Based on interview, record review, and facility policy review, the facility failed to refer the resident to the appropriate state-designated authority for Level II preadmission screening and resident review (PASARR) evaluation after the resident was identified to have a newly evident mental illness diagnosis for 1 (Resident #26) of 2 sample residents reviewed for PASARR. Findings included: An admission Record revealed the facility admitted Resident #26 on 07/16/2021. According to the admission Record, the resident had a medical history that included diagnoses of disorder of muscle, neuromuscular dysfunction of bladder, and functional quadriplegia. Per the admission Record, the resident received a diagnoses of anxiety disorder on 03/21/2023, post-traumatic stress disorder (PTSD) on 04/19/2023, and major depressive disorder on 08/31/2023. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/19/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) Score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had active diagnoses to include anxiety disorder, depression, and PTSD. Resident #26's care plan included a focus area initiated 02/27/2023 that indicated the resident was on an antidepressant due to a diagnosis of depression. Resident #26's care plan, indicated a focus area initiated 03/03/2023, that indicated the resident had PTSD. Resident #26's care plan included a focus area initiated 03/18/2024, that indicated the resident used anti-anxiety medication related to a diagnosis of anxiety disorder. Resident #26's medical record revealed no evidence to indicate the resident was referred to the appropriate state-designated authority for a Level II PASARR after the resident received a diagnosis of anxiety disorder on 03/21/2023, post-traumatic stress disorder (PTSD) on 04/19/2023, or major depressive disorder on 08/31/2023. During an interview on 10/23/2024 at 2:16 PM with the Administrator and the Director of Nursing (DON), the DON stated he was not working at the facility when Resident #26 admitted to the facility.

Based on interview and record review, the facility failed to ensure the preadmission screening and resident review (PASARR) was accurate at the time of admission for 1 (Resident #15) of 2 sampled residents reviewed for PASARR. Findings included: An admission Record revealed the facility admitted Resident #15 on 12/01/2022. According to the admission Record, the resident had a medical history that included a diagnose of anxiety disorder. Resident #15's Preadmission Screening and Resident Review Level I Screening, dated 12/02/2022, revealed the resident did not have a serious diagnosed mental disorder such as depression disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusion, and/or mood disturbance. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/2024, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) Score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an active diagnosis to include anxiety disorder. During an interview on 10/23/2024 at 2:16 PM with the Administrator and the Director of Nursing (DON), the DON he was not working at the facility when Resident #15 admitted to the facility, but added the PASARR should be accurate.

Based on observation, interview, record review, facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #150) of 5 sampled residents reviewed for infection control. Findings included: A facility policy titled, Enhanced Barrier Precautions, dated 04/2024, revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions are used an as infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity. b. Personal protective equipment is changed before caring for another resident. c. Face protections may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care. An admission Record revealed the facility admitted Resident #150 on 10/07/2024. According to the admission Record, the resident had a medical history that included diagnoses of encounter for attention to gastronomy dysphagia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/11//2024, revealed Resident #150 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for eating and had a feeding tube. Resident #150's care plan included a focus area, initiated 10/22/2024, that indicated the resident required enhanced barrier precautions (EBP) related to gastrostomy tube (G-tube) placement. Interventions directed staff to use gown and gloves during high-contact resident care activities. Resident #150's Order Summary Report that contained active orders as of 10/23/2024, revealed an order dated 10/10/2024 for EBP related to G-tube every shift. During a concurrent observation and interview on 10/22/2024 at 8:19 AM, Licensed Vocational Nurse (LVN) #1 entered Resident #150's room to administer medications to the resident via enteral route. LVN #1 wore gloves and no other personal protective equipment (PPE). The surveyor noted a sign posted on the resident's door that specified the staff wear a gown and gloves during high-contact resident activities when a resident had a central line, urinary catheter, feeding tube, or tracheostomy. LVN #1 stated gowns were necessary only for direct care like showering or changing the resident. During an interview on 10/22/2024 at 11:41 AM, Registered Nurse #3 stated nurses must wear PPE for medication administration if a resident had G-tube. During an interview on 10/22/2024 at 12:17 PM, the Director of Staff Development (DSD) stated there was verbiage posted on residents' doors when on EBP should be implemented and this guided the staff on what PPE to wear. The DSD stated the purpose of EBP was to protect residents at higher risk for infection because of opened areas such as enteral feeding, wounds, intravenous port, and a dialysis catheter. The DSD stated nurses must wear a gown when they administered medications to a resident who had a G-tube as required on the post listed on the resident's door. During an interview on 10/22/2024 at 1:25 PM, the Infection Preventionist stated the staff was required to wear PPE during high contact activities such as changing of a resident's linens, showering a resident, resident transfers, wound care, G-tube feedings, and administration of medications for residents with indwelling medical devices such as a catheter, peripherally inserted central catheters lines, feeding tubes, and chronic wounds. During an interview on 10/23/2024 at 10:52 AM, the Director of Nursing stated the administration of medication through a G-tube was a closed contact activity, and LVN #1 should have worn a gown. During an interview on 10/24/2024 at 8:29 AM, the Administrator said LVN #1 should have worn a gown during the enteral medication administration for Resident #150. The Administrator stated the expectation was for the staff to follow the facility policy and procedure for the safety of the residents.

Based on observation, interview, and facility policy review, the facility failed to ensure all food items removed from its original container were dated and labeled. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: A facility policy titled, Labeling and Dating of Food, revised 01/03/2018, revealed, All food will be dated and labeled, and prepared for storage to prevent contamination, deterioration, and dehydration. During the initial tour of the kitchen on 10/21/2024 at 9:46 AM, the surveyor noted four, unlabeled and undated bags that contained corn tortillas in the dry storage. During an observation of the kitchen on 10/23/2024 at 11:04 AM, the surveyor noted a gallon size, undated bag of nine snickerdoodle cookies on a shelf in the dry storage. During an interview on 10/23/2024 at 2:36 PM, the Dietary Supervisor (DS) stated all food should be labeled with a use-by date to ensure the food was fresh. The DS acknowledged the food items should have been dated, and stated they must have gotten missed. During an interview on 10/24/2024 at 8:12 AM with the Administrator and the Director of Nursing, the Administrator stated all items should be dated when they were taken out of the box. Per the Administrator, all food should be dated to ensure it was fresh.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the medical record for four residents (Residents 13, 19, 23, and 49) clearly indicated if the residents had advanced directives (advance directive is a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions). All four residents had incomplete documentation on their Physicians Orders for Life Sustaining Treatment (POLST - written medical orders that addresses a limited number of critical medical decisions) when: 1) For Resident 13, section D (section which includes information regarding advanced directives) of the POLST, was not completed. 2) For Resident 19, section D of the POLST was not completed. 3) For Resident 23, section D of the POLST was not completed. 4) For Resident 49, section D of the POLST was not completed. This failure had the potential to result in a delay of treatment for the residents as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted. Findings: 1) During a review of Resident 13's admission Record (clinical record with demographic information), the admission Record indicated, Resident 13 was admitted to the facility on [DATE], with diagnoses which includes chronic congestive heart failure ( a chronic condition in which the heart does not pump blood as well as it should), type 2 diabetes mellitus ( a condition where body does not produce enough insulin), COPD (a group of lung diseases that make difficult to breath), anxiety disorder, chronic kidney disease, Human Immunodeficiency Virus (HIV), hypertension (high blood pressure), atrial fibrillation (irregular rapid heart rate). During a review of Resident 13's Physician Orders for Life-Sustaining Treatment (POLST), signed April 5, 2021, Section D - Information and Signatures regarding Advance Directives, was unanswered. During a concurrent interview and record review with the Social Services Director (SSD), on February 10, 2022, at 4:50 PM, Resident 13's POLST, signed April 5, 2021, was reviewed. The POLST indicated Section D had not been answered. The SSD stated Section D must be completed and she missed it. SSD stated she had not inquired about Advance Directives to Resident 13 or family members. 2) A review of Resident 19's admission Record, indicated, Resident 19 was admitted on [DATE], with diagnoses which included muscle wasting and atrophy (decreased muscle mass), major depressive disorder, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). During a review of Resident 19's POLST, dated November 29, 2021, section D did not have information documented to indicate whether or not an advanced directive existed for the resident. There were three checkboxes in section D which related to advanced directives. The three checkbox options were, Advance directive dated [space left blank to insert date], available and reviewed . or Advance directive not available or No advance directive. None of the checkboxes were marked. During further review of Resident 19's Electronic Health Record (EHR) and physical paper chart, no documented evidence was found regarding whether or not the resident had an advance directive. During an interview on February 10, 2022, at 4:52 PM, with the Social Services Director (SSD), the SSD stated the POLST document in section D should have a checkbox marked by either advance directive dated and available, advance directive not available, or no advance directive. During a review of the facility's policy and procedure titled, Advance Directives, revised April 2013, the policy indicated, Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . 3) During a review of Resident 23's admission Record, the admission Record indicated, Resident 23 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (irregular rapid heart rate), major depressive disorder, overactive bladder ( a condition that causes sudden need to urinate), hypotension (low blood pressure), hypothyroidism (thyroid gland does not produce enough hormones), hyperlipidemia (high levels of fat in the blood), hypertension (high blood pressure), gastro-esophageal reflux disease (a condition where acid from the stomach comes into the esophagus), osteoarthritis (degenerative joint disease), and prostate cancer. During a review of Resident 23's POLST, signed November 17, 2021, Section D - Information and Signatures regarding Advance Directives, was not answered. During a concurrent interview and record review with the SSD, on February 10, 2022, at 5:00 PM, the POLST, signed November 17, 2021, was reviewed. The POLST indicated Section D was left unanswered. The SSD stated that Section D was not complete, and she had not inquired about advance directives to Resident 23 or family members. 4) During a review of Resident 49's admission Record, the admission Record indicated, Resident 49 was admitted to the facility on [DATE], with diagnoses which included Respiratory failure, COPD ( a group of lung diseases that make difficult to breath), Heart failure, Type 2 Diabetes Mellitus ( a condition where body does not produce enough insulin), Anxiety Disorder, Hypertension (high blood pressure), Atrial Fibrillation (irregular rapid heart rate). During a review of Resident 49's POLST, signed July 6, 2021, Section D - Information and Signatures regarding Advance Directives, was unanswered. During a concurrent interview and record review with the SSD, on February 10, 2022, at 4:55 PM, the POLST, signed July 6, 2021, was reviewed. The POLST indicated Section D was left unanswered. The SSD stated that Section D was not complete, and she had not inquired about Advance Directives to Resident 49 or family members. During a concurrent interview and record review on February 14, 2022, at 8:35 AM, with the SSD, the facility's policy and procedure (P&P) titled, Advance Directives, revised April 2013, was reviewed. The P&P indicated, 3. Prior to, or upon admission of a resident, the Social Services Director or designee will inquire of the resident and/or his/her family members, about the existence of any written advance directives., and 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The SSD stated that the policy was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide one of three sampled residents (Resident 154) with beneficiary liability protection notifications (notification letter/s which explain resident rights regarding financial liability and the right to appeal) when the resident was discharged from Medicare Part A services (services covered by insurance payer) on August 12, 2021. This failure had the potential for Resident 154 to be uninformed regarding his specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal. Findings: A review of Resident 154's admission Record, (contains demographic and medical information), the admission Record indicated Resident 154 was initially admitted on [DATE], with diagnoses which included complete traumatic amputation at knee level, dysphagia (difficulty swallowing), aphasia (loss of ability to understand or express speech), contracture, anxiety disorder, muscle wasting and atrophy (loss of muscle mass), and major depressive disorder. During a review of the facility document titled, [Name of facility] - Beneficiary Notice, undated, the document indicated Resident 154 was discharged from Medicare Part A services on August 12, 2021, with 17 benefit days left in the facility. The document also indicated the resident remained in the facility. During a review of the facility document titled, [Name of facility] Census List, Dated February 14, 2022, the census list indicated Resident 154 remained in the facility from August 13, 2021, through December 13, 2021. During a review of the facility document untitled and undated, in Resident 154's Electronic Health Record (EHR), the document indicated Resident 154 had Medicare A as the Primary Payer on July 30, 2021. Further review of the document indicated the Primary Payer changed to IEHP-CCI-LTSS-MCal (name of new insurance payer) on August 13, 2021. The document further indicated, Level of Care from July 30, 2021, through August 12, 2021, the services provided were Y [yes] under the question, skilled? and the level of Care, from August 13, 2021, through December 12, 2021, the services provided were N [no] under the question Skilled? During an interview on February 14, 2022, at 11:24 AM, with the Business Office Manager (BOM), the BOM, reviewed Resident 154's records. The BOM stated Resident 154 had his last covered day for Medicare Part A services on August 12, 2021. The BOM stated on August 12, 2021, Resident 154 should have been given the beneficiary notifications, but she was unable to find documented evidence that they were provided to him. The BOM stated the two beneficiary notifications which should have been provided to Resident 154 were the Skilled Nursing Facility Advance Beneficiary of Non-coverage (SNF ABN) CMS 10055 and the Notice of Medicare Non-coverage (Form CMS 10123-NOMNC) forms. The BOM stated the business office was the department which oversaw the beneficiary notifications and ensured they were provided to the residents when indicated. During an interview on February 14, 2022, at 11:38 AM, with the BOM, the BOM stated resident 154 remained in the facility as a custodial resident from August 13, 2021, through December 12, 2021. During an interview on February 14, 2022, at 12:14 PM, with the Director of Nursing (DON), when asked about the process for providing beneficiary notifications to residents, the DON stated she deferred all questions regarding beneficiary notifications to the business management office because they were the ones who managed the process. During an interview on February 14, 2022, at 11:36 AM with the BOM, the BOM stated the facility did not have a policy and procedure regarding beneficiary notifications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for two of 20 sampled residents (Resident 13 and 19) when: 1. Resident 13's RAI-MDS submitted by the facility on November 8, 2021, did not indicate the resident had weight gain, but instead had listed weight loss. 2. Resident 19's RAI-MDS submitted by the facility on December 1, 2021, inaccurately indicated the resident did not use tobacco products. These failures in MDS coding had the potential to result in unmet care needs for Residents 13 and 19, which can potentially jeopardize their health and safety. Findings: 1. During a review of Resident 13's admission Record (clinical record with demographic information), the admission Record indicated, Resident 13 was admitted to the facility on [DATE], with diagnoses which included chronic congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), type 2 diabetes mellitus ( a condition where body does not produce enough insulin), COPD ( chronic bstructive pulmonary disease-a group of lung diseases that make difficult to breath), anxiety disorder, chronic kidney disease, Human Immunodeficiency Virus (HIV), hypertension (high blood pressure), atrial fibrillation (irregular rapid heart rate). During a concurrent observation and interview on February 8, 2022, at 5:39 PM, Resident 13 resident was sitting at the edge of the bed, eating dinner. Resident 13 stated that he had good appetite and had not lost weight. During a review of Resident 13's IDT ( Interdisciplinary team- a group of clinical staff) Weight Management Assessment, dated November 4, 2021, indicated that Resident 13 gained twenty-one pounds (16%) in six months and there was no significant weight changes for thirty and ninety days. During a review of Resident 13's RAI-MDS Assessment, dated November 8, 2021, section K0300 Weight Loss, indicated Resident 13 had a weight loss of 5% or more in the last month or 10% or more in the last six months. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on February 10, 2022, at 2:50 PM, she reviewed Resident 13's clinical record and the RAI-MDS assessment dated [DATE]. The MDSC stated Resident 13's clinical record had no documentation indicating the resident had lost weight and the MDS section K0300 was incorrect, and facility used the current RAI manual to complete RAI-MDS assessments. During a concurrent interview and record review with the Director of Nursing (DON), on February 10, 2022, at 2:59 PM, she reviewed Resident 13's clinical record and the RAI-MDS assessment dated [DATE]. The DON stated the MDS section K0300 was incorrect, and the correct section should be MDS K0310, which indicated Resident 13's weight gain. A review of the MDS 3.0 RAI Manual titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1, dated October 2019, section K0300: Nutritional Approaches, indicated Steps for Assessment - This item compares the resident's weight in the current observation period with his or her weight at two snapshots in time: At a point closest to 30-days preceding the current weight and at a point closest to 180-days preceding the current weight. 2) A review of Resident 19's admission Record, indicated, Resident 19 was admitted on [DATE], with diagnoses which included muscle wasting and atrophy (decreased muscle mass), major depressive disorder, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). During an interview on February 8, 2022, at 11:00 AM, with Resident 19, Resident 19 stated she smoked daily and had been a smoker the entire time she lived at the facility. During a review of the facility document titled, List of Patients Who Smoke, undated, the document indicated Resident 19 was a smoker at the facility. During a review of Resident 19's smoking assessment (an assessment to determine safety risk for residents who smoke), dated November 26, 2021, the smoking assessment indicated Resident 19 could light her own cigarette, needed a smoking apron (a fire-retardant apron used to prevent any hot ash from burning resident's clothes), and supervision. During a review of Resident 19's care plan, dated November 26, 2021, the care plan indicated, .is a smoker resident is non-compliant with smoking apron . During a review of Resident 19's RAI-MDS assessment, dated December 1, 2021, the MDS section J1300 (current tobacco use) indicated no which indicated the resident did not use tobacco. During a concurrent interview and record review on February 10, 2022, at 3:37 PM, with the Director of Nursing (DON), Resident 19's RAI-MDS assessment, dated December 1, 2021, was reviewed. The DON stated section J1300 was incorrectly coded by the Minimum Data Set Coordinator (MDSC). The DON further stated the section should have indicated Resident 19 used tobacco. During a concurrent interview and record review on February 10, 2022, at 3:43 PM, with the MDSC, Resident 19's RAI-MDS assessment, dated December 1, 2021, was reviewed. The MDSC stated she was the one who completed the RAI-MDS for Resident 19 and confirmed section J1300 indicated no for the resident's use of tobacco. The MDSC stated she incorrectly completed the section and should have looked more closely at the resident's records. The MDSC further stated she used the current version of the RAI manual for instructions regarding how to complete each section of the RAI-MDS assessment. A review of the MDS 3.0 RAI Manual titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.17.1, dated October 2019, section J1300: Current Tobacco Use, indicated, 1. Ask the resident if he or she used tobacco in any form during the 7-day look-back period. 2. If the resident states that he or she used tobacco in some form during the 7-day look-back period, code 1, yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 29) had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) next to his bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident). This failure had the potential for the resident to sustain an injury during a fall in which the severity of the injury may have been lessened had the fall mat been in place. Findings: 1. During a review of Resident 29's admission Record (clinical record with demographic information), the admission Record indicated, Resident 29 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection, epileptic seizures (convulsions), muscle wasting and atrophy (loss of muscle mass), encephalopathy (disease or damage to the brain causing an altered mental state), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). During a review of Resident 29's fall risk assessment (a document used to determine if a resident was at risk for falls), dated September 3, 2021, indicated Resident 29 was at risk for falls. During a review of Resident 29's care plan, dated September 3, 2021, the care plan titled, The resident is at risk for falls r/t [related to] right sided weakness, dx [diagnosis] of seizure, use of meds [medications] . Interventions for this care plan included, follow facility fall protocol. During a review of Resident 29's care plan, dated January 4, 2022, the care plan indicated, Unwitnessed fall on 1/3/22 [January 3, 2022]: Resident found on the floor next to bed .fall mat on one side of bed . During a concurrent observation and interview on February 9, 2022, at 3:07 PM, with Certified Nursing Assistant 3 (CNA 3), in room [ROOM NUMBER] bed B, Resident 29 was observed to be lying in his bed. There was no floor mat on either side of his bed. CNA 3 confirmed Resident 29 did not have any floor mats next to his bed. CNA 3 further stated she was familiar with Resident 29's care and Resident 29 was brought into room [ROOM NUMBER] about two weeks ago and she (CNA 3) did not see a fall mat next to Resident 29's bed for the entire two weeks. When asked if Resident 29 was at risk for falls, CNA 3 stated she did not think so, because if the resident was a fall risk, he would have had a fall mat next to his bed. During a review of the facility document titled, Falls in the last 4 months, dated October 8, 2021, through February 8, 2022, the Falls in the last 4 months indicated Resident 29 had a fall on December 3, 2021, and January 4, 2022. During a review of Resident 29's progress notes, dated January 6, 2022, the progress note indicated, .Resident had unwitnessed fall on 1/3/22 [January 3, 2022] resident was found on the floor on a sitting position. Resident unable to state cause of the incident. Call light was not activated and is within reach . During an interview on February 9, 2022, at 3:25 PM, with the Director of Nursing (DON), the DON reviewed Resident 29s electronic health record. The DON stated Resident 29 had a care plan for falls and was supposed to have a fall mat next to his bed. The DON further stated Resident 29 had a room change on January 3, 2022 (37 days prior to observation of resident without floor mat) and stated she thought maybe the resident's floor mat was not implemented with the room change. During a review of the facility's policy and procedure titled, Falls - Clinical Protocol, revised September 2012, the policy indicated, Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .Monitoring and follow-up .2.b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff followed the physician's order as evidenced by the blood sugar testing and insulin (medication to control blood sugar) administration record were not completed for one of 20 sample residents (Resident 252). These failures resulted in poor coordination of care and had the potential to cause diabetes complications that can negatively affect Resident 252's health such as high or low blood sugar, and diabetic neuropathy (a common and serious complication of diabetes that damage nerves). Findings: During a review of Resident 252's admission Record (Patient demographic), not dated, the admission Record indicated, Resident 252 was admitted into the facility with diagnoses including diabetes (a condition when the body cannot control blood sugar), anxiety disorder, and hypertension (high blood pressure). During a concurrent observation and interview on February 8, 2022, at 9:30 AM, in room [ROOM NUMBER], Resident 252 was lying in bed. Resident 252 stated, he did not know all his medications. During a review of the Resident 252's Order Summary Report, dated February 2, 2022, through February 28, 2022, the Order Summary Report indicated, a finger blood sugar check was ordered to be performed three times a day (TID) before meals and to give insulin based on a blood sugar result. During a concurrent interview and record review on February 14, 2022, at 9:45 AM, with a Licensed Vocational Nurse (LVN) 1, in the nursing station, Resident 252's Medication Administration Record (MAR), dated February 2022, was reviewed. The MAR indicated, the blood sugar testing and insulin administration record were not completed, on February 7, 2022, at 11:30 AM. LVN 1 stated, Resident 252 had an order to check the blood sugar TID before meals and insulin administration based on the blood sugar result. LVN 1 confirmed, he did not see the blood sugar check and insulin administration record, on February 7, 2022, at 11:30 AM. LVN 1 stated, he wanted to go through the chart and see documentation to explain about the tasks not completed. A follow-up interview on February 14, 2022, at 10:45 AM, with LVN 1, LVN 1 stated, he was unable to provide documentation to indicate the reason of missing blood sugar check and insulin administration record, on February 7, 2022, at 11:30 AM, as ordered. LVN 1 confirmed, staff did not follow the physician's order to check the blood sugar and document on the insulin administration record. During a concurrent interview and record review on February 14, 2022, at 2:55 PM, with the Director of Nursing (DON), in the DON's office, the DON stated, staff had to document on the MAR the reason for holding medication at the date and time scheduled. The DON confirmed, staff did not follow the facility's policy and procedure (P&P) for medication holds. A review of the facility's P&P titled, Administering Medication, revised December 2012, indicated the following: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . A review of the facility's P&P titled, Medication Holds, revised April 2007, indicated the following: Policy Statement: Temporary medication holds may be ordered by the resident's Attending Physician. Policy Interpretation and Implementation: 1. A hold order for a medication must be accompanied by a restart date or time. Hold orders without a restart date or time will be considered discontinued. 2. When medications are held, they must be stored in a separate location in the medication room or returned to the issuing pharmacy. 3. The nursing staff must document in the resident's medication administration record (MAR) that such medication(s) is being held .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a resident's weight on admission for one of 20 sampled residents (Resident 13). This failure had the potential to negatively affect Resident 13's health such as inaccurate assessment of nutritional status and fluid balance, and wrong medication quantities on weight-based medication dosing. Findings: During a review of Resident 13's admission Record (Patient demographic), not dated, the admission Record indicated, Resident 13 was re-admitted into the facility on February 4, 2022, with diagnoses including diabetes (a condition when the body cannot control blood sugar), anxiety disorder, and chronic kidney disease (a condition when kidneys do not work normally). During an observation on February 8, 2022, at 5:59 PM, in room [ROOM NUMBER], Resident 13 was having a regular diet dinner without any assistance. During an interview on February 10, 2022, at 9:10 AM, with the Director of Nursing (DON), in the DON's office, the DON stated, all residents were expected to have their weight measured and documented upon admission by a Restorative Nursing Assistant (RNA). During a concurrent interview and record review on February 10, 2022, at 2:15 PM, with an RNA 1, in the Director of Rehabilitation's office, Resident 13's Monthly Weight Report, dated February 2022, was reviewed. There was no weight documented in February 2022. RNA 1 stated, RNAs would be responsible to weigh every resident upon admission, monthly, and any additional as needed per the physician's order. RNA 1 stated, Resident 13 was admitted into the facility on late Friday, February 4, 2022. RNA 1 further stated, Resident 13 should have been weighed over the weekend, but was unable to provide documentation or reason the admission weight was not completed for Resident 13. A concurrent follow-up interview and record review on February 10, 2022, at 2:59 PM, with the DON, in the DON's office, Resident 13's Monthly Weight Report, dated February 2022, was reviewed. The DON stated, there was no weight documented for Resident 13 upon admission on [DATE]. The DON confirmed, the facility's policy and procedures (P&P) was not followed. A review of the facility's P&P titled, Weight Assessment and Intervention, revised September 2008, indicated the following: Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation: Weight Assessment 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical records for two residents (Residents 29 and 49) were complete when Restorative Nursing Assistant (RNA) services (services from health-care professionals who are responsible for providing restorative and rehabilitation care for residents) were not documented in the Residents' medical records for January 2022, and February 2022. This failure resulted in Resident 29 and 49 to have incomplete medical record documentation which led to inaccurate records of services provided to the residents, and the residents' progress or decline not being identified timely. Findings: During a review of Resident 29's admission Record, (record with medical and demographic information), undated, the admission Record indicated Resident 29 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection, epileptic seizures (convulsions), muscle wasting and atrophy (loss of muscle mass), encephalopathy (disease or damage to the brain causing an altered mental state), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). During a review of Resident 29's physician orders, dated January 12, 2022, the physicians orders indicated, RNA for sit to stand w/hemi walker [a type of walker which assists with mobility] QD [every day] 3x/week [three times a week] for 10 repetitions or as tolerated by patient. During a review of Resident 29's Restorative Nursing Flowsheet [Flowsheet-a record where RNA services is documented], dated January 1, 2022, through January 31, 2022, the Flowsheet had no documentation of RNA services provided to Resident 29 from January 20, 2022, through January 31, 2022 (12 consecutive days). The Flowsheet was blank for those dates. There was no other documented evidence of RNA services in the medical record for January 2022. During a review of Resident 29's Restorative Nursing Flowsheet, dated February 1, 2022, through February 28, 2022, the Flowsheet had no documentation of RNA services provided to Resident 29 from February 1, 2022, through February 10, 2022 (the date of review). There was no other documented evidence of RNA services in the medical record for February 2022. During a review of Resident 49's admission Record, undated, the admission Record, indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included heart failure, muscle wasting and atrophy (loss of muscle mass), Hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). During a review of Resident 49's physician orders, dated December 21, 2021, the physicians order indicated, .RNA to do AAROM [Active Assisted Range of Motion] on bilateral [both] upper extremities up to 15 reps [repetitions] x 3 sets daily 5 per week as tolerated. Every day shift. Upon Further review of Resident 49's physicians orders, there was an order dated December 21, 2021, which indicated, RNA to do AAROM on bilateral lower extremities up to 15 reps [repetitions] x 3 sets daily 5 x [five times] per week as tolerated. Every day shift. During a review of Resident 49's Restorative Nursing Flowsheet, dated January 1, 2022, through January 31, 2022, the Flowsheet had no documentation of RNA services provided to Resident 49 from January 13, 2022, through January 31, 2022 (19 consecutive days). The Flowsheet was blank for those dates. There was no other documented evidence of RNA services in the medical record for January 2022. During a review of Resident 49's Restorative Nursing Flowsheet, dated February 1, 2022, through February 28, 2022, the Flowsheet had no documentation of RNA services provided to Resident 49 from February 1, 2022, through February 10, 2022 (the date of review). There was no other documented evidence of RNA services in the medical record for February 2022. During a concurrent interview and record review on February 10, 2022, at 3:03 PM, with Restorative Nursing Assistant 1 (RNA 1), RNA 1 stated the restorative nursing services provided to each resident was documented on the Restorative Nursing Flowsheet. Resident 29 and Resident 49's Restorative Nursing Flowsheets, dated January 2022, and February 2022, were reviewed. RNA 1 stated she had performed RNA services with both Resident 29 and Resident 49 but had been having trouble documenting the services concurrently when the services were provided to the residents. RNA 1 stated she had not been able to document consistently in January and February 2022 and that she was supposed to document concurrently but did not. During an interview on February 10, 2022, at 3:32 PM, with the Director of Nursing (DON), the DON stated her expectation was that the RNA's were supposed to document all RNA services provided to the residents concurrently in the medical record. During an interview on February 10, 2022, at 3:53 PM, with the Director of Staff Development (DSD), the DSD stated she had general oversight of the RNA services and the RNA staff was supposed to document RNA services provided to residents concurrently in the residents' medical record. During an interview on February 14, 2022, at 11:00 AM, with Resident 49, Resident 49 stated that he was currently receiving RNA services five days a week and that the staff work with both his upper and lower extremities each time. During a review of the facility's policy and procedure titled, Charting and Documentation, revised July 2017, indicated, Policy Statement. All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the residents medical record.

Based on interview and record review, the facility failed to ensure two staff members (Certified Nursing Assistants- CNA 4, and CNA 5) unvaccinated for COVID-19 (an illness caused by a virus), were tested for COVID-19 twice a week as specified by the facility's policy and procedure during the week of January 23, 2022. This failure had the potential to compromise the health and safety of all residents residing within the facility by increasing the risk of exposure to COVID-19 by not performing screening testing of unvaccinated staff entering the facility. Findings: During an interview on February 14, 2022, at 8:56 AM, with the Administrator (ADMIN), the ADMIN stated the facility used the public health order, dated August 5, 2021, as their guidance for COVID-19 testing. The ADMIN further stated staff with COVID-19 vaccination exemptions were supposed to be tested two times a week. During a concurrent interview and record review on February 14, 2022, at 8:57 AM, with the Infection Prevention Nurse (IPN), an electronic log (with no title and undated) used by the facility to track and monitor staff COVID-19 testing, was reviewed. The log indicated CNA 4 and CNA 5 were not vaccinated and had exemptions from receiving the COVID-19 vaccine. The log indicated CNA 4's exemption was dated September 29, 2021, and CNA 5's exemption was dated January 18, 2022. The log further indicated both CNA 4 and CNA 5 only tested on e time during the week of January 23, 2022. The IPN stated both staff members were full time employees at the facility and should have tested for COVID-19 two times during the week of January 23, 2022, but did not. During a concurrent interview and record review on February 14, 2022, at 11:29 AM, with the IPN, the IPN provided timecard records (untitled), dated January 23, 2022, through January 29, 2022, for CNA 4 and CNA 5. The timecard records indicated both CNA 4 and CNA 5 worked four shifts each at the facility that week. The IPN stated both staff members should have tested two times for COVID-19 during the week of January 23, 2022, or submitted testing results from an outside vendor, or should have been removed from the schedule until testing was completed. The IPN stated the facility used All Facility Letter (AFL- a document with written guidance from the California Department of Public Health) AFL (All Facilities Letter) 21-28.2 as their policy regarding staff COVID-19 testing and it was not followed. The IPN further stated she had general oversight and responsibility for the testing and vaccination of the staff. During an interview on February 14, 2022, at 11:46 AM, with the IPN, the IPN stated she was unable to find documented evidence of why CNA 4 and CNA 5 did not test two times for COVID-19 during the week of January 23, 2022. During an interview on February 14, 2022, at 2:05 PM, with CNA 4, CNA 4 stated she could not remember if she tested two times during the week of January 23, 2022. During an interview on February 14, 2022, at 3:39 PM, with the Director of Nursing (DON), the DON reviewed the facility's electronic log (with no title and undated), used by the facility to track and monitor staff COVID-19 testing, was reviewed. The DON stated both CNA 4 and CNA 5 should have been tested two times for COVID-19 during the week of January 23, 2022, through January 29, 2022, but they were not. During a review of the facility's policy and procedure titled, AFL 21-28.1 Coronavirus Disease 2019 (COVID-19) Testing, Vaccination Verification and Personal Protective Equipment for Health Care Personnel (HCP) at Skilled Nursing Facilities (SNF) [previous version of AFL 21-28-2 which was in effect the week of January 23, 2022] dated December 27, 2021, indicated, Updated Routine Diagnostic Screening Testing of Unvaccinated Exempt or Booster Eligible HCP -HCP who are unvaccinated exempt or booster-eligible HCP who have not yet received their booster must undergo at least twice-weekly SARS-CoV-2 diagnostic screening testing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed safe infection control practice as evidenced by staff did not perform hand hygiene (cleaning hand) after touching contaminated (dirty) areas and before handling a resident's meal tray for one of 20 sampled residents (Resident 9). This failure had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to a vulnerable resident whose health conditions are already compromised. Findings: During a review of Resident 9's admission Record (Patient demographic), not dated, the admission Record indicated, Resident 9 was admitted into the facility with diagnoses including Corona Virus Infection (COVID 19-respiratory infection), hypertension (high blood pressure), and atherosclerotic (build-up of plaque or fat) heart disease (a condition of thickening inside the arteries wall). During an observation on February 8, 2022, at 5:50 PM, in the hallway, there were alcohol-based hand rub (ABHR) located by the entrance and outside Resident 19's room. Certified Nursing Assistant (CNA) 1 was observed to open the door push bar with bare hands, carried residents' drink tray and coffee inside, and used bare hands to turn off the alarm panel by the door. Licensed Vocational Nurse (LVN) 2 made a statement out loud, wash your hands. CNA 1 did not perform hand hygiene. CNA 1 picked up a cup of water from the resident's drink tray and placed a cup on Resident 19's dinner tray. A follow-up interview on February 8, 2022, at 5:55 PM, with CNA 1, in front of room [ROOM NUMBER], CNA 1 stated, he knew he had to wash his hands after touching dirty areas. CNA 1 further stated, he did not hear LVN 2's statement about hand washing. CNA 1 confirmed, he did not clean his hands with ABHR after touching the door push bar and the alarm panel before handling a resident's food tray, CNA 1 stated, I'm sorry. A follow-up interview on February 8, 2022, at 6:02 PM, with LVN 2, LVN 2 stated, she is a registry staff and new to this facility. LVN 2 stated, she tried to tell CNA 1 to wash his hands after she saw CNA 1 touched the door push bar and the alarm panel. LVN 2 further stated, she did not know CNA 1's name yet so he might not know when she tried to tell him to wash his hands. LVN 2 confirmed, CNA 1 should have washed his hands with ABHR after touching the door push bar and the alarm panel before handling residents' meal trays. During an interview on February 14, 2022, at 11:50 AM, with the Infection Prevention Nurse (IPN), the IPN stated, appropriate hand hygiene practices should be implemented and followed throughout all areas within the facility to prevent the spread of infection. The IPN stated, she was informed of the incident. The IPN further stated, staff should most definitely wash hands after touching the potential contaminated areas and before handling food. The IPN confirmed, staff did not follow the facility's policy and procedure (P&P) for hand hygiene. A review of the facility's P&P titled, Handwashing/Hand Hygiene, revised August 2015, indicated the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; n. Before and after entering isolation precaution settings; o. Before and after eating or handling food .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when: 1. One table mounted can opener was observed with rust (a reddish-brown brittle coating form on iron when is exposed to air and moisture) in the slide bar (used to adjust different can sizes) near the knife, and in the washer inside the slide bar. 2. The ice machine had a hard deposit of white-greenish-black buildup inside the ice machine. These failures had the potential to contaminate residents' food and cause foodborne illnesses to a population 49 of 51 medically compromised residents who received food from the kitchen. Findings: 1.During a concurrent observation and interview on February 7, 2022, at 10:01 AM, with the Dietary Services Supervisor (DSS), inside the kitchen, one table mounted can opener had rust in the slide bar near the knife, and in the washer inside the slide bar. The DSS stated that the can opener was considered a utensil and it had rust and was not clean. During an interview on February 9, 2022, at 8:14 AM, with the Dietary Aid 1 (DA 1), she verbalized the can opener was cleaned in the dishwasher and left to air dry after each use. During a concurrent interview and record review on February 10, 2022, at 9:23 AM, with the DSS, the facility's policy and procedure (P&P) titled, Sanitation, revised October 2008, was reviewed. The P&P indicated, .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . The DSS stated that facility did not follow the policy and rust can contaminate the food. During a concurrent interview and record review on February 10, 2022, at 9:40 AM, with the Registered Dietitian (RD), the facility's policy and procedure (P&P) titled, Sanitation, revised October 2008, was reviewed. The P&P indicated, .2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning ., The RD stated that the policy was not followed. During a review of the Food and Drug Administration (FDA) Federal Food Code 2017, 4-602.13, indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2. During a concurrent observation and interview on February 7, 2022, at 10:25 AM, of the ice machine with the Supervisor of Maintenance Services (SMS), inside the kitchen, the ice machine had hard deposits of a white-greenish-black buildup on top of a metal nut (a thick metal ring used to hold pieces of machinery together) attached to a clear plastic device located at the left front side inside the ice machine. The SMS stated that he sanitized the ice machine once a month and the last time he did was on January 21, 2022. The SMS further stated that he did not remember seeing that buildup in the machine when he sanitized it, and the machine was cleaned in August 2021 by a vendor company, per manufacturer's instructions. During a concurrent observation and interview on February 7, 2022, at 11:25 AM, of the ice machine with the SMS, inside the kitchen, the SMS removed the ice chute. The surveyor used a white paper napkin to wipe the tray and no residue was visible on the napkin. Afterward, the surveyor used a paper napkin to wipe on top of the metal nut and the clear plastic device located at the left front side of the ice machine and no residue was visible in the napkin. The SMS stated that he uses a solution of one ounce (oz- unit of volume) of bleach and diluted in a gallon of water to sanitize inside the ice machine, including the plastic and metal parts with a clean cloth and let air dry, according to the ice machine sanitation log. During an interview on February 7, 2022, at 12:30 PM, with the Dietary Services Supervisor (DSS), the DSS verbalized that a vendor cleans the ice machine every six months, and the SMS was responsible for sanitizing it every month and signing in the log. The DSS further stated that the part of the ice machine that contains the white-greenish-black buildup must be completely clean and without any stains. During a telephone interview on February 10, 2022, at 8:19 AM, with the [name of company] Ice Machine Technician (IMT), the IMT verbalized that no chlorine-based solution such as bleach shall be used to disinfect inside the ice machine, because it can cause rust when in contact with metal parts. The IMT further stated that it was recommended a nickel-safe sanitizer solution (cleaner solution formulated for remove scale deposits in ice machine) to be used. During a concurrent interview and record review with the SMS, on February 10, 2022, at 8:49 AM, Ice Machine Sanitation Log (Log), dated August 2008, was reviewed. The Log indicated that ice machine was sanitized on January 21, 2022. The Log indicated Procedure to Clean Ice Machine .5. After cleaning, rinse inside the bin with fresh water. Rinse again using a solution of 1 oz of bleach to 1 gallon of tepid water. The SMS stated that he follows the facility Log when cleaning the ice machine. During a review of the manufacture's guidelines titled [name of the company] Cleaning and Sanitizing an [name of the company] commercial Ice Machine, revised June 2015. The manufacture's guidelines indicated .it is important to use solutions that do not harm the ice machine. Never use cleaning or sanitizing solutions that contain Nitric Acid, Sulfuric Acid or any chlorine-base solution such as bleach, chlorine dioxide or any type of salts such as potassium chloride or sodium chloride These chemicals can attack the surface of the evaporator as well as other metal components causing corrosion and flaking. During a review of facility invoice [name of the company] number 79451, dated August 18, 2021, indicated that ice machine was cleaned and sanitized with a nickel safe cleaner. During a concurrent interview and record review on February 10, 2022, at 8:55 AM, with the SMS, the facility's policy and procedure (P&P) titled, Sanitation, revised October 2008, was reviewed. The P&P indicated, .12. Ice machine and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy . The SMS stated the facility did not follow the policy. During a concurrent interview and record review on February 10, 2022, at 9:40 AM, with the RD, the facility's policy and procedure (P&P) titled, Sanitation, revised October 2008, was reviewed. The P&P indicated, .12. Ice machine and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy . The RD stated that the policy was not follow and the ice machine must be clean and free of any residue inside and out. During a review of the FDA Federal Food Code 2017, 4-202.11, indicated, Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage and refuse when one of two lids on garbage receptacles, was not closed and there was trash on the ground. This failure had the potential to attracts pests. Findings: During a concurrent observation and interview on February 9, 2022, at 1:11 PM, with the Supervisor of Maintenance Service (SMS), in the garbage storage area, located outside the facility, one of two garbage containers was not closed, and there was trash on the ground between the containers. The SMS stated the garbage container lid should be closed to avoid pest infestation and trash must be inside the containers. During an interview on February 10, 2022, at 9:42 AM, with the Registered Dietician (RD), the RD verbalized the garbage containers should be closed always, because of the potential to attract pests. The RD also stated the trash should not be on the ground. During a concurrent interview and record review on February 10, 2022, at 9:45 AM, with the RD, the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised October 2017, was reviewed. The P&P indicated, .7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. The RD stated that facility did not follow the policy. During a review of the Food and Drug Administration (FDA) Federal Food Code 2017, 5-501.113, indicated, Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the food establishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 2, Resident 15 and Resident 10) medical record contained a completed advance directive. This failure had the potential to result in delaying treatment in an emergency. Findings: 1. During an observation on March 25, 2019 at 3:35 PM, Resident 2 was lying in bed under the covers dressed in gown. During a record review of the clinical record on March 27, 2019 at 12:57 PM, there was no documented evidence of a completed Advance Directive or POLST (Physician Order of Life Sustaining Treatment) in the chart at the nurse's station for Resident 2. During a concurrent interview with the Medical Records Director (MRD) on March 27, 2019 at 12:57 PM for Resident 2, the MRD confirmed there was not an advance directive in the chart. During a subsequent record review on March 28, 2019, Resident 2 was admitted on [DATE] with diagnoses which included: leg cast, physical deconditioning, cervical spine osteomyelitis (infection in the neck vertebra), pain management, hypertension (high blood pressure), deep vein thrombosis (blood clots in the vein) and a wound on the right buttock. Resident 2 had the capacity to understand and make decisions. The facility policy and procedure titled, Advance Directives dated 2001, indicated, 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 2. During an observation on March 27, 2019 at 12:03 PM, Resident 15 was lying in bed with the bed in low position and fall mats adjacent to the bed. During a record review of the clinical record on March 27, 2019 at 12:54 PM, there was no documented evidence that the physician completed the Advance Directive Section D Information and Signatures which requires: Physician name, Physician phone number, Physician license number, Physician signature and date. During an interview on March 28, 2019 at 11:40 AM with the MRD, she stated, I audit that too and follow up with the Social Services Director and the nurses. The MRD confirmed the physician had not signed the advance directive and completed Section D. During a subsequent record review on March 28, 2019, Resident 15's Advance Directive was signed on March 26, 2019 by her responsible party. Resident 15 was admitted on [DATE] with diagnoses which included: urinary tract infection, anemia, Type 2 Diabetes Mellitus, hypertension (high blood pressure), GERD (gastro esophageal reflux disease - acid reflux from the stomach), history of falling, muscle weakness, and altered mental status. Resident 15 does not have the capacity to understand and make decisions. The facility policy and procedure titled, Advance Directives dated 2001, indicated, 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The facility policy and procedure titled, Record Content Subject: Documentation Principles, dated April 2010, indicated, Resident's health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to the resident. 3. During an observation on March 26, 2019 at 3:39 PM, Resident 10 was receiving a tube feeding of Jevity at 60 cc/hour (cubic centimeters - a unit of measurement). Resident 10's head of bed was elevated and she was lying in bed on her back. During a record review of the clinical record on March 26, 2019 at 4:07 PM, there was no documented evidence of a completed Advance Directive or POLST (Physician Order of Life Sustaining Treatment) in the chart at the nurse's station for Resident 10. During an interview with the Medical Records Director (MRD) on March 28, 2019 at 11:45 AM for Resident 2, the MRD confirmed there was not an advance directive in the chart. During a subsequent record review on March 28, 2019, Resident 10 was admitted on [DATE] with diagnoses which included: hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke) on right non-dominant side, chronic pain syndrome, hypertension (high blood pressure), arteriosclerotic heart disease of coronary artery (plaque build-up in the major heart vessel), hyperlipidemia (high cholesterol), major depressive disorder, GERD (gastro esophageal reflux disease - acid reflux from the stomach), dysphagia (difficulty swallowing), gastrostomy tube (opening in the stomach through the abdomen for food by a tube). The facility policy and procedure titled, Advance Directives dated 2001, indicated, 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on observation, interview, and record review, the facility failed to report to the California Department of Public Health a fall resulting in major injury affecting the health and safety of one sampled resident (Resident 2). This failure to report an incident resulted in a violation of Title 22 which requires facilities to report unusual occurrences to CDPH within 24 hours. During an observation on March 25, 2019 at 3:21 PM, Resident 2 laid in her bed in a gown. A wheelchair and front wheel walker (FWW) were in the room near her bedside. During an interview on March 25, 2019 at 3:50 PM, Resident 2 stated she quit smoking because she had a fall in the smoking area. During an observation of the smoking area on March 28, 2019 at 2:12 PM, the smoking area had a tent covering (a veranda), a metal object for cigarette butts, four yellow parking curb marking the area, and a red picnic bench down a slope from the tented area. During a review of the clinical record on March 28, 2019 at 3:24 PM, the document titled, Nursing Progress Note, dated November 27, 2019 indicated Resident 2 went out to the smoking area at 4:45 AM accompanied by CNA 2. RN 2 noted CNA 2 came to her 10 minutes later reporting the fall. RN 2 assessed Resident 2 noting, the resident was in pain, a cut was on the left side of the forehead with a little bleeding and the left foot was under her. The progress note indicated 911 was called at 5 AM, Resident 2's responsible party and physician was notified at 6:30 AM. Another document titled, Nursing Progress Note, dated November 30, 2019 indicated Resident 2 was readmitted from [hospital name] after a fall with a diagnosis of right ankle fracture. Resident 2 was in a cast. During an observation on March 28, 2019 at 3:49 PM, the Director of Nurses sat at her computer reviewing the risk management and progress notes in the computer software application of an electronic health care record system. During a concurrent interview on March 28, 2019 at 3:49 PM, with the DON, she confirmed she could not locate any report to CDPH (California Department of Public Health) regarding Resident's 2 fall resulting in injury. When asked how the facility tracks reporting of incidents, the DON replied, I would put them under the action tab under risk management where we also put our IDT meeting notes. The DON stated she did not see anything in electronic health record about reporting the fall and would have to check with the Administrator to see what he had in his records. During an interview on March 28, 2019 at 4:06 PM, the Administrator stated, I have no record of a report to CDPH. I did not report it because it was a witnessed fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accuracy of resident assessment were completed for three of 17 sampled residents (Residents 2, 25, and 35) as evidenced by: 1. Resident 2's MDS (Minimum Data Set-a comprehensive assessment of a resident's needs), Section J (Health Conditions) was coded inaccurately and the PASRR (Preadmission Screening and Resident Review-an assessment for mental illness or intellectual disability) assessment was incomplete. 2. Resident 25's pre-dialysis care assessment was incomplete. 3. Resident 35's MDS Section N (medication) was coded inaccurately These failures had the potential of resulting in inaccurate development of resident care plans and not meeting the needs of the residents. Findings: 1a. During an observation on March 25, 2019 at 3:19 PM, Resident 2 laid in bed dressed in a gown under the covers. A wheelchair and front wheeled walker were near the bedside. During an interview on March 25, 2019 at 3:21 PM, Resident 2 stated she had a fall on November 27, 2018 at 5:30 AM in the smoking area near the red bench because she flipped over and broke her ankle. During a review of the clinical record on March 25, 2019 for Resident 2, Resident 2 was admitted on [DATE] with diagnoses which included: leg cast, physical deconditioning due to left trimalleolar (ankle) fracture from a mechanical fall (resident lost balance and fell), cervical spine (neck) osteomyelitis (infection of bone), pain management, hypertension (high blood pressure), deep vein thrombosis (DVT- blood clot in the leg) prophylaxis (prevention of blood clots). Resident 2 had the capacity to understand and make decisions. During a review of the clinical record on March 28, 2019, the reentry MDS (Minimum Data Set-a comprehensive assessment of a resident's needs), Section J (Health Conditions) dated November 30, 2018 was coded inaccurately in: a. Section J1700 Fall History on admission Part A, B, and C was left blank. These parts to Section J1700 should have been coded 1 as Yes. b. Section J1800 was left blank. This section should have been coded 1 as Yes. c. Section J1900 C was left blank. This section should have been coded 1 as Yes. During an interview on March 28, 2019 at 3:21 PM, the MDS nurse stated the entries were made by the prior MDS nurse who is no longer employed by the facility and should have been coded yes. The facility policy and procedure titled, Resident Assessment Instrument, dated October 2010, indicated, 2. The Interdisciplinary Assessment Team must use the MDS form currently mandated by Federal and State regulations to conduct the resident assessment .3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity .7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. 1b. During an observation on March 25, 2019 at 3:19 PM, Resident 2 laid in bed dressed in a gown under the covers. During a review of the clinical record on March 25, 2019 for Resident 2, Resident 2 was admitted on [DATE] with diagnoses which included: leg cast, physical deconditioning due to left trimalleolar (ankle) fracture from a mechanical fall (resident lost balance and fell), cervical spine (neck) osteomyelitis (infection of bone), pain management, hypertension (high blood pressure), deep vein thrombosis (DVT- blood clot in the leg) prophylaxis (prevention of blood clots). Resident 2 had the capacity to understand and make decisions. During a clinical record review for Resident 2 on March 27, 2019 at 12:56 PM, a PASRR (Preadmission Screening and Resident Review) level one assessment dated [DATE], was found in the chart and indicated in Section V Mental illness, question 27 suspected mental illness was left blank. By not completing question 27 the PASRR system inaccurately gave a negative assessment (not needing mental health services) for Resident 2. During an interview on March 28, 2019 at 11:06 AM, the MDS nurse stated the PASRR level one was transmitted by the previous administrator and confirmed question 27 was blank. The MDS nurse stated he remembered seeing a diagnosis of psychosis on the medication administration record and the last hospital admission record. During a subsequent clinical record review for Resident 2 on March 28, 2019, a quarterly MDS assessment dated [DATE], indicated in Section A1500 the resident did not have a serious mental illness requiring a PASRR level two evaluation and in Section I - Active diagnoses indicated Resident 2 had a psychotic disorder (abnormal thinking and perceptions causing the person to lose touch with reality) other than schizophrenia (chronic, severe mental illness that affects how people think, feel and behave). During an observation on March 28, 2019 at 3:31 PM, Resident 2 was yelling at the staff. During an interview on March 29, 2019 at 9:35 AM, an interview was attempted with Resident 2. Resident 2 became agitated and refused to answer any questions. The facility document titled, Guide to Completing the PASRR Level I Screening, dated May 2018, indicated, Level I - Positive if there is a diagnosed or suspected mental illness identified on the Level I Screening (at least one YES for questions 260-28 and at least one UNKNOWN or YES for questions 29-30), the case will be coded as Positive. The case state, resolution, and reason code fields will be blank on the Level 1 Screening for Positive cases. The Level I Screening will automatically be sent to the DHCS Contractor for a Level II prescreening call. Please periodically check the Level I Case list online for an update. 2. During an observation on March 25, 2019 at 11:23 AM Resident 25 was lying in bed. A fall mat was located adjacent to the bed on the right side. During a concurrent interview with Resident 25, he stated, I do not understand you. During a review of the clinical record for Resident 25, Resident 25 was admitted on [DATE] with diagnoses which included end stage renal disease (kidney failure), dependence on dialysis (the process of removing waste products and excess fluids from the body when the kidneys are not able to adequately filter the blood) , Type 2 Diabetes Mellitus with diabetic neuropathy (loss of peripheral nerve sensation), hyperlipidemia (high cholesterol), and cerebral infarction (stroke) with hemiplegia (paralysis on one side) on the left non dominant side. During an interview on March 28, 2019 at 8:27 AM with Resident 25's responsible party (RP-person who has legal authority to make health care decisions), the RP stated, He goes to dialysis on Tuesday, Thursday and Saturday. I go with him and follow him there. The dialysis staff asks me about his medications and blood pressure because it is not on the form. During a review of the clinical record on March 28, 2019 at 9:15 AM, the document titled, Dialysis Communication Record indicated the pain assessment was missing on the document for the following days: March 5, 2019, March 7, 2019, March 12, 2019, March 14, 2019 and March 19, 2019. The vital signs for March 2, 2019 were left blank on the document. The assessment for the arterial venous shunt (AV- a surgical grafting of a vein and artery) site for a bruit and thrill was not documented on March 7, 2019, March 14, 2019, and March 19, 2019. During an interview on March 28, 2019 at 9:21 AM, a Licensed Vocational Nurse (LVN 4) was asked about the assessment of the resident prior to dialysis. LVN 4 stated, Check for bruits/thrills (abnormal sound generated by turbuklent flow of blood in an artery), check for bleeding, check for redness, take vital signs (temperature, pulse, blood pressure, respirations and pain). When the LVN 4 was asked if the assessment would be complete if the pain or bruits/thrills were not filled out, LVN 4 stated, No, not completed. During an interview on March 28, 2019 at 9:32 AM, the Director of Nurses (DON) confirmed the missing entries for vital signs, pain, thrills/bruits. The DON stated the nurse assesses the resident by checking for a bruit/thrill, site access, check blood pressure and vital signs - temperature, respirations, pulse, pain and checks oxygen saturation if on oxygen. The DON acknowledged the nurses were not following the policy if the pain, vital signs, or bruit/thrill were not assessed and documented. During a review of the clinical record for Resident 25, the care plan titled, [name of resident] has renal insufficiency and requires hemodialysis (process of prurifying the blood when kidneys aqre not functioning propery) indicated under interventions, Monitor vital signs pre and post dialysis. The facility policy and procedure titled, Renal Dialysis, Care of Residents dated December 2013, indicated in, Standard 2. Access site care (fistula/graft) is checked for condition and patency every shift except on return from the dialysis unit .Routine Access Site Care Guidelines 2. Inspect total access site for color, warmth, redness, edema, pain and drainage once per shift. 3. Routine access checks for a bruit (a pulsation felt of blood flowing through the arteriovenous anastomosis) once per shift. If bruit changes in regularity and depth, NOTIFY PHYSICIAN IMMEDIATELY The facility policy and procedure titled, Documentation Principles, dated April 2010, indicated, Resident's health record shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each resident. 3. During an observation of Resident 35 on March 25, 2019 at 8:59 AM, she was lying in bed, awake and responded verbally to greetings. A review of Resident 35's clinical record indicated she was admitted on [DATE] with diagnoses of chronic kidney disease (kidneys are damaged and cannot filter blood leading to renal failure), anxiety disorder (feelings of worry or fear), and hypertension (high blood pressure). A review of admission MDS, with ARD (assessment reference date) of February 19, 2019, indicated that section N0410 (medication received) was coded (0) zero to reflect that Resident 35 did not receive antipsychotic (medication for treating psychosis) in the past seven days. A review of MDS, Section N0450 (antipsychotic medication review) was coded as one (1) to reflect response as in Yes which indicated antipsychotics were received on a routine basis only. During an interview with MDS Nurse on March 28, 2019 at 9:50 AM, the admission MDS was reviewed. MDS Nurse confirmed Resident 35 had no antipsychotic medication ordered. Section N0450 (medication) was coded as YES. MDS Nurse stated that was an error and should have been coded as NO. During a review of Resident 35's February 2019 recapitulation (summary of physician orders) with MDS Nurse, he confirmed that Resident 35 was not on any antipsychotic medication ordered since admission. A review of the MDS Section Z (Assessment Administration) was signed as completed by a licensed vocational nurse, on February 25, 2019 certifying the information entered in the MDS accurately reflected resident assessment. A review of the facility policy and procedure titled, Resident assessment Instrument, revised October 2010 indicated, Purpose of Assessment: .4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her the highest practicable level of functioning. 7. Certifying Accuracy: All persons who have completed any portion of the MDS Resident Assessment Instrument form must sign such document attesting to the accuracy of such information.

Based on observation, interview, and record review, the facility failed to ensure: a. Hardened brown food residue was cleaned off the top of the steam table b. Grey sticky residue was cleaned off the base of the food blender c. [NAME] and black particles of residue was cleaned off the top of the dishwasher machine These failures had the potential to contaminate food prepared in the kitchen or contaminate cleaned dishware that lead to a food borne illness. Findings: a. During an initial tour of the kitchen observation on March 25, 2019 at 8:18 AM, a brown, hard food residue was seen on the top of the steam table near the edges. During a concurrent interview with the Dietary Services Supervisor (DSS), she acknowledged the unclean equipment and stated, I will clean it off. b. During an initial tour of the kitchen observation on March 25, 2019 at 8:18 AM, a grey sticky substance was seen and felt on the base of the blender. During a concurrent interview with the Dietary Services Supervisor (DSS), she acknowledged the unclean equipment and stated, I will clean it off. c. During an observation on March 27, 2019 at 5:32 AM, black and brown particles of residue were on the top of the dishwasher machine. An air vent was directly above the dishwasher machine. During a concurrent interview with the DSS, when asked what was on top of the dishwasher machine, the DSS replied, It is from the vent they cleaned yesterday, we will clean it up. The DSS acknowledged black and brown residue was on top of the dishwasher machine. The facility policy and procedure titled, Cleaning Instructions: Food Preparation Appliances dated 2010, indicated, 6. Clean the outer surface of the appliance with a clean cloth that has been moistened with hot, soapy water. Follow with a hot water rinse. Do not immerse the base of the appliance in water.