**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes) was completed correctly for one of two residents (42). This failure had the potential to result in Resident 42's mental health needs to be unmet. Findings: Resident 42 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental illness that affects a person's thoughts, perceptions, emotions, and social interactions), according to the admission Record. A joint interview and record review was conducted with the Minimum Data Set (MDS; assessment tool) Nurse (MDSN) on 11/21/24 at 8:25 A.M. The MDSN stated that Resident 42 had a diagnosis of schizophrenia on admission, but the PASARR, dated 3/21/24 did not indicate Resident 42 had any serious mental illness. A review of the MDS dated [DATE], indicated Resident 42 had an active diagnosis of schizophrenia. A second PASARR, dated 6/10/24, also did not indicate Resident 42 had any serious mental illness. The MDSN stated the PASARR should have been reviewed and corrected both times because the resident had a diagnosis of schizophrenia. An interview with the MDSN was conducted on 11/21/24 at 11:07 A.M. The MDSN stated that the PASARR should have been reviewed and corrected to make sure Resident 42 received the correct mental health care and services. An interview with the Director of Nursing (DON) was conducted on 11/21/24 at 3:42 P.M. The DON stated the PASARR should have been revised. The DON stated an accurate PASARR was important so Resident 42 could have received appropriate mental health treatment. A review of a directive from the California Department of Health Care Services (HCS) titled Skilled Nursing Facilities' (SNF's) Preadmission Screening and Resident Review (PASARR) Responsibilities, dated 8/30/23, indicated The SNF is required to initiate a Resident Review (RR) .when the Minimum Data Set (MDS) does not match the .screening from the hospital. The SNF must initiate the RR .within 72 hours of .identification of variance between the MDS and .Screening .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide needed care and services that are resident-centered in accordance with professional standards of practice for one of 18 residents (Resident 82) reviewed with congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). This failure had the potential to contribute to Resident 82's declining health status with worsening CHF complications. Findings: A review of Resident 82's admission Record indicated Resident 82 was admitted to the facility on [DATE] with diagnoses which included a history of CHF. A record review of Resident 82's Minimum Data Set (MDS: a federally mandated resident assessment tool) dated 10/19/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven day period) score of 0 points out of 15 possible points which indicated Resident 82 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. A record review of Resident 82's Medical Doctor (MD) orders dated 10/12/24 indicated, Daily weights 3x/wk [three times per week] every day shift Mon (Monday), Wed (Wednesday), Fri (Friday) . A review of Resident 82's History and Physical (H&P) dated 10/14/24 indicated, .CHF with exacerbation (increase in severity): edema present to BUE [bilateral upper extremities]/BLE [bilateral lower extremities] managed on [diuretic-medication that removes excess fluid from the body] and fluid restriction . A record review of Resident 82's CHF care plan interventions dated 10/13/24 indicated, .Observe for edema, weight gain .report abnormal findings to physician .Weights as ordered. A record review of Resident 82's weights indicated that Resident 82 gained five pounds (lbs) within one week that included: - On 10/13/24 Resident 82 weighed 139.8 lbs - On 10/21/24 Resident 82 weighed 144.8 lbs On 11/21/24 at 10:40 A.M., an interview and record review was conducted with Restorative Nurse Assistant (RNA) 1. RNA 1 stated that he checked Resident 82's weight on 10/13/24. RNA 1 stated that only the RNAs weighed the residents, and on 10/21/24, Resident 82's weight was checked by either him or RNA 2. On 11/21/24 at 10:45 A.M., an interview and record review was conducted with RNA 2. RNA 2 stated that the charge nurse was responsible for communicating with the RNA team regarding which residents had weight orders and their frequency to check weights. RNA 2 stated that she did not have a binder or a formal order list, but a cheat sheet that she relied on that was not part of the medical record. RNA 2 stated the cheat sheet listed residents who had weight orders. RNA 2 reviewed Resident 82's October 2024 record, titled Order Listing Report provided by the Medical Records (MR) department. This record indicated that Resident 82 was on the list for weight orders. RNA 2 stated that Resident 82's weights were not taken/checked 3x/week as ordered by the MD. RNA 2 stated that Resident 82's weight should have been checked as ordered, to help monitor Resident 82's health status. On 11/21/24 at 1:06 P.M., a concurrent interview and record review was conducted with LN 1, in the conference room. LN 1 stated that on 10/12/24 she was the nurse that completed the admission for Resident 82. LN 1 stated that on 10/12/24 the MD ordered for weights to be taken 3x/week and that Resident 82 had edema (swelling) on her upper arms and legs. LN 1 stated that Resident 82 was being treated for CHF with diuretic medications, fluid restrictions, and weight orders. LN 1 stated Resident 82 was not being weighed according to MD orders. LN 1 stated it was important to monitor Resident 82's weight because this could indicate worsening CHF symptoms and that Resident 82 could go into fluid overload (occurs when body has too much fluid) complications. LN 1 stated Resident 82 gained five pounds within a week on 10/21/24 and stated there was no evidence that the MD was notified that day regarding the five-pound weight gain. LN 1 stated it was necessary to follow Resident 82's CHF plan of care and MD orders regarding the weight gain to prevent complications. On 11/21/24 at 3:58 P.M., an interview and record review was conducted with the Director of Nursing (DON), in the conference room. The DON stated his expectation was for the nursing staff to make sure the MD orders to monitor Resident 82's weights 3x/week were followed. The DON stated it was important to notify the MD of the five pound weight gain to prevent any delay in caring for Resident 82's CHF symptoms that may worsen. The DON stated that the facility's CHF policy and procedure was in accordance with the American Heart Association (AHA) recommendations for heart failure, and acknowledged that they did not meet the professional standards of practice for Resident 82's CHF plan of care when they did not notify the MD of the resident's (5 lb) weight gain. According to the American Heart Association titled MANAGING HEART FAILURE SYMPTOMS dated 2024 https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure/managing-heart-failure-symptoms .Many people are first alerted to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period or more than five pounds in a week . A review of the facility's policy and procedure titled HEART FAILURE-CLINICAL PROTOCOL dated, November 2018, indicated .The physician will prescribe treatments for residents with heart failure that are consistent with relevant guidelines and protocols; for example, those of the American Heart Association and American Medical Directors Association (AMDA).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure low air loss mattresses (LAL - an air flow mattress used to prevent skin breakdown by distributing weight over the mattress to reduce pressure to the skin) were set according to the physician's order, for one of four residents (Resident 47) reviewed for pressure ulcers. This failure had the potential to increase the risk for skin breakdown and pressure ulcers for residents who used LAL mattresses. Findings: A review of Resident 47's admission Record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses which included a history of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). A record review of Resident 47's Minimum Data Set (MDS; assessment tool) dated 10/31/24, indicated that Resident 47 was rarely or never understood, with severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to understand and make decisions. A record review of Resident 47's MDS dated [DATE] indicated Resident 47 was at risk for pressure ulcers/injuries and had one or more unhealed pressure ulcers/injury. Resident 47's MDS also indicated Resident 47 required dependent ( .helper does ALL of the effort .) to substantial/maximal assistance ( .helper does MORE THAN HALF the effort .) with bed mobility. A record review of Resident 47's care plan dated 10/27/24 indicated, .Resident has a DTPI [deep tissue pressure injury] upon admit (admission) (left heel area) and is at risk for further skin breakdown .Pressure reduction mattress for bed . On 11/19/24 at 8:28 A.M., a concurrent observation and interview was conducted with Resident 47 and Certified Nursing Assistant (CNA) 1, in Resident 47's room. CNA 1 stated that Resident 47 was on a LAL mattress because Resident 47 was at risk for pressure ulcers. Resident 47 was in a semi-upright position in bed, wearing her own clothing, and stated she did not have any skin breakdown that she knew of. Resident 47 stated she did not know why she was using a LAL mattress. Resident 47's LAL mattress was set at 250 pounds (lbs). CNA 1 stated that they (the CNAs) did not touch the LAL mattress and that the licensed nurses (LN) were responsible for changing settings and monitoring the LAL mattress. On 11/20/24 at 2:12 P.M., an observation was conducted. Resident 47 was laying in a semi-upright position in bed, watching TV. Resident 47's LAL mattress was set at 250 lbs. On 11/20/24 at 2:49 P.M., an observation, interview, and record review was conducted with LN 3, at the 2nd floor nursing station. LN 3 stated that Resident 47's weight was checked and recorded on 11/19/24 at 189 lbs. LN 3 went to Resident 47's room to observe the LAL mattress settings. LN 3 stated that the LAL mattress was set at 250 lbs. LN 3 acknowledged that Resident 47's LAL mattress was not set according to Resident 47's weight. LN 3 stated Resident 47's LAL mattress should be readjusted and set correctly for management and prevention of pressure ulcers. LN 3 stated that she did not know how to change the LAL mattress settings and would need to call the maintenance director (MTD) to adjust the settings, since the MTD sets up all LAL mattresses. On 11/21/24 at 9:17 A.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated that on 10/31/24 the MDS nurse coded a DTPI on 10/31/24 on the MDS. The DON stated that Resident 47 had a DTPI on her admission assessment with treatment orders for both heels, and stated the LAL mattress was for the DTPI on Resident 47's heels. The DON stated his expectation was for the LNs to make sure the LAL mattresses were adjusted to the correct weight and comfort level. The DON stated it was important to set the LAL mattresses correctly to prevent pressure ulcer injuries for residents at risk. A review of the manufacturer guidelines for Front Panel diagrams, provided by the facility: [Brand Name] Low Air Loss Mattress manual dated 2017 When the mattress is fully inflated, set the dial in accordance with the patient's size and weight . A review of the facility's policy and procedure titled PREVENTION OF PRESSURE ULCERS dated April 2022, indicated, .Select appropriate support surface based the resident's risk factors, in accordance with current clinical practice .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 78 was admitted to the facility on [DATE] with diagnoses which included a history of end stage kidney disease (ESRD-irreversible kidney failure), per the admission Record. A review of Resident 78's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 10/29/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven day period) score of 12 points out of 15 possible points which indicated Resident 78's mental cognition (pertaining to memory, judgement and reasoning ability) was intact. On 11/19/24 at 8 A.M., an observation and interview was conducted with Resident 78 and LN 1, in Resident 78's room. Resident 78 stated that he was not here yesterday (11/18/24) morning because he went out for dialysis. Resident 78 stated that he returned from dialysis at night around 7 PM, and further stated that they did not change his dialysis dressing that night. Resident 78 stated, They're [LN-Licensed Nurse] supposed to change it within 6 hours after dialysis. On 11/19/24 at 8:07 A.M., an interview was conducted with LN 2, outside of Resident 78's room. LN 2 stated Resident 78 goes to dialysis on Monday, Wednesday and Friday (MWF). LN 2 stated that Resident 78 leaves for dialysis in the morning and returns to the facility at NOC [night] shift. LN 2 was shown a picture of Resident 78's dialysis site, which was not dated. LN 2 stated that Resident 78's dialysis site should be changed within 4-6 hours, and further stated that post-dialysis care included monitoring the dialysis site, dressing changes as ordered, and the observation of the dialysis site should be documented. On 11/19/24 at 11:38 A.M., a review of Resident 78's Daily Skilled Nurse Charting dated 11/18/24 at 2:33 A.M., was conducted. There was no documentation of post-dialysis observations/site care or dressing change. On 11/20/24 at 2:19 P.M., a concurrent interview and record review was conducted with LN 3, at the second-floor nursing station. LN 3 stated Resident 78 had dialysis dressing change orders from dialysis, dated 11/19/24, that indicated remove 4 hours after dialysis. LN 3 stated the dressing should have been removed during NOC shift to observe the dialysis site for complications. LN 3 stated there was no documentation on the Daily Skilled Nurse Charting or progress notes regarding post-dialysis care for Resident 78's left upper arm dialysis site. On 11/21/24 at 9:31 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated his expectations was for the LNs to provide post-dialysis care for residents with dialysis, such as Resident 78. The DON stated it was important that Resident 78's dressing was removed as ordered within 4 hours to observe the site for infection and prevent the clogging of the site, excessive bleeding, and reinforced as necessary, to prevent complications. A review of the facility's policy and procedure titled HEMODIALYSIS CATHETERS-ACCESS AND CARE of revised February 2023 indicated, .The nurse should document in the resident's medical record every shift as follows: 1. Location of catheter 2. Condition of dressing .5. Observation post-dialysis. Based on observation, interview, and record review, the facility failed to ensure dialysis (the process of cleaning the blood through a machine) access site was properly cared for two of two residents reviewed for dialysis (2 and 78). This deficient practice had a potential for Resident 2 and Resident 78's dialysis access to clot. Findings: 1. A review of Resident 2's admission Record indicated Resident 2 was re-admitted to the facility on [DATE], with diagnoses which included end stage renal disease (ESRD - kidney failure) and was dependent on dialysis. A review of Resident 2's History and Physical (H&P) dated 10/21/24, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's minimum data set (MDS - a federally mandated resident assessment tool) dated 10/24/24, indicated Resident 2 had a brief interview for mental status (BIMS - ability to recall) was 14/15 (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 11/18/24 at 3:43 P.M., a concurrent observation and interview was conducted in Resident 2's room. Resident 2 was in bed. A meal tray was on the bedside table. Resident 2 had a pressure dressing on the dialysis access of his left upper arm. Resident 2 stated that he had two dialysis accesses, one on his right upper arm and one on his left upper arm. Resident 2 stated the dialysis access on his right upper arm was clotted. Resident 2 stated they are using my left upper arm. Resident 2 stated that he had dialysis, and the facility Licensed Nurses (LNs) removed the pressure dressing on his left dialysis access arm the next day. On 11/19/24 at 8:19 A.M., an observation and interview of Resident 2 was conducted in his room. Resident 2 was sitting up in bed, with a meal tray at the bedside table. Resident 2 had a pressure dressing on his left upper dialysis access arm. Resident 2 stated the pressure dressing was from the dialysis center on 11/18/24. Resident 2 stated They (LNs) will take if off when they want to. On 11/19/24 at 8:40 A.M., a joint observation and interview was conducted with LN 11. LN 11 stated the pressure dressing on Resident 2's dialysis access arm was still on and should have been removed after 4-6 hours to prevent irritation and clotting of Resident 2's dialysis access. A review of Resident 2's physician's order dated 10/21/24 indicated check .site dressing upon return from dialysis. May remove the pressure dressing ([4] enter number of hours) following dialysis and apply non-pressure dressing. The non-pressure dressing may be removed ([4] enter number of hours) .every Monday, Wednesday, and Friday afternoon . On 11/20/24 at 4:02 P.M., a joint interview and review of Resident 2's clinical record was conducted with LN 12. LN 12 stated the physician order and the care plan for Resident 2's dialysis access was for the LNs to check the dialysis access site and remove the pressure dressings after four hours from dialysis to prevent clotting of the access. On 11/21/24 at 8:19 A.M., a telephone interview was conducted with the outpatient dialysis nurse (ODN). The ODN stated she was familiar with Resident 2. The ODN stated Resident 2 had two access, one on his right upper arm which was clotted, and one on his left upper arm. The ODN stated Resident 2 received dialysis through his left upper arm access. The ODN stated the pressure dressings on Resident 2's left upper arm should be removed not more than four hours after his dialysis to prevent clotting of the access. On 11/21/24 at 1:32 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the LNs to check and remove the pressure dressings on the resident's dialysis access arm four hours after the resident's dialysis to prevent clotting of the access. A review of the facility's policy titled, Hemodialysis - Access and Care of, revised 2/2023, was conducted. The policy did not provide instructions or guidance of the hours related to removal of access dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to include the appropriate indication (reason) and monitor the target behaviors for two of five residents (16 and 134) when: 1. Resident 16 did not have appropriate indications for the use of an antipsychotic medication (a medication used to treat symptoms of psychosis such as hallucinations and delusions). 2. Resident 134 did not have appropriate indication for anti-anxiety (medication used for worry and fear) medications and appropriate target behavior for the use of anti- anxiety medications. These failures had the potential for unnecessary psychotropic (mind-altering medications) medication use and a decline for resident's psychological and mental well-being. Findings: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental abilities that would affect a person's daily life) and anxiety disorder (a mental health condition that involved persistent and uncontrollable feelings of fear and worry), according to the admission Record. A joint interview and record review was conducted with the minimum data set (MDS; an assessment tool) nurse (MDSN) and Licensed Nurse (LN) 20 on 11/21/24 at 9:04 A.M. The MDSN stated that Resident 16 had an active physician's order (November 2024) for quetiapine (Seroquel, an antipsychotic medication), ordered on 10/13/24, to be given for dementia. The MDSN stated there was a physician's order, dated 10/13/24, indicating quetiapine was to be given because Resident 16 had sudden mood changes with agitation. The MDSN stated that dementia was not a psychotic diagnosis. A review of hospital discharge paperwork dated 9/27/24 was conducted with LN 20. LN 20 stated quetiapine was not listed as a discharge medication. The MDSN and LN 20 stated they did not know why Resident 16 was taking quetiapine. A review of Resident 16's medication administration records (MAR) dated October and November 2024, was conducted on 11/21/24. The MAR indicated Resident 16 did not have any sudden mood changes with agitation in the month of October 2024. The MAR dated November 2024 indicated Resident 16 had one occurrence of sudden mood changes with agitation in which she was easily redirected. A telephone interview with Resident 16's responsible party (RP 21) was conducted on 11/21/24 at 10:12 A.M. RP 21 stated he was not aware that Resident 16 was taking quetiapine/seroquel. An interview with LN 20 was conducted on 11/21/24 at 12:21 P.M. LN 20 stated that dementia was not a psychotic diagnosis. LN 20 stated anxiety medications could be given if Resident 16 had agitation. LN 20 stated Resident 16 did not do much of anything and needed family to try and convince her to participate in activities. An interview with the Director of Nursing (DON) was conducted on 11/21/24 at 3:48 P.M. The DON stated quetiapine was an antipsychotic medication. The DON stated agitation was not a psychotic behavior. The DON stated agitation was not an adequate indication for the use of quetiapine. The DON acknowledged that the indication should have been questioned/clarified, but was not. A review of the facility's policy titled Antipsychotic Medication Use, revised 7/2022, indicated .5. Residents who are admitted .the interdisciplinary team will .re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks .9. Diagnoses alone do not warrant the use of antipsychotic medication . 2. Resident 134 was re-admitted to the facility on [DATE], with diagnoses which included aphasia (a language disorder that makes it difficult to understand, speak, read, or write) after a stroke, per the admission Record. A review of Resident 134's History and Physical (H&P) dated 11/13/24, indicated Resident 134 had no capacity to understand and make decisions. On 11/18/24 at 8:41 A.M., an observation was conducted in Resident 134's room. Resident 134 was sitting up in bed. A staff member was at the beside, feeding her. Resident 134 did not respond when her name was called. On 11/19/24 at 8:26 A.M., an observation of Resident 134 was conducted in her room. Resident did not respond to questions or to greetings. On 11/20/24 at 2:06 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 11. CNA 11 stated Resident 134 was non-verbal and just looks at the person. CNA 11 stated Resident 134 could not say a word or formulate a sentence. CNA 11 stated there was no behavioral monitoring for Resident 134 because she was a nice resident. On 11/20/24 at 3:44 P.M., a joint interview and review of Resident 134's clinical record was conducted with Licensed Nurse (LN) 11. LN 11 stated that Resident 134 was non-verbal, alert to self, followed eye contact, and was not able to verbalize her feelings. On 11/21/24 at 10:18 A.M., a joint interview and review of Resident 134's clinical record was conducted with the Minimum Data Set (MDS; assessment tool) Nurse (MDSN). The MDSN stated Resident 134 had no diagnosis of anxiety from the acute hospital records. The MDSN stated the facility record indicated Resident 134 was placed on lorazepam (anti-anxiety medication) for anxiety. The MDSN stated the LNs should have clarified the indication for lorazepam to prevent unnecessary medication and to prevent confusion among staff members. The MDSN stated the target behavior to be monitored of Resident 134 for taking the lorazepam was verbalizing anxiety. The MDSN stated Resident 134 was non-verbal. On 11/21/24 at 1:32 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the LNs to clarify the indication of the psychotropic medication, resident's correct diagnosis, and the target behavior to prevent the use of unnecessary medication. The DON stated it was also important to know if the medication was appropriate for the resident's behavior and ensure its effectiveness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure infection control procedures were followed when a Licensed Nurse (LN) 14 did not perform hand hygiene (the practice of cleaning hands to remove germs, dirt, or other harmful substances) consistently after removing her gloves while providing wound care to one of four residents (Resident 43), reviewed for pressure ulcer (sore). This failure had the potential for cross contamination, spread of infection, and Resident 43's decline in health. Findings: Resident 43 was re-admitted to the facility on [DATE], with diagnoses which included immunodeficiency (when the body's immune system is reduced or absent) and an infection on her right knee, per the admission Records. A review of the facility's matrix (used to identify pertinent care categories), indicated that Resident 43 had an unstageable (a type of bed sore that occurs due to prolonged pressure on a specific area of the skin) pressure sore on her right heel. On 11/21/24 at 9:48 A.M., an observation of Licensed Nurse (LN) 14 providing wound care to Resident 43 was conducted. LN 14 prepared supplies for Resident 43's wound care and placed them on a tray. LN 14 put on a pair of gloves, removed the old dressing from Resident 43's right knee, took off her gloves, put on a new pair of gloves, treated Resident 43's knee with betadine (antiseptic solution), and placed a bandage on Resident 43's right knee with a gauze on top of the wound. LN 14 wrapped Resident 43's right knee wound with a rolled gauze. LN 14 then moved to Resident 43' right heel pressure sore. LN 14 put on a new pair of gloves and removed the old dressing from Resident 43's right heel pressure sore. LN 14 removed her gloves, applied betadine to Resident 43's right heel pressure sore, wiped it dry with dry dressings, and placed a bandage on Resident 43's right heel pressure sore. LN 14 removed her gloves, put on a new pair of gloves, wrapped Resident 43's right leg with an elastic wrap and placed an immobilizer (used to correct or help certain injuries heal) on Resident 43's right leg. LN 14 did not perform hand hygiene in between tasks. On 11/21/24 at 10:12 A.M., an interview with LN 14 was conducted. LN 14 stated Resident 43 had an infection on her right knee after a surgery. LN 14 stated Resident 43 developed a pressure sore on her right heel. LN 14 stated she did not perform hand hygiene after removing her gloves. LN 14 stated she usually brings a little spray and forgot it today. LN 14 stated, it was important to perform hand hygiene before putting on new gloves to prevent infection because anything can get into the gloves. On 11/21/24 at 1:32 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the staff to sanitize their hands every time they removed their gloves to prevent cross contamination because there might be some bacteria on their hands and this may cause infection to the residents. A review of the facility's policy titled, Wound Care revised October 2010, indicated .5. Pull gloves over dressing and discard .Wash and dry .hands thoroughly . A review of the facility's policy titled, Infection Prevention and Control Program, revised October 2018, indicated, .11. Prevention of Infection .a .(2) educating staff and ensuring that they adhere to proper techniques and procedures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure a care plan for Resident 1 ' s refusal of medications was developed and implemented. This failure had the potential for the care and interventions to not be communicated to all health care providers. Findings. A review of Resident 1 ' s dated admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included Orthopedic Aftercare Following Surgical Amputation, Diabetes (abnormal blood sugar) with chronic kidney disease (failure of the kidneys to filter waste from the blood). An interview was conducted on 3/13/24 at 10:47 A.M., with certified nursing assistant (CNA) CNA 1 stated Resident 1 never complained of not having water at his bedside. An interview on 3/13/24 at 10:55 A.M., with licensed nurse (LN) LN 1 was conducted. LN 1 stated Resident 1 loved his snacks and enjoyed foods brought by his family when they visited. An interview on 3/13/24 at 11:10 A.M. with LN 2 was conducted. LN 2 stated Resident 1 never refused his snacks, blood sugars checks but Resident 1 was always concerned with it and his medications. On 3/13/24 at 11:30 A.M. with the Physical therapist (PT) was conducted. The PT stated Resident 1 was very impulsive and was very adamant on going back to his wheelchair from his bed during therapy sessions. The PT stated he had to remind Resident 1 not to bear weight on his bilateral lower extremities. A record review of Resident 1 ' s Physicians order summary report dated March 13, 24 indicated that Resident 1 had orders for the following medications : Gabapentin ( medication for nerve pain) capsule (CAP) by mouth three times a day, Insulin Glargine( diabetic injection ) 100 unit/m inject 40 units ( unit of measurement )subcutaneously ( SQ- under the skin ) at bedtime, and tuberculin PPD solution (Tuberculosis test) given once intradermal under the (epidermis-layer of skin). A record review of Resident 1 ' s nursing progress indicated that Resident 1 had episodes of refusing the medications on the following dates and times: · Gabapentin three times a day on 2/22/24 and 2/26/24, · tuberculin test on 2/22/24 · insulin glargine at bedtime on 2/20/24, 2/22/24, 2/29/24, 3/3/24 and 3/5/24. A record review of Resident 1 ' s medication administration record (MAR) indicated that Resident 1 refused his Gabapentin on 2/22/24 and 2/26/24, tuberculin test on 2/22/24 and insulin glargine on 2/20/24, 2/22/24, 2/29/24, 3/3/24 and 3/5/24. A record review of Resident 1 ' s medical record indicate there was no care plan on Resident 1 ' s refusal of these medications and injections. An interview on 3/21/2024 at 10:50 A.M., with the assistant director of nursing (ADON) was conducted. The ADON stated the care plan on Resident1 ' s refusal of medications needed to be initiated, developed, and implemented. The ADON stated a care plan was important to make everyone aware of the care that their residents need, and it tells the story of how they took care of their residents, including Resident 1. A joint interview and record review on 3/21/2024 at 10:30 A.M., with the Director of Nursing (DON) was conducted. The DON stated there was no care plan of Resident 1 ' s refusals of medications and tuberculosis testing in Resident 1 ' s medical record. The DON stated there was poor documentation on the nurse ' s part. The DON stated a care plan was very important so that everyone was aware of the care being provided to Resident 1. A record review dated February 2021 of the facility ' s Policy and Procedure titled, Requesting, Refusing or Discontinuing Care or Treatment . #7. If the decision to refuse or discontinue treatment results in a significant change of condition, a reassessment will occur, and appropriate changes will be made to the resident ' s care plan. #8. Detailed information relating to the request, refusal or discontinuation of treatment are documented in the resident ' s medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure staff are competent in managing Resident 1 ' s Diabetes (a chronic [long lasting] health condition that affects how your body turns food into energy) when staff did not notify Resident 1 ' s medical doctor on his medication refusals. This failure had the potential to negatively affect Resident 1 ' s health condition and possible decline. Findings. A review of Resident 1 ' s dated admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included Orthopedic Aftercare Following Surgical Amputation, Diabetes (abnormal blood sugar) with chronic kidney disease (failure of the kidneys to filter waste from the blood). An interview on 3/13/24 at 11:00 A.M., with licensed nurse (LN) LN 1 was conducted. LN stated Resident 1 had episodes of refusing his medications including his insulin (diabetic medication) and that they have explained to him it ' s risk and consequence for his actions. LN1 stated that the medical doctor (MD) notification was important so that the MD can adjust Resident 1 ' s medications if needed. A record review of Resident 1 ' s medication administration record (MAR) indicated that Resident 1 refused his Gabapentin (medication for nerve pain) on 2/22/24 and 2/26/24, tuberculin test (tuberculosis skin testing) on 2/22/24 and insulin glargine (diabetic medication) on 2/20/24, 2/22/24, 2/29/24, 3/3/24 and 3/5/24. A record review of Resident 1 ' s nursing progress indicated that Resident 1 had episodes of refusing the medications on the following dates and times without the MD notification. · Gabapentin three times a day on 2/22/24 and 2/26/24, · tuberculin test on 2/22/24 · insulin glargine at bedtime on 2/20/24, 2/22/24, 2/29/24, 3/3/24 and 3/5/24. An interview on 3/21/24 at 10:43 AM., with the assistant director of nursing (ADON) was conducted. The ADON stated it was important for the nurses to notify Resident1 ' s MD regarding his refusals on his medications so Resident 1 ' s MD will make the decision to adjust Resident 1 ' s medications, either to lower or increase the dosage or discontinue the medication. The ADON stated Resident 1 ' s MD can also provide education to the nurses regarding managing Resident 1 ' s overall health condition. An interview on 3/21/22 at 11:00A.M., with the Director of Nursing (DON) was conducted. The DON stated MD notification was important so that Resident 1 ' s MD was aware if the plan of care was not implemented regarding Resident 1 ' s episodes of medication refusals. A record review of the facility ' s policy titled, Change in a Resident ' s Condition or Status .Policy Interpretation and Implementation .#1 The nurse will notify the resident ' s his or her attending physician and the resident representative of changes in the resident ' s medical/mental condition and/or status .f. refusal of treatment or medications two (2) or more consecutive times .

Based on observation, interview, and facility document and policy review, the facility failed to ensure the environment was free from accident hazards by failing to secure a stairwell that started at the ground floor and extended to the first, second, and third floor residential areas. Specifically, the first, second, and third floors had doors that exited to an exterior stairwell. None of the doors had any type of safety precaution to prevent a resident from exiting into the stairwell unattended. This deficient practice had the potential to affect 8 of 8 residents identified by the facility as at risk for elopement and 5 of 5 residents identified by the facility as ambulatory. Findings included: A review of an undated facility policy titled, WANDERGUARD, Code Alert etc. Resident Monitoring System revealed, It is the policy of this facility to provide a safe and secure environment to ensure the safety of any resident attempting to elope from the facility. During an interview on 12/18/2023 at 3:08 PM, the Director of Nursing (DON) stated a door security code was not needed to take the stairwell to the third-floor residential area. Observations on 12/18/2023 at 3:10 PM of the third floor revealed double fire doors that opened to an area near the elevator and a door leading to an outside landing and stairwell. The double fire doors and the door to the outside landing and stairwell were not secured with a code or locking system to prevent residents from exiting the unit through the door leading to the stairwell. During an interview on 12/18/2023 at 3:29 PM, Activities Assistant (AA) #5 stated there was no code required to go out of the facility to the stairwell, noting there was only a code outside on the ground level to prevent anyone from entering the building. During an interview on 12/19/2023 at 9:55 AM, the Social Services Director (SSD) stated the facility had a departure alert system for residents identified as at risk for elopement; however, the SSD stated the ground floor exit doors and front door were the only ones equipped with the departure alert system. During an interview on 12/19/2023 at 12:06 PM, the Dietary Director (DD) stated there was no code required to go out the doors to the stairwell. The DD stated anyone could leave the facility, but there was a code outside on the ground level to prevent anyone outside from entering. The DD further stated the facility used a departure alert system for some residents, but only the ground floor doors were equipped to alarm. Observation on 12/19/2023 at 12:08 PM of the second floor revealed the exit door to the outside landing and stairwell were not secured with a code or locking system to prevent residents from exiting the unit through the door leading to the stairwell. Observation on 12/20/2023 at 10:51 AM of the first floor revealed the exit door to the outside landing and stairwell was propped open. Observations on 12/20/2023 between 10:55 AM and 11:10 AM of the third floor revealed staff and residents passed near the exit door leading to the stairwell. During an interview on 12/20/2023 at 12:15 PM, Certified Nurse Aide (CNA) #2 stated she had never seen a resident try to exit through the door to the stairwell. During an interview on 12/20/2023 at 12:21 PM, Licensed Vocational Nurse (LVN) #4 stated the exit door to the stairwell was not secured or locked. LVN #4 stated she had never known a resident to go out the door to the stairwell. During an interview on 12/21/2023 at 7:14 AM, the DON stated there was no code required to go out the doors to the stairwell, but noted there was a code on the outside to prevent people from coming into the facility. The DON stated he had never known a resident to attempt to go down the stairs, and he did not think a resident would try to go outside to the stairwell and fall. The DON stated they conducted assessments on new residents to identify any resident at risk of wandering, and stated the ground level doors were equipped with a departure alert system. A review of a list provided by the facility labeled, Risk of Elopement- at Risk, dated 12/19/2023, reveled the facility identified eight residents who were at risk for elopement. During an interview on 12/21/2023 at 7:21 AM, the Administrator stated he was not aware of any resident attempting to exit through the doors leading to the stairwell. The Administrator stated the doors were heavy and they had never had a problem with any resident going out them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to ensure food was covered to prevent potential contamination during meal delivery to resident rooms. Specifically, the facility failed to ensure food was covered during meal delivery to resident rooms located on 1 (second floor) of 3 residential floors. This deficient practice had the potential to affect 29 residents who consumed their meals on the second floor of the facility. Findings included: A review of a facility policy titled, Food Preparation and Service, revised in November 2022, revealed, When meals are assembled in the kitchen and then delivered to residents' rooms or dining areas to be distributed, covering foods is appropriate, either individually or in a mobile food cart. Observations on 12/19/2023 at 12:06 PM revealed the food delivery cart was delivered to the second floor. The cart was parked between the shower room and room [ROOM NUMBER]. The puddings on the trays were not covered. Staff were observed removing the meal trays from the cart and carrying the trays with the uncovered puddings down the hallway to residents' rooms. Observations on 12/20/2023 at 12:08 PM revealed a food delivery cart was parked between room [ROOM NUMBER] and a shower room. Staff removed a tray from the cart and delivered the meal tray to room [ROOM NUMBER], which was approximately 20 feet down the hallway. The pureed dessert was uncovered on the meal tray. Staff then removed a meal tray from the cart and took the meal tray to the dining room, which was approximately 20 feet down the hall. The chocolate chip bar was uncovered on the tray. During an interview on 12/20/2023 at 12:12 PM, Certified Nurse Aide (CNA) #1 stated food should be covered to prevent any germs from getting in it and to maintain the temperature. CNA #1 stated that when an item was uncovered and carried down the hall, it could get germs in it. During an interview on 12/20/2023 at 12:15 PM, CNA #2 stated food was covered to maintain the temperature and to protect it from germs, chemicals, and other contaminants. CNA #2 stated everything on the tray should be covered, because when it was carried down the hall, anything could happen to it. During an interview on 12/20/2023 at 12:17 PM, Licensed Vocational Nurse (LVN) #3, who was sitting with Resident #188, stated food should be covered to maintain the temperature and to protect the food from germs, dirt, and contamination. When the surveyor asked LVN #3 what could happen to the food if it was carried down the hallway uncovered, Resident #188 replied that it could get germs on it. During an interview on 12/20/2023 at 12:21 PM, LVN #4 stated food should be covered to keep it warm and safe from contamination. LVN #4 stated all food items should be covered, because if it was carried down the hallway uncovered, there was a potential for contamination. During an interview on 12/20/2023 at 1:25 PM, the Dietary Director (DD) stated most of the food should be covered but the dessert was sometimes an exception due to presentation. The DD stated he believed the dessert was covered during transportation on the covered cart, noting nursing staff should be taking the cart to each room, instead of carrying the meal trays down the hallway. During an interview on 12/20/2023 at 1:27 PM, the Registered Dietitian (RD) stated for presentation reasons they did not individually cover the dessert items, but noted the entire food delivery cart was covered. The RD stated the nursing staff should be taking the cart to the residents' doorways before removing the trays, instead of carrying the meal trays down the hallway. During an interview on 12/21/2023 at 7:21 AM, the Administrator stated he expected staff to follow the regulations for delivering food to residents' rooms. The Administrator stated he expected the food to be delivered in a safe and sanitary manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility document and policy review, the facility failed to ensure their water management plan was fully implemented to prevent the potential for waterborne illnesses, including Legionella (a bacteria most commonly transmitted through contaminated water sources that could cause Legionnaires' disease). This failure had the potential to affect all 81 residents residing in the facility. Findings included: A review of the facility's policy titled, Legionella Water Management Program, revised in September 2022, revealed, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The Policy Interpretation and Implementation section specified, 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread and to reduce the risk of Legionnaires' disease. The policy further specified, 5. The water management program includes the following elements: a. An interdisciplinary water management team (see above); b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria included the following: (1) Storage tanks; (2) Water heaters; (3) Filters; (4) Aerators; (5) Showerheads and hoses; (6) Misters, atomizers, air washers and humidifiers; (7) Hot tubs; (8) Fountains; and (9) Medical devices such as CPAP [continuous positive airway pressure] machines, hydrotherapy equipment, etc. d. The identification of situations that can lead to Legionella growth, such as: (1) construction; (2) water main breaks; (3) changes in municipal water quality; (4) the presence of the biofilm, scale or sediment; (5) water temperature fluctuations; (6) water pressure changes; (7) water stagnation; and (8) inadequate disinfection. e. Specific measures used to control the introduction and/or spread of Legionella (e.g. temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; j. Documentation of the program. During an interview on 12/20/2023 at 8:21 AM, the Maintenance Director stated the facility did not have a waterborne illness plan. He stated the facility did not have any stagnant water, so they did not perform any testing and did not need a waterborne illness plan. The Maintenance Director stated the facility did have drinking water dispensers that were cleaned by an outside company every three months. He further stated any shower heads were cleaned by housekeeping staff, so there was no need to test them for waterborne pathogens. During an interview on 12/21/2023 at 7:23 AM, the Administrator stated the local water authority came to the facility on [DATE] and provided them a printout of the prior six months of water testing. The Administrator said the water authority's testing only included Escherichia coli. He said he knew the water authority tested the water that came into the facility from the outside, and he thought they tested other items, such as the shower heads and ice machine. A review of a letter addressed to the facility from the local water authority, dated 12/20/2023, revealed they tested the bacteriological water quality and chlorine residual every week near the facility to ensure compliance with all state and federal drinking water standards. The letter included the results of the testing for the timeframe from July 2023 to December 2023 that consisted of only chlorine residual, the presence or absence of total coliform, and the presence or absence of Escherichia coli. During an interview on 12/21/2023 at 8:18 AM, the Infection Preventionist (IP) stated she did not have anything to do with the water management plan, noting the Maintenance Director was responsible for the water management plan. During an interview on 12/21/2023 at 8:53 AM, the Maintenance Director stated he had a diagram and checked water temperatures. He stated the local water authority also did testing, but he believed they only tested the water where it came into the building. The Maintenance Director further stated he disinfected the shower heads and the ice machine weekly but did not document it. During an interview on 12/21/2023 at 9:06 AM, the Maintenance Director provided a copy of an undated water source diagram. The following areas were highlighted on the diagram as areas at risk for potential waterborne pathogens: the fire suppression system (sprinkler system), water dispensers, ice machines, cold water distribution, sinks, showers, water heaters, heat exchangers, hot water storage with heat exchangers, washing machines, and the sanitary sewer system. After the surveyor and Maintenance Director reviewed the water source diagram, the Maintenance Director said he had no evidence of any testing of the highlighted areas, because no one had ever told him he needed to conduct any type of testing. The Maintenance Director stated he had now read the policy, so he knew what needed to be included and what he needed to be doing. During an interview on 12/21/2023 at 9:25 AM, the Director of Nursing (DON) stated he expected the residents to be protected from any waterborne illnesses, and they should be drinking safe water. The DON said the Maintenance Director was responsible for performing any water testing. During an interview on 12/21/2023 at 9:28 AM, the Administrator stated his expectation was to follow whatever the regulations and guidelines the state and the Centers for Medicare and Medicaid Services (CMS) dictated. He stated he wanted the water to be safe for all the residents, noting that was most important as they did not want anyone to get sick. During an interview on 12/21/2023 at 11:24 AM, the Assistant Lab Supervisor (ALS) from the local water authority stated they conducted weekly water testing at the facility. The ALS confirmed the local water authority did not perform any water testing inside the facility, noting they only tested the drinking water that came into and out of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Per the facility's admission Record, Resident 9 was admitted to the facility on [DATE], with diagnoses to include Chronic Obstructive Pulmonary Disease (a breathing disorder), and Unspecified Asthma (A respiratory condition marked by spasms in the lungs). Per the facility's admission Record, Resident 18 was admitted to the facility on [DATE], with diagnoses to include COVID-19 (An acute respiratory illness in humans caused by a coronavirus), and Contact with and (suspected) exposure to other viral communicable diseases. Per the facility's admission Record, Resident 48 was admitted to the facility on [DATE], with diagnoses to include Pneumonia (Lung inflammation caused by bacterial or viral infection), and Acute Respiratory Failure with Hypoxia (A condition that occurs when fluid builds up in the air sacs in the lungs, causing abnormally low concentration of oxygen in the blood). Per the facility's admission Record, Resident 62 was admitted to the facility on [DATE], with diagnoses to include Chronic Kidney Disease (The gradual loss of kidney function), and Anemia (A condition marked by a deficiency of red blood cells). Per the facility's admission Record, Resident 233 was admitted to the facility on [DATE], with diagnoses to include Pleural Effusion (A buildup of fluid in the pleural space, an area between the layers of tissue that line the lungs and the chest wall), and Acute Kidney Failure (A condition that occurs when the kidneys suddenly become unable to filter waste products from the blood). On 5/6/21 at 9A.M., an interview and record review was conducted with the Infection Preventionist (IP). The IP stated that the consents for the 5 residents (9, 28, 48, 62, and 233) were obtained by nurses. The IP also stated that they didn't have a policy specifically for obtaining consents for vaccination. On 5/6/21 at 2:49 P.M., an interview was conducted with the Charge Nurse (LN42) on 2nd floor. LN42 stated that she had the residents sign the consent for vaccinations, then she would call the doctor for the order and forward it to pharmacy, and then she would administer the vaccine. On 5/7/21 at 1:50 P.M., an interview was conducted with the Assistant Director of Nursing (ADON) and the Administrator (Admin). The ADON stated that the nurses were the ones who obtained the consents for vaccinations. The Admin stated that the physicians should be the ones who obtain the consents for vaccinations, and apologized because he stated that the nurses were doing it. According to the facility's policy, dated April 2017, titled, Informed Consent Policy, .2. The physician will provide education and discuss with the resident or responsible party, informing them of risks, benefits, and alternatives or options of a proposed treatment, care or intervention. According to the facility's policy, dated October 2019, titled, Pneumococcal Vaccine, .3.When indicated, the physician will obtain an informed consent. According to the facility's policy, dated October 2019, titled, Influenza Vaccine, .When necessary, the physician will obtain informed consent. Based on interview and record review, the facility failed to: 1. Obtain consent prior to administering psychotropic medications, and 2. Failed to utilize practitioner's (physician, nurse practitioner, or physician assistant) to obtain resident consent for vaccines for six residents sampled for consents (228, 9, 28, 48, 62, 233). As a result, the residents may not have been fully informed of the risks and benefits of the psychotropic medications and vaccines. Findings: 1. Per the facility's admission Record, Resident 228 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's disease (A progressive disease that destroys memory and other mental functions), and dementia (a progressive physical and mental decline). Per the facility's Telephone/Verbal Order Signature Details, dated 5/6/21, Resident 228 had an order on 4/29/21 for hydroxyzine (a medication which can treat anxiety) 25mg every 6 hours as needed for agitation, and an order on 5/5/21 for divalproex sodium 125mg two times per day for dementia with behavioral disturbance. On 5/6/21 at 8:36 A.M., a telephone interview was conducted with RP 1 (responsible party). RP 1 stated, the facility did not call to notify him when they ordered any new medications for Resident 228, and they did not tell him about her new medications, including hydroxyzine until he asked for Resident 228's medication list. RP 1 did not mention divalproex sodium when he described Resident 228's new medications. RP 1 further stated, he had not spoken with the facility's physician since she was admitted to the facility, and he wanted the facility to notify him when they ordered new medications for Resident 228. On 5/6/21 at 2:10 P.M., a concurrent interview and record review was conducted with LN 61. LN 61 stated, when the facility ordered a new psychotropic medication (a medication which alter's a person's mental state) LN's called a resident's RP to obtain verbal consent over the phone. LN 61 further stated, the facility ordered divalproex sodium for Resident 228 on 5/5/21, but she was not able to find a consent form for divalproex sodium in Resident 228's medical record. LN 61 stated, she entered the order for hydroxyzine, but did not get consent from RP 1 because other LNs at the facility told her she did not need to get a consent for hydroxyzine. On 5/6/21 at 3:35 P.M., a concurrent interview and record review was conducted with the ADON. The ADON stated, if a medication was being used for anxiety or behaviors, the facility had to obtain consent prior to administering the medication. The ADON further stated, consents must be obtained by a practitioner, and not by LNs. The ADON stated, when the facility obtained consents, it should have been documented under progress notes and on the consent form. The ADON stated, a resident's RP should be notified of any newly ordered medications, and the facility should not administer psychotropic medications until they have obtained consent. The ADON reviewed Resident 228's medical record and was unable to find evidence of consents for hydroxyzine or divalproex sodium. Per the facility's MAR (Medication Administration Record), for Resident 228, dated 5/1/21-5/31/21, the facility administered divalproex sodium on 5/6/21 at 9 A.M., and 1 P.M. Per the facility's MAR (Medication Administration Record), for Resident 228, dated 5/1/21-5/31/21, the facility administered hydroxyzine on 5/1/21, 5/2, 5/3, 5/4, 5/5, and 5/6. Per the facility's policy, titled Behavior Management, dated 12/31/15, .3. Whenever an order is obtained for psychotropic medication(s), the licensed nurse verifies that informed consent has been obtained .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the environment free of accident hazards for two of 30 sampled residents (9, 279) when: 1. Resident 9 kept her smoking materials at her bedside. 2. Resident 239 was left alone with a chemical disinfectant on her bedside table. Findings: 1. According to the admission Record, Resident 9 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a type of breathing disease). Her Brief Interview for Mental Status (BIMS) score was 15, meaning Resident 9 was mentally intact. On 5/4/21 at 4:04 P.M., an observation was conducted of Resident 9. Resident 9 was sitting in a wheelchair bedside her bed. On her bedside table lay a cigarette lighter and a clear plastic bag containing cigarettes. On 5/5/21 at 12:17 P.M., a joint observation and interview was conducted with Resident 9. Resident 9 was lying in her bed and stated her cigarette lighter and cigarettes were in her purse. On 5/6/21 at 3:45 P.M., a joint observation and interview was conducted with Resident 9. A box of cigarettes was observed to be laying on Resident 9's bed. Resident 9 pulled a cigarette lighter from her pocket, then stated she was allowed to keep those items with her in her room. Resident 9 further stated facility staff had never discussed with her whether she was permitted to keep smoking supplies in her room. On 5/6/21 a record review was conducted. Per the facility's Smoking Safety Assessment for the resident, dated 5/1/21, question four of the assessment read: Does resident attempt to keep smoking paraphernalia on self or in room? The documented answer was no Resident 9's smoking care plan, revised 4/22/21, included an intervention that indicated, Cigarettes and lighter will be stored at the nurse's station. On 5/7/21 at 8:47 A.M., an interview was conducted with a social worker (SW). The SW stated social workers or nurses were required to review each point of the Smoking Safety Assessment with residents who smoked. The SW stated it was facility policy that smoking supplies were kept at the nurse's station, to be checked out and returned by residents who smoked. The SW stated Resident 9 was not permitted to keep a lighter or cigarettes at her bedside. On 5/7/21 at 11:09 A.M., an interview was conducted with the ADON. The ADON stated it was not acceptable for Resident 9 to keep smoking supplies at her bedside. The ADON stated the protocol required all smokers to store their materials at the nurse's station. The ADON stated the nursing staff should have noticed Resident 9's lighter and cigarettes in her room and removed them from her possession. According to the Facility Smoking Policy, signed and dated by Resident 9 on 5/1/21: .6. Residents are not permitted to keep cigarettes, matches, or lighters in their possession. All smoking materials must be kept by facility personnel . 2. According to the admission Record, Resident 239 was admitted to the facility on [DATE] with diagnoses including intracranial injury (brain dysfunction caused by an outside force) and memory deficit. On 5/5/21 at 9:30 A.M., an observation of Resident 239 was conducted. Resident 239 was observed to be laying in bed with her eyes closed with her bedside table pulled approximately 10 inches from the resident . Resident 239 was alone in the room. Her . The table was wet with a substance that smelled like cleanser. Resident 239's open water cup and open milk carton were sitting in the wet substance. Resident 239 was alone in the room. On 5/5/21 at 9:35 A.M., a housekeeper (HK) was observed entering Resident 239's room. The HK was interviewed at this time. The HK stated she was the one who had sprayed Resident 239's table and she had used a virucidal (having the ability to destroy viruses) chemical. The HK stated she left it on the table without wiping it off because it required one minute to kill germs. The HK stated she had moved Resident 239's drinks prior to spraying and set them down in the disinfectant after spraying. When demonstrating this, the HK lifted Resident 239's water and milk. The table was dry under both drinks, indicating they had not been moved while the disinfectant was sprayed. On 5/7/21 at 10:25 A.M., an interview was conducted with the Housekeeping Supervisor (HS). The HS stated the disinfectant used on Resident 239's bedside table was used throughout the facility for cleaning tables, floors, bedrails, and other surfaces. The HS stated the contact time (the amount of time required for a surface to remain wet with a cleaner for germ killing to take place) was three minutes for the chemical used. The HS stated the bedside table should be moved away from the resident, everything taken off the table, and then the table should be sprayed. After spraying, it should remain wet for 3 minutes, without placing it back near the resident with bedside items. After 3 minutes, the HS stated the table should be wiped off. The HS stated residents should not be left alone with a table wet with the disinfectant. The HS stated residents should not touch the disinfectant. On 5/7/21 at 11:09 A.M., an interview was conducted with the ADON. The ADON stated it was not safe to leave a resident unattended with disinfectant on their bedside table. The facility was not able to provide a policy regarding specific cleaning procedures. The disinfectant's Directions for Use indicated: .Food products .must be removed or carefully protected prior to using this product . The Safety Data Sheet for the disinfectant used indicated: .Health Hazards-serious eye damage/eye irritation .prolonged inhalation may be harmful .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to correctly label a gastrostomy tube feeding (tube inserted in the abdomen to provide liquid nutrients) bottle and water flush bag for one of one sampled resident investigated for tube feeding (48). This failure had the potential for residents to receive expired feeding formula and contaminated water. Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes (abnormal blood sugar) and dysphagia (difficulty swallowing) per the facility's admission Record. An observation was conducted of Resident 48's room on [DATE] at 10:23 A.M. Inside the room was a tube feeding machine pump with a half-empty formula feeding bottle and a clear bag with a half-filled colorless liquid inside. The feeding formula bottle did not have a date or time it was hung. The clear bag did not have a label or resident identifier. On [DATE] at 3:19 P.M., an interview was conducted with Resident 48. Resident 48 stated he did not know when his tube feeding bottle and water flush bag was hung. Resident 48 further stated that there should be a date on the tube feeding bottle and the water flush bag. On [DATE] at 4:04 P.M., an interview was conducted with LN 40. LN 40 stated the tube feeding bottle and the water flush bag should have a label, date, and time. LN 40 stated she did not see a date and time on both the tube feeding bottle and the water flush bag did not have any label. On [DATE] at 4:06 P.M., an interview was conducted with LN 41. LN 41 stated the correct process was to put label on both the tube feeding bottle and the water flush bag. LN 41 further stated that the label should include the date and time when it was hung. On [DATE] at 9:32 A.M., an interview was conducted with LN 42. LN 42 stated all tube feeding bottles and water flush bag should have a label, especially the date and time in order for the staff to know if the tube feeding formula and the water flush was okay to use or not. On [DATE] at 10:53 A.M., an interview was conducted with the ADON. The ADON stated tube feeding bottles and water flush bags should have labels including the date and the time it was hung. Per the facility's policy titled, Enteral Tube Feeding via Continuous Pump, revised 11/2018, . Initiate Feeding . 5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order .

Based on observation, interview, and record review, the facility failed to remove expired medications from the facility. This failure had the potential for the facility to administer expired medications to residents. Findings: On 5/6/21 at 10:20 A.M., an observation was conducted of the Emergency kits (E-kits, containers of multiple medications used if a resident was ordered a medication and it was not in the facility). The E-kit contained six vials of expired medications. A separate E-kit on that floor had completely expired in 2020, meaning every medication it contained was expired. On 5/6/21 at 10:27 A.M., an observation was conducted on another floor's medications. On this floor, the E-kit contained nine vials of expired medications. On 5/6/21 at 10:34 A.M., an interview was conducted with LN 55. LN 55 stated all expired medications needed to be removed from the unit. On 5/6/21 at 10:46 A.M., an interview was conducted with LN 56. LN 56 stated all expired medications needed to be removed from the floor. LN 56 stated expired medications could accidentally be given to a resident and you don't know what the side effects could be if you give an expired med(ication). LN 56 stated medication nurses or charge nurses were responsible for checking for expired medications. LN 56 stated the E-kits were not checked for expired medications. On 5/7/21 at 10:56 A.M., an interview was conducted with the ADON. The ADON stated usually E-kits that are close to their expiration date are swapped out for new ones prior to their expiration. The ADON stated the expired E-kit and medications should have been removed from the floors. On 5/7/21 at 1:40 P.M., an interview was conducted with the pharmacist for the facility. The pharmacist stated it was the facility's responsibility to check the medications and E-kits for expiration and notify the pharmacy. The pharmacist stated E-kits and expired medications would be replaced when the pharmacy was notified. On 5/7/21 at 2:01 P.M., an interview was conducted with the ADON. The ADON stated that prior to this, E-kits were only checked for expired medications when a medication was used. The ADON stated a new procedure needed to be started to ensure no medications were expired. According to the facility policy, titled Storage of Medications, revised November 2020: .discontinued, outdated, or deteriorated drugs .are returned to the dispensing pharmacy or destroyed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor the meal preferences for 1 of 2 residents investigated for meal preferences (229). As a result, Resident 229's plate contained food she would not eat. Findings: Per the facility's admission Record, Resident 229 admitted to the facility on [DATE]. Per the facility's dining card, dated 5/6/21, Resident 229's dislikes included Vegetables . Per the facility's menu for Resident 229, dated 5/3/21 - 5/9, Italian [NAME] Beans had a line drawn through it. On 5/4/21 at 3:45 P.M., a concurrent observation and interview was conducted with Resident 229. Resident 229 stated the facility gave her greenbeans for lunch even though she had told them she did not want vegetables. A full serving of green beans was observed on resident 229's lunch meal tray. On 5/6/21 at 8:05 A.M., a concurrent interview and record review was conducted with the RD. The RD stated, green beans were crossed out on Resident 229's menu, which indicated she did not want them. Per the facility's policy titled System for Recording Food Preferences, updated 10/17/19, .1. Note the food and beverage preferences on the individual's meal ticket .

Based on observation, interview, and record review, the facility failed to remove expired items from the dry storage room and ensure staff covered all facial hair in the kitchen. As a result, there was the risk of: 1. The facility providing expired food to residents 2. Unsecured hair falling onto food. Findings: 1. On 5/4/21 at 8:05 A.M., the DS (Dietary Supervisor) was observed with facial hair on the front of his neck uncovered by his facial mask. On 5/4/21 at 8:25 A.M., the DS stated, he should have been wearing a beard net. Per the facility's policy titled Employee Sanitary Practices, dated 2019, . 1. Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food . 2. On 5/4/21 at 8:12 A.M., an observation was conducted of the dry storage room. A container of dried shredded coconut had a label dated 5/1/21. There was another number written under the 5, which was unclear if it was a 3 or an 8. Four individual servings of honey thickened lemon flavored water were observed with the use by dates of 4/29/21. On 5/4/21 at 8:15 A.M., the DS stated the expired thickened water should have been thrown out. The DS further stated, the container of dried, shredded, coconut should have been thrown out because the label was not clear. The DS stated, the staff should have gotten a new label if they wrote it down wrong instead of writing a new date over it. Per the facility's policy titled Food Storage, dated 2017, .d. Date marking to indicate the date or day by which a use by potentially hazardous food should be consumed, sold, or discarded will be visible on all high risk food .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1b. On 5/4/21 at 11:45 AM, an observation was conducted on the third floor of the facility (PUI overflow wing). During the meal tray pass, CNA 70 and CNA 71 were observed passing meal trays to all the residents in the overflow wing. CNA 70 and CNA 71 did not perform hand hygiene prior to handling the meal trays and in between passing the meal trays from one resident to another. Both CNAs were also observed entering isolation rooms without wearing gloves and gowns. On 5/6/21 at 10:48 AM, an interview was conducted with CNA 70. CNA 70 was asked about the process for passing meal trays. CNA 70 stated she delivered the meal trays to the residents after the licensed nurses checked the meal trays. CNA 70 did not verbalize that she would perform hand hygiene prior to handling the meal trays. On 5/6/21 at 11:03 AM, an interview was conducted with CNA 71. CNA 71 was asked about the process for passing meal trays. CNA 71 stated she would wash her hands, don on (put on) gown and gloves, and will stand on the doorway; while another staff, who was outside the residents' room, handed her the meal trays for the residents inside the room. CNA 71 did not verbalize that she would perform hand hygiene in between passing the meal trays to each of the residents in the room. On 5/6/21 at 9 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated CNA 70 and CNA 71 should have washed or sanitized their hands before and after handling the meal trays. The IP stated the CNAs were instructed to wear full personal protective equipment (PPE), which includes gown, gloves, face shield, and N-95 respirator (a respiratory protective device), when entering PUI rooms. On 5/7/21 at 1:50 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the nurses and the CNAs should perform hand hygiene before handling the meal trays, in between and after passing the meal trays. The ADON also stated that staff should wear full PPE when entering a PUI room. According to the facility policy dated, October 2010, titled, Infection Control Guidelines for All Nursing Procedures, . 3. Employees must wash hands .c. Before and after direct contact with residents.d. After removing gloves. 4.If hands are not visibly soiled, use an alcohol-based hand rub .a. Before and after direct contact with residents.i. After contact with objects in the immediate vicinity of the residents.j. After removing gloves. According to the facility's COVID-19 pandemic mitigation plan, approved by CDPH on 10/14/2020, titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities, .E. Staff have been trained on selecting, donning and doffing appropriate PPE and demonstrate competency of such skills during resident care. 2b. On 5/6/21 at 9 AM, an interview was conducted with the IP (Infection Preventionist). The IP stated that residents who have completed their quarantine (a period of isolation) should not be placed in the same room as residents who were currently placed on quarantine. If the resident who completed the quarantine was placed in the same room with a resident who was just starting his or her quarantine, that would mean that the resident who completed the quarantine, will have to be placed on quarantine again. The IP stated that the practice was Not acceptable. According to the facility policy dated, March 2020, titled, Coronavirus Disease (COVID-19) Prevention and Control, .13. Residents with suspected or confirmed COVID-19 infection are placed in a separate room or cohorted with other residents with the same infection status. Residents who cannot be treated adequately or safely separated from other residents will be transferred. 2a. On 5/4/21 at 10:00 A.M., an observation was conducted on the third floor hallway. Each resident room was labeled with residents' names with dates written in red ink. On 5/4/21 at 10:44 A.M., an interview was conducted with CNA 52. CNA 52 stated the red dates next to the names indicated quarantine for Covid-19. She stated the first date listed was the resident's admission date, and the the second date indicated when that resident had finished their quarantine days. CNA 52 further stated that if a resident did not have a date beside their name, it meant that they were long-term residents whose admission and quarantine dates were long past. On 5/6/21 at 9 A.M., an interview was conducted with the IP. The IP stated persons under investigation for Covid-19 were admitted into rooms where residents were already found to be uninfected. The IP stated this was the practice of the facility and it was done because there were no available rooms to move residents to after their observation period. The IP stated residents who shared rooms with residents needed to be monitored for Covid-19 for another 14 days. The IP stated this was not acceptable infection control and said, It's not right. On 5/6/21 at 3:24 P.M., an observation was conducted of the dates on resident rooms. Room A had a resident admitted on [DATE] and their observation period ended on 4/22/21. Another resident was admitted to the room on 4/23/21 with their observation period to end on 5/6/21. Room B had a resident admitted on [DATE] and their observation period ended on 4/10/21. Another resident was admitted to the room on 5/6/21 with their observation period to end on 5/19/21. Room C had a resident with no date beside their name, which meant they were a long-term resident with no recent observation period. Another resident was admitted on [DATE] and their observation period to ended on 3/17/21. Room D had a resident admitted on [DATE] and their observation period ended on 4/7/21. Another resident was admitted on [DATE] and their observation period ended on 4/25/21. A third resident was admitted to the room on 5/5/21 with their observation period to end on 5/18/21. Room E had a resident admitted on [DATE] and their observation period ended on 4/30/21. Another resident was admitted to the room on 5/4/21 with their observation period to end on 5/17/21. Room F had four residents in total. Three of the residents had no dates beside their names, which meant they were long-term residents with no recent observation periods. The fourth resident was admitted to the room on 4/28/21 with their observation period to end on 5/11/21. Room G had three residents in total. One resident, had no dates beside their name, which meant they were a long term resident with no recent observation period. Another resident was admitted to the room on 4/29/21 with their observation period to end on 5/12/21. Another resident was admitted to the room on 5/6/21 with their observation period to end on 5/19/21. Room H had a resident admitted on [DATE] and their observation period ended on 4/20/21. Another resident was admitted to the room on 4/27/21 with their observation period to end on 5/10/21. On 5/7/21 at 9:55 A.M., an interview was conducted with LN 53. LN 53 stated when residents were admitted to the facility, they were observed for signs and symptoms of Covid-19 for 14 days. LN 53 stated that residents under observation for Covid-19 were placed on droplet precautions and staff who entered the room were required to wear an N95 respirator, a gown, gloves, and a face shield or goggles. She stated this was to protect staff from exposure to Covid-19. LN 53 stated residents under quarantine were not permitted to leave their rooms. LN 53 stated the whole room was considered a quarantined area, even if only one resident was being observed for Covid-19. LN 53 stated residents who had finished their quarantine were potentially exposed if their roommate was found to be infected. On 5/7/21 at 11:20 A.M., an interview was conducted with the ADON. The ADON stated the decision to mix residents who were under observation for Covid-19 with residents who were past their quarantine was a joint decision reached by the DON, the Administrator, and the IP. She stated it was what the facility had always done and had not been considered a problem. According to the facility's current Covid-19 Pandemic Mitigation Plan, .D. All residents who are not suspected to be infected with Covid-19 are in rooms or units that do not include confirmed or suspected cases .E. Upon admission, new and readmitted residents with unknown Covid-19 status are placed in a separate observation unit in the building .Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their exposure (or admission to the facility) . Based on observation, interview, and record review, the facility failed to follow proper infection control practice when: 1. Two Certified Nurse Assistants (CNA 70, 71) entered, and exited the PUI isolation rooms (Person Under Investigation for COVID-19 [a contagious respiratory infection]) without performing hand hygiene, not wearing gloves and gowns while handling and passing meal trays in between residents. 2. The facility placed in the same room, residents that were considered PUI and residents that have been cleared and had completed quarantine days (a period of isolation). These failures had the potential to spread infection amongst the residents, staff, and visitors. In addition, placing PUI residents and cleared residents in the same room had the potential to infect the residents that had already been cleared from COVID-19. Findings: 1a. On 5/4/21 at 12:09 A.M., CNA 62 was observed walking into room [ROOM NUMBER] carrying a meal tray, without donning a gown or gloves, then walked out of the room with an empty meal tray. CNA 62 did not perform hand hygiene prior to going in or out of the room. On 5/4/21 at 12:25 P.M., CNA 62 was observed entering room [ROOM NUMBER] without a gown or gloves, then left the room, picked up a meal tray, and delivered the meal tray to room [ROOM NUMBER]. CNA 62 did not perform hand hygiene between rooms [ROOM NUMBERS]. On 5/4/21 at 310 P.M., the entry to room was observed, and the label read, 118a 4/10 to 4/23, and 118b 4/21 to 5/4, On 5/4/21 at 3:15 P.M., the SC stated, the dates outside of a resident's room indicated when the resident's quarantine isolation ended. The SC further stated, if one resident in a room was on isolation, but the other resident had finished their 14 day isolation, staff should still wear PPE when visiting either resident. The SC stated, the second date listed was the last day of a resident's isolation. On 5/6/21 at 7:58 A.M., CNA 62 stated, when she dropped off the lunch tray for room [ROOM NUMBER] on 5/4, she forgot to put on the gown and gloves. On 5/6/21 at 9:35 A.M., an interview was conducted with the IP. The IP stated, when a CNA entered an isolation room to drop off a meal tray, they should have worn the appropriate PPE, including a gown and gloves.