard Care Areas Triggered section indicated, cognitive loss, dementia, communication, psychosocial wellbeing, behavioral symptoms, falls, and pain were all included in Resident 5's Care Plan. During a review of the clinical record for Resident 5, the last Weekly Summary was dated 7/1/19. 12 days prior to the review. During a review of the clinical record for Resident 5, the Care Plan indicated Resident 5 was admitted to hospice on 9/25/18. The goal of Resident 5 will be made comfortable during the end of life process. Hospice interventions included a modified diet texture, supplemental oxygen therapy, and medications used for comfort care. No wellbeing or psychosocial interventions were listed. During a review of the clinical record for Resident 5, the tasks section, which directs the care provided by Certified Nursing Assistants, had no psychosocial wellbeing tasks. During a review of the clinical record for Resident 5, the Care Plan indicated, behavior problems dated 7/6/18, last revised on 9/9/18. The Intervention section indicated, see hospice, mood, and psychotropic medication care plans for additional details, created on 7/8/19. All other interventions had not been revised since their creation in 2017. Mood problem, feelings of sadness, emptiness, anxiety, uneasiness, hopelessness, and powerlessness, created and last revised on 9/19/18. The goal indicated, Resident 5 will accept care and medication as prescribed, created and last revised on 9/19/18. The interventions indicated, acknowledge elders' moods in 1:1 interactions, remove her to a quiet room and spend time to reassure, created and last revised on 9/19/18. The positions assigned to the intervention were social services, activity aides, and licensed nurses. The intervention section indicated, Assess or treat needs for comfort: heat, light, foods, fluids, and bowel regimen, created and last revised on 9/19/18. The position assigned to the intervention was licensed nurses. Full review of the 22-page Care plan indicated, no focus or intervention to address feelings of powerlessness and helplessness with non-medication interventions. During a review of the clinical record for Resident 5, the Psych Meds Administration Record indicated, 6 Behaviors to be monitored. Verbalization of inability to relax (Ativan) every shift. For the month of July Resident 5 had 1 episode in 42 shifts. Occasional moaning (Ativan) every shift. For the month of July Resident 5 had 0 episodes in 42 shifts. Harmful to self or others (Haldol) every shift. For the month of July Resident 5 had 0 episodes in 42 shifts for hitting. Harmful to self or others (Haldol) every shift. For the month of July Resident 5 had 0 episodes in 42 shifts for kicking. Harmful to self or others (Haldol) every shift. For the month of July Resident 5 had 1 episodes in 42 shifts for scratching. No documentation was noted for calling out, visible distress, thoughts of losing a baby, repeatedly yelling out help me. During an interview with the Director of Staff Development (DSD), on 7/15/19 at 12:08 p.m., she stated she held a dementia training in June. The DSD stated not many staff attended. The DSD stated she has not done an audit to know how many staff were non-complaint with the 5 hours of required dementia training. When the observations from 7/9/19 were read to the DSD and she was asked if the response from staff met her expectation, she stated, I don't know. When asked if the facility had a policy for nonpharmacological interventions to treat residents with dementia, the DSD stated, I don't know if we have a policy about that. The facility policy and procedure titled, Dementia - Clinical Protocol, dated 11/18, indicated the Interdisciplinary team would identify a resident-centered care plan to maximize remaining function and quality of life. The policy further indicated the interventions on the care plan would be adjusted depending on the resident's response and the progression on their dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that: 1) Expired drugs and biologicals were discarded per facility policy, and; 2) A resident's capsule was discarded appropriately after it fell on the floor during self-administration of medications. This had the potential to cause medication errors, incorrect blood tests, incorrect blood glucose tests and ingestion of drugs by wondering residents. Findings: 1) During a concurrent observation and interview on 7/9/19 at 8:42 a.m., a box with more than ten blood collection tubes was noted inside the medication room of the facility. Each blood collection tube was labeled, Vacutainer gel liquid lithium heparin (Blood collection tubes used for plasma determinations in chemistry). All these blood collection tubes intended for residents' blood draws had an expiration date of 6/30/19. This was confirmed by the MDS (U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) Coordinator, who stated that the DON (Director of Nursing) along with the treatment nurse used to check for expired medications and equipment, but that the last DON had recently left the facility. The box of blood collection tubes was stored on top of other boxes with unexpired blood collection tubes, and was not labeled indicating that the collection tubes were expired. During medication storage observation and interview on 7/10/19 at 11:44 a.m., a box of Glucose Control Solution (A liquid that contains a known amount of glucose which reacts with the test strips used in glucometers [a medical device for determining the approximate amount of glucose in the blood] to give a result. The resulting number on the glucometer should correspond with the range listed on the vial of test strips. If the number is not within that range, there could be a problem with that vial of test strips or with the glucometer itself) to test the glucometers, was noted to be expired. This box was stored inside the medication cart that served the east wing of the facility. The box had an expiration date of 8/31/18. The box of Glucose Control Solution was not labeled as expired by facility staff to alert Licensed Nurses not to use it. Licensed Nurse J confirmed the finding, and stated that NOC (Night) shift was responsible for checking these solutions. During medication storage observation and interview on 7/09/19 at 10:12 a.m., a box of Atropine Sulfate 1% eye drops (Medication used to relieve pain caused by swelling and inflammation of the eye) labeled with Resident 12's name, was found in the medication cart that served the west wing of the facility. This medication had an expiration date of 12/2018. Another box containing Haloperidol Lactate 5 mg/ml intramuscular solution (Medication used in the treatment of Schizophrenia) labeled with Resident 5's name was also found, with an expiration date of 3/2019. Licensed Nurse C, assigned to the cart, confirmed the findings and stated that all licensed nurses were responsible for checking the carts for expired meds. 2) Resident 11was admitted to the facility on [DATE] with Medical Diagnoses including Postpolio syndrome (A cluster of potentially disabling symptoms that appear decades after the initial polio illness-a disease that causes severe nerve injury) and paraplegia (A form of paralysis in which function is substantially impeded from the waist down), according to the facility Face Sheet. Resident 11's MDS dated [DATE], indicated her BIMS (Brief Interview for Mental Status-a structured evaluation aimed at evaluating aspects of cognition in residents in Medicare or Medicaid certified nursing homes) score was 15, which indicated her cognition was intact. Resident 11's MDS also indicated that she required extensive assistance with bed mobility, and total dependence for transfers. According to Resident 11's MDS dated [DATE], she was not ambulatory. Physicians' orders active as of 6/14/19, indicated Resident 11 was allowed to self-administer Enerprime capsules (A dietary supplement), and keep them at her bedside. During a concurrent observation and interview on 7/9/19 at 9:17 a.m., an unlabeled and unattended medication capsule was found in Resident 11's room, on top of a plate placed on Resident 11's dresser. The medication capsule was exposed. The capsule was not within reach of Resident 11, who was in bed at the time. The MDS Coordinator stated that it was a vitamin that Resident 11 was allowed to take on her own. Resident 11 stated that the day before (on 7/8/19) the capsule fell on the floor during self-administration, and that she assumed housekeeping picked it up and put it on the plate where it was found on 7/9/19 at 9:17 a.m. During an interview on 7/09/19 at 10:00 a.m., Housekeeper K, currently in charge of housekeeping, denied having found the capsule in Resident 11's room floor, or having been notified of the incident by housekeeping staff. Housekeeper K stated that if they found an unlabeled, unattended medication in a resident's room, they were expected to pick it up and take it to the DON (Director of Nursing). During an interview on 7/12/19 at 12:23 p.m., Resident 11 stated that she kept her vitamins in a pillbox. She assumed that the capsule found on 7/9/19 on top of her dresser was the capsule she dropped on the floor the day before. Resident 11 stated that several facility staff came into her room from the time she dropped the capsule on the floor until the time the surveyor found it on top of her dresser, but did not mention anything about the capsule. Resident 11 stated that there was one resident in the facility that wondered around and tried to get into other residents' rooms. The facility policy titled, Storage of Medications last revised in April of 2007 indicated, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The facility policy titled, Self-Administration of Medications, last revised in December of 2016, indicated, Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that drinking water was available, and within reach of three residents (Resident 93, Resident 36, and Resident 7) with mobility issues. This failure had the potential to cause dehydration to the residents of the facility. Findings: Resident 93 Resident 93 was admitted to the facility on [DATE] with Medical Diagnoses including Fracture of the Lower End of the Right Femur (A bone in the human leg extending from the pelvis to the knee) according to the facility Face Sheet. Resident 93 had a Nursing Plan of Care initiated on 7/9/19 that indicated, High risk for nutritional/hydration complications. Some of the interventions for this Nursing Plan of Care indicated, Food/fluid supplements: as ordered .Offer extra liquid (at least 240 ml[Milliliters]) every shift. During an interview on 7/11/19 at 11:43 a.m., Unlicensed Staff G, stated that Resident 93 could not get up from bed because she had a brace on the right leg due to a fracture. During an observation on 7/11/19 at 3:43 p.m., Resident 93's water pitcher was observed on top of her dresser, out of Resident 93's reach. Resident 36 Resident 36 was admitted to the facility on [DATE] with Medical Diagnoses including Diabetes Mellitus and Abnormalities of Gait and Mobility, according to the facility Face Sheet. Resident 36's MDS (U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated 6/17/19, indicated that Resident 36 was totally dependent on staff for transfers, and required extensive assistance with locomotion on the unit. During an observation on 7/9/19 at 11:52 a.m., Resident 36's water pitcher was observed too far from Resident 36's bed, where he was resting at the time. The water pitcher was on top of Resident 36's dresser, unable to be reached by hand from Resident 36's bed. During an interview on 7/9/19 at 11:56 a.m. Unlicensed Staff H, Resident 36's assigned nursing assistant, confirmed that the water pitcher was out of reach of Resident 36, and could not be accessed other than if she offered it to him. Unlicensed Staff H stated that Resident 36 was not ambulatory. Resident 7 Resident 7 was admitted to the facility on [DATE] with Medical Diagnoses including Diabetes Mellitus and Morbid Obesity. Resident 7's MDS dated [DATE], indicated that she required extensive assistance with transfers, bed mobility, and locomotion on and off the unit. During medication administration observation on 7/10/19 at 3:31 p.m., Licensed Nurse I was ready to administer Resident 7's medications with water. Resident 7's water pitcher had been placed on top of the resident's dresser below the television, which was several feet away from Resident 7's bed where she was resting at the time. The water pitcher was not within reach of Resident 7. Licensed Nurse I attempted to obtain some water from Resident 7's water pitcher to administer the medications, and noticed that the water pitcher and plastic cup were empty. License Nurse I had to leave the room to get drinking water for Resident 7's medication administration. During an interview on 7/10/19 at 3:34 p.m., Resident 7 stated that she could not walk without assistance. When asked what she would do if she were thirsty since her water pitcher was not within reach, Resident 7 responded, I don't drink. During an interview on 7/10/19 at 3:40 p.m., Licensed Nurse I stated that Resident 7 required extensive assistance with ambulation. During an interview on 7/12/19 at 11:40 a.m., the Dietician stated that water pitchers should be within resident's reach, and were usually placed on top of the bedside tables. The facility policy titled, Hydration-Clinical Protocol last revised in September of 2017 indicated, The staff will provide supportive measures such as supplemental fluids and adjusting environmental temperature, where indicated.

Based on observation, interview, and record review, the facility failed to prepare, distribute and store food in accordance with professional standards for food service safety when: 1. food preparation areas and cutting boards were not cleaned and sanitized between uses, 2. meal carts that transported meal trays to residents were not sanitized between uses, 3. meal carts with fabric insulators that had Velcro closures were not able to close, 4. there was no designated refrigerator to store food brought in by visitors. These failures had the potential to result in a food-borne illness outbreak amongst a population of vulnerable residents with complex medical conditions. Findings: 1. During a dining tray observation, on 7/11/19, at 11:58 a.m., Dietary Aide V pulled 2 trays of sweet potatoes out of the oven and placed them on the food preparation table. The trays were transferred to the steam table. The preparation table was not cleaned or sanitized. Dietary Aide V gathered the ingredients to prepare 3 grilled cheese sandwiches. The bread, sliced cheese, and butter were put onto the food preparation table. Dietary aide V prepped the sandwiches and put the supplies back into storage. The preparation table was not cleaned or sanitized. During a dining tray observation, on 7/11/19, at 12:29 p.m., the Dietary Manager (DM) put a purple cutting board on the food preparation table. The DM put a lunch plate onto the purple cutting board and plated cottage cheese and fruit. The cottage cheese container was placed on the food preparation table that had already been used multiple times without being cleaned and sanitized. Dietary Aide U then put the cottage cheese container back into fridge. The purple cutting board was not cleaned or sanitized, it remained out for use. During a dining tray observation, on 7/11/19, at 12:37 p.m., The DM put a lunch plate on the purple cutting board. She then put a cooked grilled cheese onto the cutting board, cut it in half, and then put the sandwich onto the plate. The cutting board was not cleaned or sanitized prior to contact with the cooked grilled cheese or after the plate was served. The purple cutting board remained out for use. During a dining tray observation, on 7/11/19, from 12:40 p.m. through 1:15 p.m., the food preparation table and purple cutting board were used multiple times to prepare and plate alternate lunch items. One metal spatula used to flip grilled cheeses, one plastic scraper that was used to remove butter from a large container and butter bread, were both placed on the purple cutting board between uses. The work surfaces were not cleaned or sanitized between use. 2. During a dining tray observation, on 7/11/19, at 10:12 a.m., there were five meal carts all with clean trays on the racks. Each tray had a napkin with flatware on top of the napkin, various condiments, Covering the carts were black insulators made of fabric. During a dining tray observation on 7/11/19, from 1:15 p.m., to 2 p.m., all five of the meal tray carts were pushed out of the kitchen and into the hallway. From the hallway, the carts were pushed by various staff around the parameter of the building. Staff removed meal trays and delivered them to residents' rooms. After the meal, trays were stacked back onto the racks, with the dirty dishes and food remnants on them. In the hallways were facility pets; cats, dogs, and birds. There was no barrier preventing animals from brushing up against the fabric insulators. After all trays were collected, carts were pushed back into the kitchen. Carts were positioned near the dishwasher to enable staff to remove the trays and dishes. During an interview with the Dietary Manager (DM), on 7/11/19, at 3 p.m., she stated she had worked at the facility for approximately 7 months. The DM confirmed the carts were covered with the same fabric insulators every meal. The DM could not provide documentation of a cleaning schedule to show how often the insulators were removed and laundered. The DM could not provide a policy or procedure that directly described the process for cleaning the meal tray cars and fabric insulators between meals. During an interview with the Registered Dietician (RD), on 7/12/19, at 11:52 a.m., she stated she was contracted to work 8 hours a week. The RD confirmed she had worked at the facility for years. When asked if she considered the carts with fabric insulators going back into the kitchen and restocked with clean trays for the next meal after being out in the facility and carrying used trays an issue, she stated yes and no. The RD stated at one point the carts were covered with a foil type cover that could be cleaned and sanitized prior to the next use. The RD confirmed there was no log indicating when the insulators were laundered. 3. During a dining tray observation, on 7/11/19, at 10:12 a.m., tray distribution cats were covered with fabric insulators that had Velcro to close and seal the panels. The Velcro had multiple remnants of cloth, thread, and fuzz stuck in it. During a dining tray observation, on 7/11/19, at 12:44 p.m., cart 4 was loaded and ready to be pushed into the hallway. The Velcro on the fabric insulator to close the cart would not stick together and close. The cart was pushed out into the hallway and used for meal distribution without fixing or replacing the insulator. During an interview with the Registered Dietician (RD), on 7/12/19, at 11:52 a.m., she stated she watched meal distribution on a monthly basis. When asked about the Velcro closure on the fabric insulators she confirmed sometimes they close and sometimes they did not. The RD also confirmed the flatware was not sealed or independently covered when the carts were unable to close. 4. During an interview with Certified Nurse Assistant E (CNA E), on 7/12/19, at 2:55 p.m., she stated food left in the resident's room had to be thrown out. During an interview with the Director of Nursing (DON), on 7/12/19, at 3:18 p.m. she stated the facility would not keep leftovers. the DON confirmed the facility did not provide a space to store or reheat food brought in from outside the facility. The facility policy and procedure titled, Food from Outside Sources, dated 1/1/17, indicated residents had the right to accept food brought in from outside sources. 6. C. containers brought into the facility from visitors should be labeled and dated. The facility policy and procedure titled, Personal Hygiene and Appearance, dated 2014, was not updated to be in compliance with current food code regulations. The Facility policy and procedure titled, Food from Outside Sources, dated 1/1/17, was not updated to be in compliance with the california state food code. The 2019 California Food and Safety Code indicated, Food contact surfaces, utensils, and equipment shall be cleaned and sanitized at the following times: before each use with different type of raw food of animal origin, when changing from raw food to ready to eat food, between uses with raw produce and potentially hazardous food, before using a thermometer, any time during the operation when contamination may have occurred. Food-contact surfaces and utensils shall be clean to sight and touch. (114113, 114115, 114117, 114125(b), 114141)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an Infection Prevention and Control Program (IPCP) when: 1. The facility did not develop an infection prevention and control program based on current national accepted standards; 2. The facility did not initiate contact precautions that included physical barriers for pets; 3. The facility did not ensure housekeeping staff were competent to clean an isolation room; 4. A licensed nurse was observed wearing artificial nails while caring for severely immunocompromised patients; and 5. A licensed nurse was observed using sanitizing wipes used for medical equipment for hand hygiene during medication administration. These cumulative failures could lead to the facility's inability to control and prevent the spread of infections and potentially lead to harm or death for a population of elderly residents with complex medical conditions. Findings: 1. The facility did not have an annual review antibiotic stewardship system for investigating, and controlling infections and communicable diseases based on current standards, and facility assessment, a system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. During an interview with the Minimum Data Set (MDS) assessment Nurse, and the Treatment Nurse, on 7/09/19, at 3:56 p.m., both nurses confirmed they were sharing the responsibilities of the Infection Preventionist. The MDS Nurse stated the Director of Staff Development (DSD) would be responsible for any training requirements related to infection control. The Treatment Nurse stated she would be responsible for any Process Surveillance (the review of practices by staff directly related to resident care. The purpose was to identify whether staff implement and comply with the facility's IPCP policies and procedures). The MDS Nurse stated she would be responsible for Outcome Surveillance (addresses the criteria that staff would use to identify and report evidence of a suspected or confirmed facility acquired infections or communicable disease. This process consists of collecting/documenting data on individual resident cases and comparing the collected data to standard written definitions (criteria) of infections). Both nurses confirmed that they were new to the position. Neither nurse had implemented any component of the IPCP. When asked for any documentation on the facility's system of surveillance, including data analysis, implementation of action plans, process surveillance of the action plans, evaluation, and reporting, both nurses stated they would need time to gather that data. During an interview with the MDS Nurse, on 7/09/19, at 4:34 p.m., she reviewed a document titled Infection Control Appendix E. The MDS confirmed that the document was completed by an Infection Preventionist that worked at the facility for an unknown amount of months and had left approximately 2 weeks prior to 7/9/19. The document was a list that had components if infection control that included the entire facility and all it's departments. The document indicated every component, facility wide was in compliance with infection control. The notes section was blank. The document was signed and dated 5/22/19, at 11:30 a.m. The MDS Nurse could not provide any documentation on how compliance was assessed. The MDS Nurse could not provide instructions on how to complete the checklist, and what components were assessed. The MDS confirmed that she was employed at the facility on 5/22/19. The MDS had no memory of performing and return demonstrations, watching any videos or training, or being asked any questions on or near 5/22/19 in regards to infection control. During an interview with the Housekeeping Supervisor (HS), on 7/10/19, at 9:40 a.m., she stated she worked with the previous IP. The HS stated she was asked about cleaning the resident's rooms. She stated the IP wanted to know how often mop water was changed. The HS stated the facility used microfiber pads, so there was no mop water to change. When asked if the IP followed any staff or ask them questions or do a physical demonstration, the HS stated not that she was aware of. The HS stated the IP might have asked her staff questions. The HS stated there had not been any transmission based precautions at the facility in a very long time. During an interview with The Administrator and the Director of Nursing (DON), on 7/15/19, at 1:49 p.m., the DON stated they had an infection control plan, it ran very effectively by one staff member. The DON stated when that person left, they hired a new Infection Preventionist (IP). That IP was going to revamp the IPCP but that person left suddenly. She stated now they had staff that were trying to piece everything together and the program should be in compliance. When asked if she thought the program was still being implemented, the DON stated she was not sure if it was working. When asked how many months from July of last year until 7/15/19 did she think the facility could show implementation documentation of a complaint IPCP, the DON stated at least 7 months' worth. During a phone interview with the Director of Staff Development (DSD), on 7/15/19, at 12 p.m., She stated that she was working with the MDS Nurse and the Treatment Nurse regarding the facility's IPCP. The DSD stated, We are actively working on creating a plan. The DSD stated she had taught a training on proper use of personal protection equipment and hand washing. The DSD confirmed the training was provided to day shift Certified Nursing Assistants that were working on the day she provided training. There had been no other attempt in include different departments, or different shift. The DSD stated that she had not trained anyone on any anything regarding working in a facility that had animals. The DSD confirmed that in all of her time as an employee at the facility, even prior to assuming the role of DSD, she had never received training regarding the facility pets. During an interview with the MDS Nurse on 7/15/19, at 4:56 p.m., she provided documentation of antibiotic use and monitoring regarding the use of antibiotics compared to a national standard on criteria for the use of antibiotics. The MDS was unable to provide any other required components of the Infection Prevention and Control Program. The facility policy and procedure titled, F441 Infection Control, date of implementation 9/3/09, indicated the policy had not been reviewed or updated to meet the current national standards. The facility policy and procedure titled, F441 Infection Control, date of implementation 9/3/09, the Infection Control section indicated, the facility must establish an Infection Control Program under which it maintains a record of incidents and corrective actions related to infections. The Components of an Infection Prevention and Control Program section indicated, an effective program incorporates, but is not limited to, the following components: program oversight and maintaining all of the elements of the program, education, and surveillance including process and outcome, monitoring, data analysis, and documentation. The facility policy and procedure titled, Antibiotic Stewardship Program Policies and Procedures Annual Authorization, indicated on 11/15/17 the facility's committees approved and adopted the program. The policy further indicated the authorization was good for one year from the aforementioned date. The facility document titled, Antibiotic Stewardship Program Policies and Procedures Annual Authorization, had no description text. The document had two signature lines. The Administrator and The Medical Director signed the document and dated it 5/17/18. No other documents were provided at the time of leaving the facility. No additional evidence was provided during the exit conference on 7/16/19. 2. During the initial tour observations on 7/9/19/ at 8:40 a.m., observed room [ROOM NUMBER] with signs posted indicating Contact Precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). The doorway was open and unobstructed. During multiple observations throughout the survey in multiple locations, noted cats, dogs, birds, and rabbits in the facility. During an observation on 7/10/19, at 2:22 p.m., at Nurse Station 1, a large orange and white cat walked across the back counter and brushed against the resident charts stored in a shelving unit mounted about the counter. The cat proceeded to walk to the handwashing sink and was observed licking at the faucet. An unknown employee noticed the cat and stated you're not supposed to be up there then she picked up the cat and moved it to the activity area. No post contact cleaning of the counter, resident charts, or faucet was observed. During an interview with the Administrator on 7/15/19, at 10:12 a.m., he stated all the staff kept a close eye on the animals. The Administrator stated the facility had 5 cats and 2 dogs. When asked, what kept the animals from entering the room on contact precautions, The Administrator stated staff kept an eye on the animals. The Administrator confirmed there was no physical barrier preventing an animal from walking into the room and then spreading infectious spores throughout the facility. The administrator stated that the animals were allowed to roam the facility 24 hours a day. The same principle of staff monitoring the animal's whereabouts was the only barrier even on the overnight shift that frequently was only staffed by 4 people. The Administrator stated there would be no way to know if an animal wondered into an out of a room on precautions unless a staff member saw it happen. The Administrator confirmed the facility assessment and the Infection Control Policy did not take into consideration the facility animals. When asked if there was a conversation about the animals prior to admitting a resident on contact precautions, the Administrator stated there was not. During an interview with the Director of Staff Development (DSD), on 7/15/19, at 12:08 p.m., she stated there had been no training in regards to isolation precautions and the facility pets. When asked what would she do if she walked by a room on contact precautions and saw a cat in the room, The DSD stated she did not know. The DSD could not provide a policy or training for staff that explained what steps to take if an animal was somewhere it was not supposed to be. The facility policy and procedure titled, Pets, Animals, and Plants, dated 3/18/12, indicated Minimal Contact. The interpretation and Implementation section indicated, all personnel and residents will minimize contact with animal saliva and dander and will use proper infection control techniques at all times. The policy further indicated Contact with Residents. The interpretation and Implementation section indicated, animals may not come into contact with any resident who does not give verbal permission for such contact. The Facility policy and procedure titled, Pets, Animals, and Plants, dated 3/18/12, was not updated to be in compliance with the current federal, state, and local regulations. 3. During an observation on 7/09/19, at 11:33 a.m., House Keeper Q (HK Q) was cleaning room [ROOM NUMBER]. HK Q was holding a mop handle with gloved hands. HK Q was wearing an insolation gown. HK Q removed an unknown amount of sanitizing wipes out of a container and wiped the mom base (a metal rectangular shaped attachment able to secure reusable microfiber mop pads). HK Q did not wipe the mop handle. HK Q put the mop in the hallway in direct contact with the floor. HK Q walked back into room [ROOM NUMBER]. No observation of monitoring for wet time (the time that a disinfectant needs to stay wet on a surface in order to ensure disinfection of the surface). At 11:35 a.m. HK Q emerged from room [ROOM NUMBER] no longer wearing an isolation gown or gloves. She picked up the mop handle with a bare hand and placed it onto the janitorial cart. HK Q then parked the cart in janitorial closet A located between room [ROOM NUMBER] and 102. During an interview with HK Q on 7/09/19, at 11:45 a.m., she described the process for cleaning a room on contact precautions. HK Q stated she wiped the mop with bleach wipes to clean the mop. When asked how many wipes she used, HK Q did not know. During an observation and concurrent interview with HK Q, on 7/09/19, at 11:56 a.m., HK Q unlocked janitorial closet A. HK Q confirmed the same mop was used everywhere. During an interview with the MDS Nurse and the Treatment Nurse, on 7/09/19, at 3:57 p.m., they could not provide any documentation that housekeeping staff had been monitored for competence when cleaning a resident's room that required enhanced environmental cleaning. The MDS nurse stated a previous Infection Prevention Nurse may have taken binders with her when she left the facility. Included in that binder would have been the environmental services policies and procedures. Both Nurses confirmed they had not spoken to anyone in the housekeeping department to review proper policy and procedure for cleaning a room on contact precautions. During an interview with the Administrator and the Director of Nursing (DON), on 7/09/19, at 5:02 p.m., they discussed the process for preparing to have a new admission that required contact precautions. The DON stated Resident 203 was admitted on [DATE] with an active infection that required contact precautions. The Administrator and the DON both stated they had multiple conversations prior to accepting the resident. The Administrator stated he spoke to the Housekeeping Supervisor to discuss the new admission. The Administrator confirmed he did not review the procedure for cleaning a room on contact precautions with any housekeeping staff. The Administrator stated the Housekeeping Supervisor had dealt with precautions before and the facility had never had an issue. The Administrator confirmed that was the basis for determining the housekeeping department was competent to clean the room on contact precautions in a way that prevented the spread of infection. The Administrator and the DON stated the policies and procedures for infection prevention and control were strong enough that any of the staff could follow them and maintain the contact precautions without cross contamination. They were unable to provide the housekeeping procedure. They were unable to provide documentation of the last time the housekeeping staff had competency checks. The DON was not familiar with the cleaning supplies used in the facility. During an interview with The Housekeeping Supervisor (HS), on 7/10/19, at 9:27 a.m., she stated she had worked at the facility for 17 years and had been the manager for 4 years. The HS confirmed she was responsible for annual performance reviews and staff competency. The HS stated she spoke to HK Q to inform her they would be getting a resident that would be on contact precautions. The HS stated she reviewed the process for cleaning the room. The HS described the process, including how the mop should be disinfected. She confirmed the entire surface of the mop needed to be wet for four minutes to ensure it was properly disinfected. The HS stated the number of wipes needed to cover that much surface area varied, depending on how long the wipes had been open. The HS confirmed the only way to ensure the mop was properly disinfected was to wipe the entire mop and watch it to ensure it remained wet the required 4 minutes. The HS stated only wiping the base, not watching to ensure it was wet for 4 minutes, and putting it back into use for the rest of the facility did not meet her expectations. The HS stated under those circumstances the mop was considered contaminated and therefore everything the mop came in contact with after that would be contaminated, putting residents, staff, and visitors at risk for contracting the infection. The facility policy and procedure titled, Equipment and Supplies Used During Isolation, dated 4/12, The Policy Revised section indicated, 4 blank lines for the date and name of person that had revised the policy. The Interpretation and Implementation section indicated, all storage and maintenance supplies and equipment shall be stored and maintained in accordance with appropriate isolation precautions, consistent with the manufacturer's recommendations. 4. During an observation on 7/10/19 at 9:23 a.m. Licensed Nurse J was observed wearing artificial nails while preparing and administering medications to Resident 13. During an interview on 7/10/19 at 9:36 a.m., Licensed Nurse J confirmed she was wearing artificial gel nails. Resident 13, a [AGE] year-old male was admitted to the facility on [DATE] with Medical Diagnoses included Diabetes Mellitus, Chronic Myeloid Leukemia (A type of cancer that starts in certain blood-forming cells of the bone marrow) and Necrosis of Bone (The death of bone tissue due to a lack of blood supply), according to the facility Face Sheet. Resident 13 passed away on 7/11/19, according to progress notes dated 7/11/19 at 2:46 p.m. 5. During an observation on 7/10/19 at 9:23 a.m., Licensed Nurse J was observed disinfecting her hands between residents, during medication administration, with germicidal disposable clothes intended for disinfecting medical equipment. The bottle of germicidal disposable clothes indicated, NOT FOR SKIN USE. The bottle had a red top which differentiated it from other disinfecting wipes. During a phone interview on 7/12/19 at 11:02 a.m., Customer Care Representative L (Employed by the company that created the germicidal disposable clothes that the facility used) stated that the wipes indicated (which Licensed Nurse J used to disinfect her hands between residents) were not for hand use and were for use on hard surfaces such as medical equipment. During an interview on 7/12/19 at 11:55 a.m., the DON (Director of Nursing) stated that the germicidal disposable clothes with the red top were not for hand use, but staff was allowed to use other wipes (in containers with blue tops) to sanitize their hands. During a phone interview on 7/15/19 at 11:58 a.m., the DSD (Director of Staff Development) stated that hand hygiene was frequently discussed with staff. The DSD stated that the disinfecting wipes in containers with blue tops were for resident use only, and not for staff. The DSD also stated that the wipes with red tops (Germicidal disinfecting clothes) were not to be used for hand hygiene by staff, and were only intended to disinfect equipment. During a second observation on 7/12/19 at 10:07 a.m., Licensed Nurse J was again observed using the Germicidal Disposable cloths which came in containers with red tops, to sanitize her hands between residents during medication administration. The facility policy titled, Handwashing/Hand Hygiene last revised in April of 2012, indicated, Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact . If hands are not visibly soiled, use an alcohol-based rub containing 60-95% ethanol or isopropanol for all the following situations: a. before and after direct contact with residents .The wearing of artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities, and is prohibited among those caring for severely ill or immunocompromised residents. The policy did not indicate that sanitizing wipes (of any kind) were allowed to be used for hand hygiene by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the equipment in good working order when; 1. The 6 burner gas range did not have a functioning ignition system and required the use of an external fire source to light the burners; 2. The drainage system for the dishwasher, the food preparation sink, and the dish pre-rinse sink were all plumbed without the required air gaps; and 3. The facility call system did not have a functioning auditory alert in resident rooms, resident bathrooms, or communal shower rooms. These failure had the potential to resulted in; 1. property damage, injury or death; 2. water from the sewage line backing up onto food preparation surfaces and into the clean water line; and 3. extended response times from staff during a potential life threatening emergency. Findings: 1. During an observation on 7/11/19, at 11:06 a.m., Dietary Aide V turned the knob on the stove and range combination. Dietary Aide V lit the front right burner with a long handled lighter. During an interview with the Dietary Manager (DM), Dietary Aide U, and Dietary Aide V, on 7/11/19, at 11:18 a.m., they confirmed the range was always lit with a long handled lighter. The DM had no record of a certified [Brand] technician performing maintenance on the range. Dietary Aide U stated once, a long time ago, a service technician was hired to fix the ovens. At that time the facility Maintenance Director was made aware the range was in need of repair. The facility only authorized repair of the ovens and kept the range as it was. During an interview with The Maintenance Supervisor (MS), on 7/11/19, at 1:20 p.m., he reviewed his phone and stated the last time he checked the range (the top part of a stove where the burners and griddle were) in the kitchen was on 6/27/19. The MS stated he checked all the equipment in the kitchen every month. The check included: checking for gas leaks with soapy water and making sure pilots (small permanent flames used to ignite gas at a burner) were lit with visual inspection. No written procedure on range maintenance was provided. No service schedule was provided. The MS stated if there was a problem he would call a service technician. The MS stated the pilot had a thermocouple safety (The thermocouple detects the heat from the pilot light, and should the pilot light go out accidentally, the thermocouple will automatically shut off the gas valve). Requested model number and manufacturers guide for the oven and range. The MS stated he did not have them on hand and would have to look for them. Requested documentation of routine maintenance, he stated no and there was none required. When asked how did he know when or if routine maintenance was recommended if he did not know the make and model of the unit, The MS did not answer. During and observation and concurrent interview with The Maintenance Supervisor (MS), on 7/11/19, at 1:35 p.m., in the kitchen, the range was in use. The 2 burners to the very left were not in use. The MS lifted the burner and confirmed the pilot light was not lit. During an interview with The Maintenance Supervisor (MS), on 7/12/19, at 2:34 p.m., he stated there was no record of a [brand] certified technician ever providing service or maintenance for the gas range. The MS stated he did not know if service or maintenance was necessary, and that he still did not know the make or model of the range. The MS stated, I can only do what I can do. The MS stated he was able to unclog the pilot lights and they were all lit. During an observation on 7/12/19, at 2:45 p.m., Dietary Aide V was preparing food on the range. Dietary Aide V turned burner knob to the very right, adjacent to griddle, front burner did not light. Dietary Aide V confirmed range continued to require outside fire source such as the long handled lighter to ignite the burner. During an interview with the Administrator and The Maintenance Supervisor (MS), on 7/15/19, at 1:55 p.m., the Administrator stated as far as he knew the range had been fixed. The administrator confirmed the facility did not have the installation or operation manual on hand for the range. The Administrator confirmed he was aware the maintenance and kitchen staff did not know the make or model of the range. The MS confirmed the front two burners still required a long handled lighter to ignite the burners. No other service or maintenance was scheduled. No additional information was provided. A review of [brand] certified service technician website, gas range section indicated, warning signs of a failing thermocouple included pilot light will not stay lit. The website further indicated, A thermocouple can break, rust, or fall out of place, and this can lead to a potential hazard if the pilot light fails. This is one of the reasons you need to schedule regular preventive maintenance for your gas range: technicians will catch failing thermocouples and replace them with the correct unit. A review of the [brand] Gas and Electric company website, gas safety tips section indicated, If the pilot light is out, shut the gas off at the appliance's gas shutoff valve. Always wait five minutes to let gas disperse before trying to relight an appliance pilot light. The website further indicated, Follow the appliance manufacturer's instructions to relight a pilot light. Often, basic relight instructions are located inside the main burner compartment door. If you cannot relight the pilot light yourself, call [brand] Gas and Electric Company or another qualified professional for assistance. A review of the [brand] website, indicated 1 general Operations Manual for 4 different gas range models and all the specific configuration types for those models. The manual indicated general operations and service recommendations for over 50 different configurations on [brand] gas ranges. A review of the [brand] recommended service guidelines, indicated equipment must be maintained and serviced by trained maintenance person or an authorized service agency at regular intervals. Frequency of service was dependent on usage hours. For units that operate 10-12 hours a day 7 days a week, the recommendation was every 30-60 days. For units with limited daily usage, the recommendation was every 180 days. The guidelines further indicated that all units should be serviced at least once a year. A review of the [brand] website, indicated 1 general Service Manual for 14 different gas range models. The Service Manual indicated it was prepared for the use of trained [brand] Service Technicians only. Included in the manual were directions for: Thermocouple Test, Operation, Pilot Checks, Thermocouple Checks, and Troubleshooting. The Tools section indicated a voltage meter and an adaptor to test the thermocouple closed circuit DC voltages were both required for service and maintenance of the range. A review of the [brand] Installation & Operation manual, page two indicated, WARNING Improper installation, adjustment, alteration, service or maintenance can cause property damage, injury or death. The facility policy and procedure titled Maintenance Service, revised 4/15/13, indicated the Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The policy indicated functions of the maintenance personnel included maintaining all equipment in the kitchen in good working order. The policy further indicated that maintenance personnel shall follow the manufacturer's recommended maintenance schedule. The Recordkeeping section indicated the Maintenance Director was responsible for maintaining records and reports including; work order requests, maintenance schedules, and warranties and guarantees. 2. During an observation on 7/11/19, at 11:10 a.m., the floor under dishwasher and two adjacent drains had no air gap (An air gap is an amount of space that separates a water line from a drain to a sewer). During an interview with the Registered Dietician (RD) on 7/12/19, at 12:01 p.m., she stated she did not realize three drains had no air gap. The RD exited the interview to go inspect the kitchen, she returned to the interview and agreed there was no visible air gap for the two compartment food preparation sink, the rinse sink, or the dishwasher. During an interview with The Administrator and The Maintenance Supervisor (MS), on 7/15/19, at 1:57 p.m., The Administrator stated he had not been made aware of any plumbing issues in the kitchen. The MS stated the lack of an air gap in the kitchen had never come up. The MS was familiar with what an air gap was, and regulations in a different county regarding the air gap. The MS stated he would have to look up the requirements for the County before he spoke about any air gap or lack thereof in the kitchen. No follow up information was provided. The facility policy and procedure titled Maintenance Service, revised 4/15/13, indicated the Maintenance Department was responsible for maintaining the building in compliance with federal, state, and local laws, regulations, and guidelines. The policy indicated functions of the maintenance personnel included maintaining plumbing fixtures in good working order. 3. During an observation on 7/10/19, at 9:21 a.m., the call light for room [ROOM NUMBER] was on. There was no sound at either nurse station. There was no sound from the resident's room. At Nurse Station 2, there was a metal display box on wall with white squares that had black room numbers on them. No squares were illuminated. During an interview with Certified Nurse Assistant R (CNA R) and CNA F, on 7/12/19, at 2:26 p.m., they stated Nurse Station 2 was used as a place to get ice, provide privacy to allow CNA staff to chart electronically. The staff confirmed the area was not stocked, not staffed, did not contain active resident charts, and was not used as a nurse station. During an observation at Nurse Station 1, on 7/15/19, at 9:46 a.m., call light above room [ROOM NUMBER] and the hall indicator light were both on. The brown metal display in Nurse Station 1 did not have the room [ROOM NUMBER] square illuminated. There were no squares illuminated on the display. There was no audible alert coming from the room or from the nurse station. Both lights at room [ROOM NUMBER] were on until 9:58 a.m. During an observation at Nurse Station 1, on 7/15/19, at 9:55 a.m., the brown metal display in Nurse Station 1 had squares labeled 118 and 125 illuminated. No audible alert was heard from the hallway or at the nurse's station. During an interview with the Administrator and The Maintenance Supervisor (MS), on 7/15/19, at 1:57 p.m., the MS stated call lights were all working. The MS stated the system was maintained, and that replacement lightbulbs were readily available. The MS stated the system did not have sound as far as he knew of. The MS walked to Nurse Station 2 to review the apparent speaker or other auditory system on the wall and stated it was a component of the old paging system, not an audible part of the call light system. The MS confirmed that no portion of the call light system was audible, not even when the cord was pulled from the outlet. During an interview with CNA N, on 7/15/19, at 3:45 p.m., he described the call light system. CNA N stated if a resident or staff member pushed the call light button in a resident room, restroom, or in the shower room, the light on the ceiling outside of that room lit up. CNA N had worked at the facility for years, and did not remember the system ever having an audible component. The facility policy and procedure titled, Maintenance Service, revised 4/15/13, indicated the Maintenance Department was responsible for maintaining the building in compliance with federal, state, and local laws, regulations, and guidelines. California Health and Safety Code 1599.1(f) indicated, A nurses' call system shall be maintained in operating order in all nursing units and provide visible and audible signal communication between nursing personnel and patients.