Every finding on record at Bancroft Healthcare Center

Based on interview and record review, licensed nursing staff did not provide care according to professional standards for 1 of 3 sampled residents (Resident 1). Resident 1 had been prescribed oxycodone (narcotic) since 2024 and was in hospice (end-of-life care for a terminal illness.) When Resident 1 could no longer swallow her pills, facility staff did not have a plan in place to address withdrawal symptoms from the oxycodone.This resulted in Resident 1 experiencing unnecessary pain, agitation and distress.During a review of Resident 1's clinical document titled admission Record, the admission record indicated, the facility admitted Resident 1 on 12/14/2023 with multiple medical diagnoses including multiple fractures, cerebral infarction (stroke) and chronic pain syndrome. During a review of Resident 1's clinical document titled Physician's Order dated 4/7/2025, the document indicated, Resident 1 was admitted into hospice care with terminal diagnosis of Dysphagia (inability to swallow) due to cerebrovascular(stroke). During a review of Resident 1's clinical document titled MDS 3.0 Nursing Home Quarterly (NQ) Version 1.19.1 (Resident Assessment) dated 3/26/2025, the MDS indicated, Resident 1 was alert, could repeat the number of words presented to her and could identify the year and month. During a review of Resident 1's clinical document titled Order Summary Report dated 4/1/2025, the document indicated, staff were to administer Baclofen (muscle relaxant) 3 times per day, Lyrica (medication for nerve pain) 3 times per day and oxycodone 10 milligrams 4 times a day for pain management for Resident 1. During a review of Resident 1's clinical document titled Medication Administration Record (MAR), dated March 2025, the MAR indicated Resident 1 had received the medications Baclofen, Lyrica and Oxycodone every day in March and into April of 2025. Further review of the MAR showed the start date for the oxycodone was 1/2/2024. During a review of Resident 1's MAR dated April 2025, the MAR indicated Resident 1 was able to take the Baclofen and Lyrica the morning of 4/12/2025 but refused subsequent dosages. Further review of the MAR showed the last dose of oxycodone was administered on 4/11/2025 at 5 p.m. During a review of Resident 1's clinical document titled Progress Notes *NEW*, the progress notes indicated, on 4/12/2025 at 2:33 a.m., Resident 1 was Resting comfortably but arousable. No complaints of pain or discomfort. Review of the note dated 4/12/2025 at 11:07 p.m. showed Resident 1 Appeared to be (having) multiple (episodes of) confusions and episodes of screaming during shift. Resident 1 had Refused most of the medications, Morphine and Ativan given. (30 hours and 7 minutes since the last administered dose of oxycodone) (Morphine: pain medication) (Ativan: anti-anxiety medication) During a review of Resident 1's clinical document titled Pulse Summary indicated at 9:22 p.m. on 4/12/2025, Resident 1's pulse was elevated at 98. Her baseline range for April 2025 showed a pulse in the 60's and 70's. (normal range is 60-100) Review of the document O2 Sats Summary showed Resident 1's oxygen saturation at 9:22 p.m. on 4/12/2025 was 52% (amount of oxygen in the blood: normal range 95-100%) During further review of Resident 1 s progress notes showed the following: 4/13/2025 at 10:43 a.m. - Resident is having frequent episodes of restlessness, agitation and screaming. Resident is clearly in severe discomfort despite administering morphine and Ativan. 4/13/2025 at 1:50 p.m. - Resident is still in severe discomfort and distress. 4/13/2025 at 9:55 p.m. - Resident is in declining condition. Resident appears to be (having) episodes of confusion and screaming. There was nothing in the clinical record which showed the doctor had been notified regarding the screaming and abrupt discontinuation of the oxycodone. During a record review of the document Hospice admission Plan of Care dated 4/7/2025 indicated no plan had been put into place to address stopping the oxycodone and potential for withdrawal. During an interview on 7/16/2025 at 4:44 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN1 confirmed, on 4/12/2025 Resident 1 had refused most of her medications and was agitated. LVN 1 stated she had not notified the doctor regarding the screaming and abrupt stoppage of the oxycodone but stated she should have because Something was wrong with the medication. During an interview on 7/25/2025 at 2:06 p.m., with Director of Nursing (DON), DON confirmed there was nothing in the clinical record which showed the doctor had been notified regarding the abrupt stopping of the oxycodone and continued screaming. The DON also stated, Stopping Oxycodone suddenly can cause withdrawal symptoms and there had been no back-up plan or updated plan of care in place when Resident 1 could no longer swallow the oxycodone. During an interview on 7/28/2025 at 1:57 p.m., with DON, DON stated Resident 1 had not received the oxycodone on 4/12/2025 because she was getting lethargic and Could not swallow it. The DON stated signs of withdrawal included being Anxious, can't relax, irritable, restless, mood changes. During a review of Resident 1's clinical document titled Progress Notes *NEW* dated 4/14/2025 timestamped at 7:40 a.m., the progress note indicated Resident 1 was Sleeping with daughter and hospice nurse at bedside, occasional moaning noted, routine morphine given and Lorazepam (anti-anxiety medication)) with good result. (41 hours and 46 minutes since she was last described as Resting comfortably on 4/12/2025 at 2:33 a.m.) Record review of Resident 1's clinical document titled Progress Notes *NEW* dated 4/14/2025 showed Resident 1 passed away on 4/14/25 at 1:40 p.m. During an interview on 8/11/2025 at 11:05 a.m., with facility's consulting pharmacist (CP), CP stated You never want to stop oxycodone because of withdrawal. The CP stated best practice is to use something similar to alcohol withdrawal and typically there is a protocol that is used. The CP stated one option would have been for staff to slowly decrease the dosage of the oxycodone and consulted with a pain management group Especially as she developed swallowing issues. The facility's physician did not respond to a request for an interview. During a review of the facility's policy and procedure (P and P) titled HO: The Plan of Care dated 1/5/2023, the P and P indicated This plan will focus on identified problems, goals, and interventions and include all services necessary for the palliation and management of the terminal illness and related conditions. (HO: hospice) During a review of the facility's undated policy and procedure titled Narcotic Medication Monitoring indicated, if pain has not been adequately controlled, the Multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Record review of a National Institute of Health article indicated Abrupt cessation of short-acting opioids (e.g. Heroin, hydrocodone, and oxycodone) is associated with severe OWS (opioid withdrawal symptoms) that typically begin within 12 hours after a missed dose, peak at 36-72 hours, and gradually taper off over the following 4-7 days. Opioid withdrawal symptoms: aches/pain, muscle spasms/twitching/tension, tremor, abdominal cramps, nausea/spasms/twitching/tension, tremor, abdominal cramps, nausea/vomiting/diarrhea, anxiety/restlessness, irritability. [Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment. NIH: National Library of Medicine: January 31, 2019: pmc.ncbi.[NAME].nih.gov/articles/PMC5590307]

Based on observation, interview and record review, the facility failed to use the communication binder (a communication visual tool that is used to help residents communicate their needs) for three of three sampled non-English speaking or aphasic (a language disorder that affects how you communicate) residents (Resident 25, Resident 24, and 17) when: 1. Resident 25 and 24's communication binders were not used, and 2. Resident 17 did not have a communication binder. This failure had the potential for Residents 25, 24 and 17 not to understand and carry out activities of daily living (ADL). Findings: 1. During a concurrent observation and interview on 10/9/24, at 10:00 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 25's room, LVN 1 could not understand Resident 25 as Resident 25 spoke only in her native language. LVN 1 stated she could only communicate with Resident 25 through gestures and pointing. LVN 1 stated she did not know what language Resident 25 spoke. During a review of Resident 25's Admission Record, dated 10/10/24, indicated Resident 25 was admitted to the facility on [DATE] and the resident's primary language was [NAME] (language of the country [NAME]). During a concurrent observation and interview on 10/9/24, at 10:40 a.m., with the Director of Nursing (DON), in Resident 25's room, the DON found Resident 25's communication binder inside Resident 25's bedside table drawer. The DON stated the binder should be on top of the bedside table so it was easily seen and used by staff. During a review of Resident 24's Admission Record, dated 10/10/24, the record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity). The record further indicated Resident 24's primary language was Chinese. During a review of Resident 24's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/24, the MDS indicated Resident 24's cognition was mildly impaired. During a concurrent observation and interview on 10/9/24, at 10:09 a.m., with the DON, in Resident 24's room, the DON found Resident 24's communication binder inside Resident 24's bedside table drawer. During an interview on 10/10/24, at 10:30 a.m., with the Certified Nursing Assistant (CNA) 3, stated he could only communicate with the resident through gestures and pointing. CNA 3 stated he did not know that the resident had a communication binder. 2. During a review of Resident 17's Admission Record, dated 10/10/24, the record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses that included aphasia following cerebral infarction (aphasia is a disorder that affects how a person communicates, cerebral infarction is a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die). During a review of Resident 17's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/28/24, the MDS indicated Resident 17 only sometimes understood others and was only sometimes understood by others. During a concurrent observation and interview on 10/9/24 at 10:45 a.m., with the DON in Resident 17's room, the DON could not find Resident 17's communication binder. DON further stated Resident 17 was supposed to have the communication binder at bedside to be able to communicate needs. During a review of the facility's policy and procedure (P&P) titled (dignity and communication), indicated, . 6. Residents who speak a different primary language other than the primary language of the facility can use some of the following resources: a. translators, including language applications for real-time translations. b. language communication boards .

Based on observation, interview and record review, the facility failed to ensure two of two sampled residents' (Resident 4 and 21) rooms had comfortable and safe temperature levels. This failure had the potential to cause overheating in residents and discomfort during severe hot weather. Findings: During a review of Resident 4's Annual Minimum Data Set (MDS - Resident assessment and care guide tool), dated 5/24/24, the MDS indicated Resident 4's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 14 and indicated intact mental status. The MDS indicated Resident 4 was able to recall the correct year and month. The MDS indicated Resident 4 had clear speech, able to express her ideas and wants, and understood what others said to her. Resident 4's diagnoses included stroke. During a concurrent observation and interview on 10/08/24 at 8:03 a.m. Resident 4 laid in bed with loose-fitted clothes, awake and verbally responsive. Resident 4 stated her room was hot and uncomfortable in the afternoon despite the use of fan. Resident 4 stated her room temperature was 83 degree Fahrenheit ( F) at nighttime. Resident 4 stated she sweated through the night. Resident 4 said facility had no air conditioning. Resident 4 showed surveyor a table thermometer she kept at her bed side indicated room temperature was 80 F. Resident 4 said facility placed a fan in the hallway that blows hot air into her room. Resident 4 stated it was uncomfortable to sleep. During a facility tour on 10/08/24 at 8:51 a.m. with Environment Supervisor (ES), observed one big standing fan in the hallway next to Resident 4's room. The following rooms air temperature were checked: Resident 4's room was 80.4 F, room [ROOM NUMBER] was 78 F, room [ROOM NUMBER] was 80.9 F, room [ROOM NUMBER] was 81.3 F, room [ROOM NUMBER] was 80. F, and room [ROOM NUMBER] was 80.2 F. During an interview on 10/8/24 at 8:51 a.m. with ES, ES stated facility had no air-conditioning. ES stated Certified Nursing Assistants (CNAs) informed him that residents' room [ROOM NUMBER] and 12 were hot. ES stated he checked room temperature and placed a fan close to the room. ES stated he did not document the temperature readings for residents' rooms. During a review of Resident 21's Annual Minimum Data Set, dated dated [DATE], the MDS indicated Resident 21's Basic Interview of Mental status score was 14 and indicated intact mental status. The MDS indicated Resident 21 was able to recall the correct month and day of the week. The MDS indicated Resident 21 had clear speech, able to express her ideas and wants, and understood what others said to her. Resident 21's diagnoses included Asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). During a concurrent observation and interview on 10/08/24 10:01 a.m. with Resident 21, Resident 21 sat up in bed in her room, awake and verbally responsive. Resident 21 stated she wore loose clothing because it was hot in her room. Resident 21 stated at night she opened up all the windows in her room. Resident 21 stated it was uncomfortable to sleep. During an interview on 10/8/24 at 9:21 a.m. with the Administrator (Admin), Admin stated she was aware that facility had no air conditioning. Admin stated she was concerned and provided in service to the staff about heat wave and what to do. Admin stated she discussed her concern with the management. Admin said facility will address what to do for nighttime heat. During an interview on 10/08/24 at 12:05 p.m. with CNA 1, CNA 1 stated over the weekend room [ROOM NUMBER] was very hot on Saturday. CNA 1 stated the fan in resident room [ROOM NUMBER] was faulty and was not working. CNA 1 stated she asked laundry staff but there was no available replacement fan. CNA 1 stated she did not notify the charge nurse that room [ROOM NUMBER]'s fan was not working, and no replacement fan was available. CNA 1 stated she kept the residents' comfortable with light clothing. During an interview on 10/08/24 at 12:10 p.m. with the Operations Manager (OPM), OPM stated the facility was an old building and did not have air-conditioning. OPM stated he had discussed issue of heat with the owner with consideration for installing air conditioning. During a review of the National Weather Service (NWS) Advisory Hazardous Heat Warning, dated 10/5/24, the NWS indicated, Hazardous heat will be ever present this weekend. Dangerously hot conditions with temperatures up to 105 F. Excessive heat warning remains in effect for Alameda, Contra [NAME], San Francisco and Santa [NAME] counties. {Reference : https://x.com/NWSBayArea/status}. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, undated, the P&P indicated: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting. These characteristics include: comfortable temperatures.

Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for four out of 14 sampled residents (Residents 17, 2, 22 and 24). This failure had the potential for the facility to provide treatment and services against the residents' wishes. Findings: During a review of Resident 17's Admission Record, dated 10/8/24, the record indicated Resident 17 was admitted to the facility with diagnoses that included aphasia following cerebral infarction (aphasia is a disorder that affects how a person communicates, cerebral infarction is a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die). During a review of Resident 17's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/28/24, the MDS indicated Resident 17 had severe cognitive impairment. During a review of Resident 17's Physician Orders for Life-Sustaining Treatment (or POLST, a form that gives instructions for the resident's care in life-threatening medical situations) form, dated 5/22/24, the POLST indicated advanced directive not available. Further review of Resident 17's medical record did not contain a copy of an advanced directive. During a review of Resident 2's Admission Record, dated 10/8/24, the record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2's POLST form, dated 8/2/24, the form indicated Resident 2 had capacity to make decisions but indicated no information on the presence of an advanced directive. During an interview on 10/9/24, at 3:31 p.m., with Social Serviced Director (SSD), SSD acknowledged she was not able to follow up with Resident 2's advanced directives. During a review of Resident 22's Admission Record, dated 10/8/24, the record indicated Resident 22 was admitted to the facility on [DATE]. During a review of Resident 22's POLST form dated 2/16/23, the form indicated no information on the presence of an advanced directive. During a review of Resident 24's Admission Record, dated 10/8/24, the record indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 24's MDS dated [DATE], the MDS indicated Resident 24's cognition was moderately impaired. During a review of resident 24's POLST form dated 4/24/23, the form indicated no information on the presence of an advanced directive. During a concurrent interview and record review on 10/7/24, at 3:30 p.m., with SSD, Resident 17, 2, 22 and 24's medical records were reviewed. SSD stated advanced directives were discussed with the Resident 17, 2, 22, and 24's responsible parties, but SSD was not able to provide documentation. During an interview on 10/9/24, at 3:31 p.m., with SSD, SSD stated the importance of advanced directive was for the residents' wishes regarding health decisions to be honored. During an interview on 10/10/24, at 11:25 a.m., with the Director of Nursing (DON), the DON stated the importance of advance directives was to help ensure that the residents' wishes for medical care were carried out in case the resident becomes incapacitated. During a review of the facility's policy and procedure (P&P) titled (Advanced Directives), 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 advanced directives. 4. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. 5. If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision .

Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when: 1. One box of expired blood glucose test strips (small, disposable plastic strips that measure blood sugar levels) for Resident 137 was stored in the medication room, 2. A bottle of liquid Lorazepam (medication used to treat anxiety) which belonged to a deceased resident was stored in the refrigerator in the medication room, and 3. A bottle of expired Senna (laxative) tablets was stored in the medication cart 2. These failed practices could contribute to unsafe medication use in the facility. Findings: 1. During a concurrent observation and interview on 10/7/24 at 10:20 a.m. with the Director of Nursing (DON), one box of expired blood glucose test strips with an expiration date of 2/25/21 for Resident 137 was found stored in the medication storage room. DON stated the expired blood glucose strips should have been disposed. Review of Resident 137's Admission Record (AR) dated 10/10/24, indicated Resident 137 was admitted on [DATE] with diagnoses that included Diabetes Mellitus (a disease of inadequate control of blood levels of sugar). The AR indicated Resident 137 was discharged on [DATE]. Review of Resident 137's Physician's Order indicated an order with a start date of 2/28/20 of Sliding Scale Insulin before meals and bedtime (Insulin is a hormone that regulates blood sugar levels in the body. Sliding scale meant the insulin dose the resident would receive before the resident's meals and bedtime was based in the blood sugar level result). 2. During a concurrent observation and interview on 10/7/24 at 10:25 a.m. with the DON, one bottle of liquid Lorazepam that belonged to Resident 15 was found stored in medication room refrigerator. DON stated that the resident was already deceased . DON also stated the Lorazepam should have been disposed. Review of Resident 15's AR dated 10/10/24 indicated Resident 15 was admitted to the facility on [DATE]. The AR also indicated that Resident 15 expired on 9/27/24. Review of Resident 15's Physician's order indicated an order with a start date of 8/15/24, of Lorazepam 2mg./ml., give 0.5 ml. by mouth every 12 hours as needed (mg. is milligrams and ml. is milliliters, mg. and ml. are forms of measurement). 3. During a concurrent observation on 10/7/24 at 3:00 p.m. with the DON present, the medication cart 2 had a bottle of the medication Senna (laxative) tablets with an expiration date of 6/2023. During an interview on 10/10/24, at 11:25 a.m., with the DON, the DON stated the expired medications should have been disposed because the residents might suffer adverse side effects if they received the expired medications. During a review of the facility's policy and procedure (P&P) titled Medication Storage, Storage of Medication dated 2007, the P&P indicated, .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock disposed of according to procedures for medical disposal .

Based on observation, interview and record review, the facility failed to ensure one (Resident 18) sampled resident was free from unnecessary drugs when Resident 18 with diagnosis of Alzheimer Dementia was administered Seroquel (Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior) medication without adequate clinical indication for continued usage. This failure had the potential for Resident 18 to receive unnecessary medications and had the potential for the Resident 18 to suffer adverse medication side effects. Findings: During a review of Resident 18's Significant change in status-Minimum Data Set (MDS, Resident Assessment and care guide tool), dated 5/17/24, indicated Resident 18's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 18's score was 01 and indicated poor cognition. Resident 18 had no physical or verbal behavioral symptoms directed towards others e.g., hitting, kicking, pushing, scratching, grabbing or screaming at others. MDS indicated Resident 18 did not exhibit behavior of rejection of care. Resident 18's diagnoses included Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 1's Order Summary Report dated 3/2/24, the order indicated the physician prescribed Resident 18, Seroquel oral tablet 25 mg give one tablet by mouth two times a day related to unspecified dementia without behavioral disturbance, psychotic disturbances manifested by kicking/hitting to others. During a review of the Medication Administration Record (MAR), dated 9/1/24 to 9/31/24 indicated Resident 18 was administered Seroquel 25 mg one tablet by mouth two times a day related to unspecified dementia manifested by kicking/hitting others. During an observation on 10/7/24 at 10:08 a.m. Resident 18 sat up in bed awake, alert and non-English speaking. Resident 18 had a laptop on her and listened to non-English program. During an interview on 10/8/24 at 2:35 p.m. Social Service Director (SSD) stated Resident 18 had no behavioral symptoms of hitting or kicking. SSD stated Resident 18 attended activities every day and had supportive family that visited daily. During an interview on 10/8/24 at 2:40 p.m. with Certified Nursing Assistant (CNA 4), CNA 4 stated Resident 18 had no behavior of hitting or kicking during care. CNA 4 stated Resident 18 attended activities and her family visited every day During an interview on 10/09/24 at 9:16 a.m. with the Director of Nursing (DON), the DON stated she was informed by CNAs that Resident 18's behavior symptoms included kicking and hitting care giver during evening time. The DON stated Resident 18 did not have behavior all the time but it depended on from day to day. During a review of Resident 18's Preadmission Screening and Resident Review (PASRR) screening dated 1/25/24, the PASRR (Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.) indicated Resident 18 had no Serious Mental illness. According to the Seroquel manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g. heart failure, sudden death). [Reference: https://www.[NAME].com/seroquel]. During a review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Management undated, the P&P indicated Residents will not receive medications that are not clinically indicated to treat a specific condition. Antipsychotic medications will not be used if the only symptoms are one or more of the following; wandering, restlessness, impaired memory, inattention or indifference to surroundings, nervousness, uncooperativeness .

Based on observation, interview and record review, the facility failed to ensure one (Resident 7) sampled resident received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician when Certified Nursing Assistant (CNA 5) served Resident 7 a meal tray of pureed diet that belonged to Resident 13. This failure had the potential to cause residents to receive and consume foods that are not in the appropriate texture and nutrient content to support the resident's needs cause choking or food allergy. Findings: During a review of Resident 7's Significant change in status-Minimum Data Set (MDS - Resident assessment and care guide tool), dated 12/25/23, the MDS indicated Resident 7's was on a mechanically altered diet. Resident 7 needed partial to moderate assistance with eating. The MDS indicated Resident 7's diagnoses included Aphasia (a language disorder that affects a person's ability to communicate) and stroke. During an observation on 10/8/24 at 12:10 p.m. in the Dining Room (DR) there were six residents eating in the dining room. Observed Certified Nursing Assistants (CNAs) serving meal trays to residents. Residents started eating, light music played with activity staff present in the dining room. Resident 7 was served a tray of puree food by CNA 3. Resident 7 started to eat from the plate. During an observation on 10/8/24 at 12:25 p.m., CNA 2 came into the dining room with a meal tray, presented a meal tray to Resident 7, swapped his meal and left. During an interview on 10/8/24 at 12:26 p.m. with CNA 2, CNA 2 stated she swapped Resident 7's meal tray because Resident 7 was served Resident 13's meal tray. CNA 2 stated it was very important to check that the right resident received the correct meal tray for residents' safety. During a review of Resident 7's physician order dated 3/14/24, physician ordered Resident 7 to receive regular diet mechanical soft texture, thin consistency for increase fiber. During a review of Resident 13's physician order dated 6/9/21, the physician ordered Resident 13 to receive fortified diet pureed texture, honey consistency, related to dysphagia, oropharyngeal large portion. During an interview on 10/8/24 at 12:13 p.m. with CNA 3, CNA 3 stated it was important to check names to make sure the right resident received the right diet order. CNA 3 stated it was also important because some residents were diabetic or allergic to some food items. During an interview on 10/8/24 at 12:53 p.m. with the DON, the DON stated the facility's protocol was that licensed nurses were responsible to check meal trays before CNAs served residents. The DON stated CNAs should also check the names on the tray. The DON stated residents should receive the right diet as ordered to prevent choking or allergy. During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals undated, the P&P indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Facility staff will serve resident trays accurately and will help residents who require assistance with eating.

Based on observation, interview and record review, the facility failed to ensure one (Resident 32) sampled resident on tube feeding (Tube feeding refers to the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum. It is also referred to as an enteral feeding.) maintained acceptable nutritional status and body weight range when Resident 32's unplanned weight loss was not reevaluated with appropriate interventions by the Registered Dietician (RD), and the facility did not notify the physician and responsible party of Resident's 32 unplanned weight loss. This failure had the potential to result in Resident 32's dehydration and unplanned weight loss. Findings: During a review of Resident 32's Admission Minimum Data Set (MDS - Resident assessment and care guide tool), dated 7/29/24, the MDS indicated Resident 32's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 00 and indicated impaired mental status. The MDS indicated Resident 32 received nutrition through abdominal feeding tube Resident 32's diagnoses included stroke and Non-Alzheimer's Dementia ((a group of diseases characterized by progressive deficits in behavior, executive function, or language). During a review of Resident 32's Order Summary Report, dated 7/3/24, the order indicated, physician prescribed Resident 32 to receive tube feeding diet, tube feeding texture and NPO (nothing by mouth). Further review of Resident 32's order summary report dated 7/6/24 indicated physician prescribed Jevity (calorically dense, fiber-fortified therapeutic nutrition and liquid food) 1.2 kcal, 45 ml/hr. for 20 hours per day via continuous drip 4 hours off per day. Provide total volume of 900 ml, 1080 kcals, 50 grams protein and 725 ml free water. During a review of Resident 32's weight summary report, dated 7/3/24 through 10/7/24, the report indicated: 7/3/24 Resident 32 weighed 94 pounds (#) 7/9/24 Resident 32 weighed 92.5# 7/16/24 Resident 32 weighed 84# 7/23/24 Resident 32 weighed 84#. 7/30/24 Resident 32 weighed 83.5# 8/2/24 Resident 32 weighed 83.1# 9/6/24 Resident 32 weighed 81# 10/7/24 Resident 32 weighed 82# Further review of Resident 32's weight summary report dated 7/3/24 through 10/7/24, indicated: Resident 32 had weight loss of 7.5% or 10.5 # change comparison weight on 7/9/24 and 10% change weight comparison 12# weight loss in 3 months. During a concurrent interview and record review on 10/9/24 at 1:41 p.m. with Registered Dietician (RD), Resident 32's weight summary record dated 7/3/24 through 10/7/24 was reviewed. The weight report indicated Resident 32 had a significant weight loss of 10.5# comparison weight 7/9/24 and 12# weight loss in 3 months. RD stated Resident 32 was on tube feeding and had nothing by mouth. RD stated Resident 32 weight loss was unplanned weight loss. RD said she did not notice that Resident 32 had a weight loss. RD stated she had not reevaluated Resident 32 tube feeding intake. RD stated she was not informed of Resident 32's weight changes. During a concurrent interview and record review on 10/9/24 at 1:20 p.m. with Licensed Vocational Nurse (LVN 3), Resident 32's weight summary record dated 7/3/24 through 10/7/24 was reviewed. LVN 3 stated Resident 32 had significant weight loss. LVN 3 stated he did not notify the physician and responsible party of Resident 32's significant weight loss. LVN stated he believed the Director Of Nursing (DON) will follow up on weight loss. LVN 3 stated was supposed to notify the family and doctor. During a review of Resident 32's potential nutritional care plan, Resident 32's nutrition risk care plan did not address significant weight loss with appropriate interventions. During a concurrent interview and record review on 10/9/24 at 11:05 a.m. with DON, Resident 32's Progress Notes dated 7/3/24 to 10/3/24 was reviewed. DON stated there was no documentation that Resident 32's responsible party and physician were notified of significant weight loss. DON stated facility's protocol was for licensed nurses to notify family and physician. DON stated its important to notify physician to reevaluate residents' nutritional status and for residents to get adequate and proper nutrition. DON stated residents' family should be notified of weight loss because responsible parties have the right to know and may have input to support care. DON stated RD had the access to electronic record to review residents weight variances. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention undated, the P&P indicated, The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change have been met.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), accurately reflect the assessment status for two (Resident 4 and 12) of fourteen sampled residents when 1. Resident 4's MDS section G did not reflect limitation in range of motion to upper and lower extremities (hip, knee, ankle, foot), and 2. Resident 12's MDS section K did not reflect a significant weight loss. These failure had the potential for residents to not receive appropriate care and services. Findings: 1. During a review Resident 4's Admission Record (AR), AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of knee (the wearing down of the protective tissue at the ends of bones cartilage occurs gradually and worsens over time). During a review of Resident 4's care plan review date 9/11/24, the care plan indicated Resident 4 had limited physical mobility to upper and lower extremities related to weakness, osteoarthritis of knee and total care. During a review of Resident 4's Annual Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated 5/24/24, Section G indicated Resident 4 had no limitation in range of motion to upper and lower extremities. During a concurrent observation and interview on 10/9/24 at 12:15 p.m. with the Director of Nursing (DON), and Registered Nurse/MDS coordinator (RN 1), in Resident 4's room, Resident 4 laid in bed both feet elevated on pillow, awake and verbally responsive. Resident 4 stated her right foot dragged to the side when she laid in bed and had to call for assistance to pull her foot back to position. Resident 4 stated she needed exercise therapy. During a concurrent interview and record review on 10/9/24 at 12:25 p.m. with RN 1, Resident 4's MDS section G dated 5/4/24 was reviewed. MDS section G indicated Resident 4 had no limitation in range of motion to lower extremities. RN 1 stated Resident 4's MDS section G limitation in range of motion was not coded accurately. 2. During a review Resident 12's Admission Record (AR), AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included Dysphagia (difficulty swallowing). During a review of Resident 12's Annual Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated 7/29/24, Section K weight loss indicated, Resident 12 had no weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. During a concurrent interview and record review on 10/09/24 at 1:26 p.m. with the Registered Dietician (RD), Resident 12's Nutrition/Dietary Note, dated 7/18/2024 was reviewed. The Nutrition note indicated, Resident 12 had a significant 9.3-pound weight loss in 90 days (5.8%) in 90 days, significant 17.4-pound weight loss in 180 days (10.3%) in 180 days (from dates December 2023-June 2024). RD stated Resident 12 had significant weight loss in the last six months. During a concurrent interview and record review on 10/10/24 at 9:46 a.m. with the Dietary Manager (DM), Resident 12's weight record was reviewed. Resident 12's weight record indicated the following: 6/4/24 = 152.5 pounds (#), 7/2/24 = 143#, 8/2/24 = 147#, 9/3/24 = 138# and 10/1/24 = 128#. DM stated he was responsible for entering data for section K weight loss. DM stated Resident 12 had significant weight loss. DM stated MDS section K was not coded accurately. DM stated he did not calculate the weight variance correctly. During a review of the facility's policy and procedure (P&P) titled, MDS-Comprehensive Assessments undated, the P&P indicated, Comprehensive assessment are conducted to assist in developing person-centered care plans. A significant error is an error in an assessment where the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care.

Based on observation and interview, the facility had one residents' room (room [ROOM NUMBER]) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied this room. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings. Findings: During an observation on 10/8/24 at 12:14 p.m., in room [ROOM NUMBER], in the presence of Certified Nursing Assistant (CNA) 1, room [ROOM NUMBER]'s corresponding sq. ft per bed was identified: Room Floor Area 12 76.26 sq. ft During an observation on 10/8/24 at 12:14 p.m., room [ROOM NUMBER] had two beds with residents laid in bed awake and nonverbal. During a concurrent observation and interview on 10/8/24 at 12:15 p.m. with CNA 1 in room [ROOM NUMBER], CNA 1 stated there was enough space to conveniently provide care for residents in the rooms and for residents that needed Hoyer lift. CNA 1 stated bed was lowered and moved to use the Hoyer lift. CNA 1 stated there was no heavy equipment kept in the room that might interfere with residents' care and each resident had adequate personal space and privacy. There were no negative consequences attributed to the decreased space in room [ROOM NUMBER]. Granting of room size waiver recommended.

Based on interview and record review, the facility failed to inform residents in a language they understood of their rights, all rules and regulations governing residents conduct and responsibilities during their stay at the facility for nine of nine sampled residents (Resident 5, 6, 8, 11, 21, 24, 25, 27 and 133), who were identified as Chinese speaking residents. A California ombudsman essentially helps senior victims of abuse or neglect to understand their rights within the legal system and reach a proper resolution}. This failure had the potential to cause residents emotional distress and despair. Findings: Review of the admission record indicated Resident 21 was Chinese and their primary language is Chinese. Resident 21 was admitted to the facility on [DATE]. During a resident council meeting on 11/14/23 at 10:04 a.m., through a phone translator (PTL), Resident 21 stated he did not know who to talk to when he had grievances. Resident 21 stated he did not know about the Ombudsmen or their phone numbers. (A California Ombudsman essentially helps senior victims of abuse or neglect to understand their rights within the legal system and reach a proper resolution}. Through the PTL, Resident 21 stated the Ombudsman poster should be written not only in English but written in traditional and simplified Chinese language. During an interview and concurrent review of the Residents [NAME] of Rights, on 11/15/23 at 10:00 a.m., the Administrator (Admin) stated Resident 21's primary language is Chinese. Admin stated the Resident [NAME] of Rights provided to Resident 21 at the time of admission to the facility was in English and not in a language Resident 21 understood. Furthermore, Admin identified Residents 5, 6, 8, 11, 21, 24, 25, 27 and 133 as having Chinese as their primary language and were not informed of their bill of rights in a language they understood. Admin stated the facility will request for an Ombudsmen poster with Chinese translation.

Based on observation and interview, the facility failed to ensure storage of food under sanitary conditions when; - one carton of thickened Apple Juice from concentrate was opened with no use- by-date; - three containers of mayonnaise opened with no use-by-date; - five brownish, discolored juice cups ready for use; - one container of chopped garlic in oil opened with no use- by-date; - staffs' personal food items of tea, cooked eggs and cell phone were placed on the kitchen preparation table; - two bags of vegetables placed on the 2-compartment sink next to dishwashing area. These failures had the potential to result in food borne illness for residents who received food from the facility's kitchen. Findings: During the initial tour of the kitchen on 11/13/23 at 9:10 a.m., accompanied by the Dietary Manager (DM), the following were observed: one cartoon of thickened Apple Juice from concentrate was opened with no use- by-date; three containers of mayonnaise opened had no use-by-date; five brownish discolored juice cups ready for use, and one container of chopped garlic in oil opened with no use- by-date. During a follow up visit to the kitchen on 11/13/23 at 10:18 a.m., accompanied by DM, observed staffs' food items of tea, cooked eggs, cell phone placed on the kitchen table and two bags of vegetable were placed on the two compartment sink next to the dishwasher. During an interview on 11/13/23 at 10:18 a.m., DM stated the cooked eggs, cup of tea, and cell phone belonged to staff. DM stated staff are not allowed to eat in the kitchen. DM said the two-compartment sink are supposed to be used for dish washing during emergencies. During an interview on 11/14/23 at 11:31a.m., Cook (CK), CK stated the two-compartment sink was used for thawing food items, such as meat, vegetables etc. During an interview on 11/16/23 at 9:48 a.m., DM stated the kitchen did not have enough space for a food prep sink and that was the reason the vegetable and meat are thawed in the two- compartment sink.

Based on interview and record review, the facility failed to ensure one (Resident 24) sampled resident's Pre-Admission Screening Resident Review (PASRR) for serious mental illness was accurately completed and referred to the appropriate state mental authority for Level II evaluation and determination. This failure had the potential to prevent Resident 24 from receiving appropriate required mental health services. Findings: Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 10/13/23, indicated the PASRR was coded zero-meaning, Resident 24 was not considered by the State Level II PASRR process to have a serious mental illness. However, Resident 24's diagnoses included Bipolar disorder (mood disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the PASRR screening dated 9/13/22 indicated Resident 24 did not have a diagnosed mental disorder such as depression, anxiety, panic and/or mood disorder. During an interview and concurrent record review, on 11/14/23 at 11:10 a.m., with Registered Nurse/MDS coordinator (MDS), MDS stated the Administrator (Admin) or designee was responsible for completing the PASRR. MDS stated Resident 24's PASRR was not completed accuratelyand Resident 24 diagnosis included Bipolar disorder a mental illness. MDS further stated Resident 24 was not referred to the State Mental Authority for specialized mental health services. During an interview on 11/15/23 at 9:28 a.m., Admin stated he or the Business Office Manager completed the residents' PASRRs. Admin stated he did not recognize that Resident 24's diagnosis included Bipolar disorder when the PASRR was completed. Review of the facility's policy and procedure titled, PASRR Screening (undated), indicated the facility will complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals).

Based on interview and record review, the facility failed to implement the nutritional interventions for one (Resident 29) of one sampled resident with significant weight loss. This failure had the potential to result in continuous weight loss, fluid imbalance, and dehydration. Findings: Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 8/18/23, indicated Resident 29 had weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Resident 29 was not on a physician-prescribed weight-loss regimen. Resident 29 had diagnoses that included heart failure (e.g. congestive heart failure or CHF and pulmonary edema- a chronic condition in which the heart doesn't pump blood as well as it should) and diabetes mellitus (high blood sugar). Review of the weight and vital summary, dated 4/1/2023 through 11/30/2023, indicated Resident 29's weight record as follows: 4/2/23 - 89 lb 7/7/23 - 80 lb 10/1/23 - 75.9 lb 11/5/23 - 71.4 lb Review of the Nutrition/Dietary Notes dated 10/13/23, indicated Resident 29 has a significant weight loss of 7.4 lb weight loss in 90 days and 13.4 lb weight loss in 180 days. Resident 29 ate on average, 25% of meals during the last 14 days. Resident 29 refused 3 meals during the last 14 days. The interventions included a liberalized diet, provide magic cup (reduced sugar) daily, provide diabetic snack at hour of sleep, honor resident's food and beverage preferences, Med Plus 2.0 (4 oz) twice a day, provide high caloric snacks in between meals, Vitamin C 500 mg (milligram) or anemia, folate, iron, and B 12 supplements for anemia, check for dehydration signs and symptoms, fluids less or equal to 1,450 ml (milliliter) /day (CHF), 800 ml/day from nursing (staff) and 2-3 cups/day from dietary. Review of the unplanned weight loss care plan initiated 12/13/22, indicated Resident 29 had unexpected weight loss related to poor meal intake, and interventions included to alert the dietician if consumption is poor for more than 48 hours, and if (weight) loss persists, contact the physician and dietician immediately and offer substitutes as requested or indicated. During an interview on 11/15/23 at 12:16 p.m., with Registered Dietician (RD), RD stated Resident 29 had significant weight loss. RD stated Resident 29 had an individual, liberalized diet and on comfort care. RD stated she expected staff to implement Resident 29's nutrition interventions, including fluid requirement due to diagnosis of CHF. RD stated she expected a fluid intake record to be kept in Resident 29 medical records. RD stated she communicated Resident 29's nutrition interventions with the Director of Nursing (DON), Dietary Supervisor (DS) and Administrator(Admin). During an interview and concurrent record review on 11/15/23 at 2:12 p.m., with Registered Nurse (RN 1), RN 1 stated she was not aware Resident 29's fluid intake needed to be recorded and was not recorded or aware of the 10/13/23 nutrition interventions. During an interview and concurrent review of Resident 29's nutrition interventions, on 11/15/23 at 2:30 p.m., DON stated Resident 29's nutrition interventions were not acted upon because Resident 29 was on comfort care and and there was no need to monitor Resident 29's fluid intake. DON stated the RD and physician were not informed that Resident 29's nutrition interventions would not be acted upon. During an interview on 11/16/23 at 9:09 a.m., DON stated RD notified her of Resident 29 nutrition interventions and recommendations. DON stated Resident 29's nutrition interventions were not implemented or acted upon. Review of the facility's policy and procedure titled, Weight Assessment and Intervention, undated, indicated the interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Interventions for undesirable weight loss shall be based on careful consideration of the followings: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident.

Based on interviews and record review, the facility failed to ensure one (Resident 20) of five sampled residents was free from unnecessary drugs when the pharmacist's recommendation for reviewing the justifciation of the continued use of Benadryl (antihistamine/allergy) medication ordered PRN (as needed) was not acted upon. Definition: Benadryl is an antihistamine drug use for relief of allergic symptoms with warning that included central nervous depression which may impair physical or mental abilities, patient must be caution about performing tasks that required alertness}. Reference: https://online.[NAME].com. This failure had the potential for adverse medication side effects and not identifying other causes of itchy skin (dry skin, allergic reactions or other skin conditions). Findings: Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 9/27/23, indicated Resident 20 had diagnoses that included chronic lung disease. Resident 20 was on hospice (end-of life) care. Review of the physician order dated 6/23/2023 indicated Resident 20 to receive Benadryl allergy oral tablet 25 mg (mill8gram) give one tablet by mouth every 4 hours as needed for itching. Review of the Medication Administration Record (MAR), dated 10/1/2020 through 10/31/2023, indicated Resident 20 received Benadryl 25 mg one tablet as needed one to three times a day for itching. Further review of the MAR, dated 11/1/23 through 11/1/15, indicated Resident 20 received Benadryl 25 mg one tablet as needed one to two times a day. Review of the Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 9/8/23 indicated Resident 20 has been taking Benadryl mostly at bedtime for itching. Please clarify the reason for this condition and if there is any other treatment we are doing to resolve this condition. During a review of Resident 20's MRR and concurrent interview on 11/14/23 at 12:52 p.m., with the Director of Nursing (DON), DON stated for Resident 20, CP's recommendations dated 9/8/23 was not acted upon. DON stated there was no stop date for Benadryl as needed because Resident 20 continued to request Benadryl. DON further stated there was no monitoring of Benadryl for adverse side effects. During an interview on 11/16/23 at 9:59 a.m., with Registered Nurse (RN 1) RN 1 stated when an as needed order has no stop date, the physician will be called for clarification. RN 1 said Resident 20 was on hospice care. RN 1 stated she did not know what to do regarding as needed medication orders for residents on hospice care. Review of the facility's policy and procedure, Titled, Medication Regimen Review undated indicated, the primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medication appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible.

Based on observation, interview, and record review, the facility failed to attempt to use alternatives, explain the risk and benefits and obtain informed consent from the resident and resident representative (RR) prior to installment of the bed side rails for 29 out of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25). Also, there was no side-rail assessment conducted prior to initiation of the bed side rails for Resident 30. The facility's failure to assess bed side rail use for Resident 30 placed Resident 30 at risk for entrapment and injuries. Also, these failures resulted in 29 of 29 residents and their RR's to be unaware of risks and benefits of side rails and to be able to make an informed decision. [cross reference F835] Findings: During a record review of the facility's undated document titled, Half side rails list, it indicated all 29 residents residing at the facility had half side rails when in bed as enabler. During an observation on 2/22/22, at 11:15 a.m. through 2:00 p.m., side rails were up on both sides of the bed for all 29 residents residing at the facility. During another observation on 2/24/22, between 9:00 a.m. through 2:00 p.m., bilateral bed side rails were up again for all 29 residents. During a record review of Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25's Side rail utilization assessment-V4,it indicated, three sections: 1. Assessment criteria, 2. Rationale, and 3. Signatures. The assessment did not indicate any section pertaining to explanation of risks and benefits or if residents/ RR agreed to provide an informed consent related to side rail use. During an interview with the Administrator (ADM ) on 2/24/22, at 12:44 p.m., the ADM stated, the facility did not have any evidence indicating the facility attempted to use alternatives prior to installing bed side rails on all 29 resident's beds. The ADM stated, the only alternative for side rails would be no side rails. The ADM also stated, we don't have the informed consent documented. During an interview and record review with the Director of Nursing (DON) on 2/25/22, at 12:11 p.m., Resident 1's side rail assessment dated [DATE] was reviewed. Resident 1's assessment had the DON, Activity Director (AD) and Social Services Director (SSD) names on the assessment. The DON stated, the Inter-Disciplinary Team (IDT) names on the assessment indicated which team members discussed side rails use. The assessment also indicated, the RP [Responsible Party] under Responsible Party Signatures. The DON stated, RP meant Resident 1's RR was aware of side rail use and it's risks and benefits. When asked if she talked to Resident 1's RR to discuss side rail use, the DON stated, I haven't talked to anyone recently. The DON stated the IDT was responsible to obtain informed consent for side rail use. During an interview with the SSD on 2/25/22, at 12:42 p.m., the SSD stated, she was responsible for obtaining care and treatment consent from residents or RR. SSD stated she never obtained an informed consent for side rail use. The SSD further stated, she called all 29 RR's only last night on 2/24/22 to discuss the use of side rails and to obtain informed consents. During an interview with RR 1 on 2/25/22, at 1:18 p.m., RR 1 stated, the facility obtained a written informed consent for side rail use only that day (2/25/22). RR 1 further stated, the facility did not explain the risks and benefits of side rails use prior to 2/25/22. During an interview with the DON on 2/24/22, at 10:07 a.m., the DON stated, she was aware the facility needed to obtain an informed consent for side rails from the resident or RR because it could be considered a restraint. The DON stated the facility did not have documentation indicating if risks and benefits for side rail use were explained to residents and/or RR to choose or decline side rails. During a concurrent observation and interview with Registered Nurse (RN 1) on 2/24/22, at 9:58 a.m., Resident 30's bed was observed with half side rails up on both sides. RN 1 stated Resident 30's bed always had half side rail up because Resident 30 always tried to get out of bed. During an interview and record review with the Director of Nursing (DON) on 2/24/22, at 10:22 a.m., the DON was unable to locate a side rail assessment and stated, the facility did not complete the side rail utilization assessment for Resident 30. The DON stated the facility placed bedside rails on all 29 residents' beds since their date of admission. The DON further stated, Resident 30 was placed on side rails since her admitted on 1/24/22. During a concurrent interview and record review with the Activity Director (AD) on 2/25/22, at 11:54 a.m., Resident 30's side rail assessment dated [DATE] was reviewed. The assessment indicated the AD, Social Services Director (SSD) and DON's names under the signatures section in the side rail assessment for Resident 30. The AD stated, she was not aware and involved in Resident 30's side rail assessment. The AD stated, she was not aware of any risks related to side rail usage. The AD further stated, she did not recall facility staff discuss the use, risks, and benefits of side rails with residents/ families.

Based on observation, interview, and record review, the facility's administration failed to identify, update and implement it's outdated policy and procedure for bed side rail use. The facility failed to administer bed side rails without reviewing risks and benefits; obtaining an informed consent from residents/ resident representatives; and without using less restrictive alternatives prior to installing bed side rails to 29 of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25) residing at the facility. This failure placed all 29 residents residing at the facility at risk for avoidable injuries. [cross reference F700] Findings: During a record review of the facility's undated document titled, Half side rails list, it indicated all 29 residents residing at the facility had half side rails when in bed as enabler. During an observation on 2/22/22, at 11:15 a.m., bed side rails were up on both sides of the bed for all 29 residents residing at the facility. During another observation on 2/24/22, at 9:00 a.m., bilateral (both sides) bed side rails were up again for all 29 residents. During an interview with the Director of Nursing (DON) on 2/24/22, at 10:17 a.m., the DON stated, the facility did not have documented informed consent for bed side rail use for all 29 residents residing at the facility. The DON stated, If we have to, we can create the consent. During an interview with the ADM on 2/24/22, at 12:44 p.m., the ADM stated, the facility did not have any evidence indicating the facility attempted to use alternatives prior to installing bed side rails on all 29 resident's beds. The ADM stated, the only alternative for side rails would be no side rails. During an interview and record review with the Assistant Administrator (AADM), on 02/24/22, at 11:11 a.m., the facility's (P&P) titled, Health Information Management Policy and Procedure Manual Approval Sheet was reviewed. The P&P indicated three columns: Review/Revision Date, Approval Date, and Approved by. Nine staff, including the Administrator (ADM), DON, Social Services Director (SSD) and Activities Director (AD) signed their names on the Approved by column and dated it 5/19/21 on the Approval Date column. The AADM stated, the facility reviewed and revised its P&P on an annual basis and the most recent P&P review and revision was conducted on 5/19/21. During a record review with the ADM on 2/24/22, at 12:44 p.m., the State Operations Manual Appendix PP (a manual that contains the primary survey and certification rules and guidance from the Centers for Medicare and Medicaid Services), revised on 11/22/17 was reviewed. Under F700 (a regulatory tag), it indicated, The facility must attempt to use appropriate alternatives prior to installing a side or bed rail . Assess the resident for risk of entrapment from bed rails prior to installation .Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. During a concurrent interview and record review with the Administrator (ADM), on 2/24/22, at 12:44 p.m., the facility's undated P&P titled, Siderails as enabler was reviewed. The ADM stated, he was a part of the policy review team back in 2021, however, the facility's current bed side rails P&P was not updated since 2017. The ADM further stated, the facility's P&P did not reflect the current requirements to explain the risks and benefits and to obtain an informed consent from residents or RPs prior to placing the bed side rails on residents' beds.

Based on observation, interview, and record review, the facility failed to treat one of 12 sampled residents (Resident 27) with respect and dignity when: 1. Resident 27 had a clothing protector, commonly known as bib on for over three hours after breakfast hours; and 2. Registered Nurse (RN 1) addressed Resident 27 as [NAME] during incontinent care. These failures resulted in Resident 27 to not receive individualized care and had potential for Resident 27 to not feel respected. Findings: During a record review of Resident 27's Admission Record dated 2/23/22, it indicated Resident 27 was admitted to the facility on [DATE]. During a record review of Resident 27's Annual Minimum Data Set (MDS- an assessment used to plan care) dated 1/27/22, the MDS assessment indicated, Resident 27's Brief Interview for Mental Status (BIMS- an assessment for cognition status) score was five (5) out of 15, indicating severe mental impairment. 1. During an observation on 2/22/22, at 10:03 a.m., Resident 27 was sitting in a wheelchair outside his room. Resident 27 had a large towel clothing protector on around his neck, covering his chest. During another observation on 2/22/22, at 11:15 a.m., Resident 27 still had the clothing protector on while he was sitting in his wheelchair by his bed. During an observation and interview on 2/22/22, at 11:35 a.m., Resident 27's clothing protector was on his bedside table. RN 1 stated she removed Resident 27's clothing protector when she provided incontinent care to him. RN 1 stated, we always put the bib [clothing protector] because he [Resident 27] drools a lot and spits on the floor. During an interview on 2/22/22, at 1:58 p.m., the Director of Nursing (DON) stated staff put the clothing protector on residents before they eat and removed when residents were done eating. The DON stated it was a resident's dignity issue if clothing protector was not removed after Resident 27 was done eating his breakfast. The DON stated facility served breakfast around 8:00 a.m. that day. 2. During an observation on 2/22/22, at 11:20 a.m., RN 1 provided incontinent care and changed Resident 27's incontinent briefs. RN 1 was observed addressing Resident 27 as [NAME] while transferring Resident 27 from wheelchair to the bed. RN 1 pulled the privacy curtain and stated, [NAME] lay down for me .okay [NAME] turn around . During an interview on 2/22/22, at 1:58 p.m., with the DON, the DON stated, staff was expected to call the residents by first or last name and it was not okay to address the residents as mama or [NAME] unless that was resident's preference. The DON stated resident's preferences were documented under care plan section in the electronic medical record. The DON also stated staff was expected to respect the residents. During an interview and concurrent record review with the DON, on 2/22/22, at 2:04 p.m., Resident 27's care plans in the electronic medical record were reviewed. The DON stated Resident 27's care plans did not indicate if Resident 27 preferred to keep the clothing protector on for longer hours and/ or if Resident 27 preferred the facility staff to address him as [NAME]. During a record review of facility's undated policy and procedures titled, Quality of Life- Dignity indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .

Based on observation and interview, the facility failed to ensure privacy and confidentiality of medical information for two of two sampled residents (Residents 23 and 30) when: 1. Resident 30's electronic medical record was left exposed at Medication Cart 1; and 2. Certified Nursing Assistant 3 (CNA 3) did not provide privacy during toileting for Resident 23. These failures had the potential for unauthorized access to Resident 30's medical information and it violated resident's right to privacy for Resident 23. Findings: 1. During a concurrent observation and interview on 2/25/22, at 9:33 a.m., with Licensed Vocational Nurse 2 (LVN 2), the computer screen was observed open to Resident 30's medical record on Medication Cart 1. The computer screen was also observed exposing Resident 30's name, vital signs, physician name, allergy status, code status, photo, care plan, and pain assessment. LVN 2 stated Resident 30's record should have been secured when she stepped away from the cart. During an interview with the Director of Nursing (DON) on 2/25/22, at 9:48 a.m., the DON stated there is a button on the computer screen for staff to use that secures the computer screen when they step away from the workstation. The DON further stated securing the computer displaying resident personal and medical information is important because the Health Insurance Portability and Accountability Act (HIPAA) requires medical records be kept confidential. 2. During an observation on 2/25/22, at 8:33 a.m., Resident 23 requested assistance from Certified Nursing Assistant (CNA 3) in emptying the [CONDITION(S)] bag (a bag attached to an opening into the abdomen to excrete the fecal matter). Resident 23 was in lying position. Resident 23 removed the blanket from the lower part of his body while his legs and [CONDITION(S)] were exposed. CNA 3 handed a bed pan to Resident 23 and told him to put it in between his legs right above the genital area. Resident 23's bed was right by the door, which was wide open. CNA 3 did not pull the privacy curtain while Resident 23 emptied the [CONDITION(S)] bag. During an interview with CNA 3 and Resident 23 on 2/25/22, at 8:45 a.m., at Resident 23's bedside, CNA 3 apologized for not pulling the privacy curtain during [CONDITION(S)] care. Resident 23 stated he would like the staff to pull the privacy curtain to provide him privacy during [CONDITION(S)] care. During a record review of the facility's undated policy and procedure (P&P) titled, Dignity and Privacy During Care, the P&P indicated, Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care .

Based on observation, interview, and record review, the facility failed to provide a home like environment to five of 12 sampled residents (Resident 1, 23, 2, 8 and 30) when: 1. the room temperature for Resident 1 and 23 were too cold; and 2. the overbed tables for Residents 2, 8 and 30 were rough and unfurnished. The above failures resulted in Resident 1 and 23 feeling cold, and the potential for Residents 2, 8 and 30 getting scratched and hurting themselves. Findings: 1. A record review of Resident 1's Admission Record dated 2/24/22, indicated Resident 1 was admitted on [DATE]. A record review of Resident 27's Admission Record dated 2/25/22, indicated Resident 27 was admitted on [DATE]. During an interview on 2/22/22 1:02 p.m., Resident 1 stated that her room is always too cold, and she doesn't like it. During an observation and interview on 2/23/22, at 12:25 p.m., with the ADM (Administrator), the ADM stated the facility temperature is kept around 70ºF (degrees Fahrenheit). The ADM stated the nurses are responsible for changing the temperature if residents make a complaint or have a request. The ADM stated there are no temperature check logs for resident rooms. The ADM measured the temperatures of the following rooms: Room 1 was 69.3º F, Room 2 was 69.3ºF, and Room 3 was 69.3ºF. During an interview on 2/25/22, at 1:23 p.m., Resident 23 stated, his room is too cold, all the time. Resident 23 further stated, it makes him feel his room is not homelike. A review of the facility's policy and procedure (P&P) titled, Homelike Environment, (undated), indicated, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .Comfortable temperatures. 2. During an observation with Certified Nursing Assistant 1(CNA 1) on 2/24/22, at 9:07 a.m., Resident 30's overbed table [a table with metal base with four wheels, a metallic leg on one side and a wooden tray on the top] was at her bedside. All four sides of the top wooden tray of the table were unfurnished, uneven and rough to touch. CNA 1 stated Resident 30 used the overbed table daily. When asked about her thoughts about overbed table being unfurnished and rough to touch, CNA 1 stated, what can I say. During an observation with Registered Nurse (RN 1) on 2/24/22, at 9:58 a.m., in Resident 30's room, RN 1 stated, most of them [overbed tables] were old in the facility. RN 1 stated, because the overbed tables were rough and uneven, that could scratch resident's hands. RN 1 stated, staff reported the facility's administration of furniture repairs needs back in 12/2021 [almost two months ago]. During another observation with RN 1 and CNA 2 on 2/24/22, at 10:04 a.m., Resident 8 and Resident 2's overbed tables were observed. The edges of the top wooden tray for Resident 8 and Resident 2 were scratched, uneven and rough to touch. The top wooden tray for Resident 8's table also had multiple chipped areas. CNA 2 stated, it could crack resident's body, we don't like it. During an interview with the Director of Nursing (DON) on 2/24/22, at 10:28 a.m., the DON stated, to ensure resident's safety, the facility checks the resident's surroundings every day, but did not notice the unfurnished overbed tables for Resident 30, 8 and 2. The DON stated unfurnished furniture's wooden particles could get mixed in resident's food and cause injuries to Resident 30, 8 and 2. During an interview and record review with the Assistant Administrator (AADM) on 2/24/22, at 11:11 a.m., the facility's Maintenance Log binder was reviewed. AADM stated, he did resident room rounds every six (6) months and the maintenance supervisor was responsible for daily rounds to ensure residents' surroundings were safe. The AADM opened the Weekly Over Bed Table Log for the month of January 2022, a section of the Maintenance log binder indicated the maintenance supervisor did not check the overbed tables for all residents after 1/27/22. The weekly overbed table log indicated, Examine all overbed tables weekly to ensure they are clean and in good repair. Wheels are clean and roll smoothly. Note location of table and comment on repairs made or need to discard or replace. AADM stated, the log did not indicate if overbed tables for Resident 30, 8 and 2 required repairs or needed to be replaced and the comment section was left blank. The AADM also stated, he did not think overbed tables for Resident 30, 8 and 2 turned into an unfurnished condition just in one month. The AADM stated, the maintenance supervisor was not available during the survey week. During a record review of the facility's undated policy and procedure (P&P) titled, Homelike Environment, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment .2 .The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .d. Personalized furniture and room arrangements .

Based on observations, interviews and record review, the facility failed to ensure that four (2, 4, 3, 6) of ten sampled residents were free from unnecessary restraints such as bed side rails and/or a soft trunk restraint (device which is applied around the waist to restrict movement) which resulted in Resident 4 falling and hitting her head and had the potential for more serious injury. a. Resident 4 climbed over full siderails and fell hitting her head on 11/7/10. Resident 4 had full siderails and a belt restraint in the wheelchair. Both of her bed siderails were kept up to prevent her from climbing out of bed. b. Resident 2 had trunk restraint in bed and full bed side rails to prevent him from climbing out of bed without assessments for their use. c. Resident 3 had a wrist restraint on and an abdominal binder and her tube feeding was not in progress. d. Resident 6 had both of bed rails and soft trunk as restraints without medical [DIAGNOSES REDACTED]. Findings: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the RAP summary dated 11/20/09 showed that Resident 4 had been accostumed to independent behavior in walking, attempts to stand alone and had a history of [REDACTED]. Record review on 11/16/10 showed that the quarterly MDS dated [DATE], indicated that Resident 4 had memory problems and was moderately impaired for cognition. She need limited assistance for transfers and walking. The MDS indicated that siderails were in use for bed mobility or transfer and the resident had a trunk restraint used daily. The care plan updated on 8/13/10 indicated that the resident had a history of [REDACTED]. A review of nurses notes dated 11/7/10 at 12 noon showed that Resident 4 sustained a head injury on 11/7/10 and was transferred to an acute facility for treatment and evaluation. Resident 4 returned to the facility that same day and was monitored for neurological signs and further bleeding. Resident 4 was observed in her bed awake on 11/16/10 at 11:00 a.m. both of her full bedside rails were up. On 11/17/10 at 7:40 a.m. during an interview, CNA 2 who was assigned to Resident 4, stated that Resident 4 needed one person assistance. CNA 2 stated that the resident could walk with the aid of a front wheelwalker to the bathroom. When asked why Resident 4 had her bed side rails up, CNA 2 stated that Resident 4 sometimes tries to get out of bed without assistance. On 11/17/10 at 11:10 a.m. during an interview, the Activity Director stated that she knew Resident 4 had no safety awareness, and was likely to climb over the siderails to get out of bed. In a telephone interview on 11/22/10 at 2:27 p.m., CNA1, who was assigned to take care of Resident 4 on 11/7/10, stated that Resident 4 was given a suppository that day (11/7/10) and was trying to get out of bed. CNA1 left the room to get a bedpan in the utility room. Before she left the room, CNA 1 stated that she made sure that both of the resident's full bedside rails were up. When she returned with the bedpan, she saw Resident 4 on the floor in front of the bathroom with her pants halfway down. CNA1 stated that she saw bowel movement and some droplets of blood near her head. A review of the facility's undated restraint policy and procedure produced by the DON showed the following: "Side rails sometimes restrain residents. The use of side rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. Residents who attempt to exit a bed through, between, over or around side ralis are at risk of injury or death. The potential for serious injury is more likely from a fall from a bed with raised side rails than from a fall from a bed where side rails are not used...If a device must be used to prevent a resident from leaving the bed alone, a roll belt will be used as well as the bed rails." 2. Record review showed that Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was physician's orders [REDACTED]. During the initial tour on 11/16/10 at 8:45 a.m., Resident 6 was observed in bed awake with a brown colored soft trunk restraints accross her chest, in conjunction both of her bedrails were observed in up position. On 11/18/10 a review of Resident 6's clinical record showed nurses notes dated 3/6/2010 at 01:20 a.m. indicating "Attempted to get out of bed roll belt knotted and hanging on the side rails. Nurses notes on 3/19/2010 at midnight indicated "Found resident without belt and attempted to get out of bed assisted to wheelchair with belt restraint, [MEDICATION NAME] ( anxiety medication) 0.25 mg (milligram) given." In an interview, the DON stated that Resident 6 had soft trunk restraints and the facility kept both of her bed rails in up position because she had a history of [REDACTED]. There was no medical symptoms for the continued use of soft trunk restraints in conjunctions with the use of bed rails at the same time. 3. Resident 2 was a [AGE] year old man was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to his most recent minimum data set (MDS) quarterly assessment dated [DATE], he had short term memory loss, but had long term memory and was independent for decision making. His behavior indicated on the MDS was sleeping problems, and he needed extensive assistance to transfer from his bed to the wheelchair. In addition he had full side rail restraints and a trunk restraint. The resident assessment protocol (RAP) dated 12/7/09 stated, "He's still at risk for falls because he can forget and try to stand alone. Belt restraint is used in the wheelchair." On 11/17/10 at 9:40 a.m. Resident 2 was lying in bed with both side rails in the upright position and the soft trunk restraint tied across his abdomen to the bed frame, while CNA 2 was preparing to give him a bed bath. She pulled the sheet down and untied the trunk restraint. and then went into the bathroom. Resident 2 then called out to CNA 2 asking "Did you take this thing off?" pointing to his abdomen. She said, "Yes, I took it off." Resident 2 then stated, "I still feel it - get it off." Later that morning on 11/17/10 at 10:00 a.m., the resident was in the bathroom and able to hold the grab bars and pull himself up, pivot and lower himself to the toilet. CNA 2 who was assisting the resident stated he was able to shave and brush his teeth with set-up help. According to the undated "Fax information for Physician" the DON wrote to Resident 2's physician stating, "Confusion is getting worse, trying to get OOB (out of bed) at night, insisting to put the siderails down, very anxious and confused. High risk for fall. May we get an order: Both siderails up with roll belt in bed for safety wife agreed/(consent given to this. Pls (please) advise thank you." To which the physician sent an order dated 2-2-10 for the resident to have bilateral side rails up with a roll belt in bed for safety. Another physician's orders [REDACTED]." The care plan for the restraints was written on 2/17/10 as an intrvention to prevent falls. The plan was "Side rails up in bed, roll belt to prevent climbing out. Belt restraint in wheelchair to prevent standing alone - continue close monitoring." According to the nurses notes dated 9/25/10 at 1:00 a.m., "Awake, confused, calling out and yelling. talking to himself most of the time. Attempted to get out of bed several times by crossing the leg over the siderails. Roll belt in place. 'I want to go home.' still agitated, shaking siderails and ed board..awake till 5:00 a.m." The next note at 6:30 a.m. read, "Quiet, eyes closed. Sleeping soundly. Up in wheelchair in hallway. quiet and calm." The DON offered a copy of the facility's undated restraint policy and procedure for review. According to the policy and procedure, "Side rails sometimes restrain residents. The use of side rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. Residents who attempt to exit a bed through, between, over or around side ralis are at risk of injury or death. The potential for serious injury is more likely from a fall from a bed with raised side rails than from a fall from a bed where side rails are not used...If a device must be used to prevent a resident from leaving the bed alone, a roll belt will be used as well as the bed rails." 3. Resident 3 was a [AGE] year old female who had the [DIAGNOSES REDACTED]. According to her minimum data set (MDS) assessment dated [DATE] she had a behavior of resisting care. She also had a gastrostomy tube placed into her stomach where she received most of her nutrition, during the evening and night shifts. The resident was observed during the tour of the facility on 11/16/10 at 9:00 a.m. lying in bed with a wrist restraint on her right wrist. There was a GT feeding pump next to the bed but the tube feeding was not in progress at that time. According to the medical record, the physician wrote an order for [REDACTED]. According to the Director of Nurses on 11/16/10 at 2:05 p.m., she said she has told the physician that the facility cannot have PRN restraint orders, but he has not changed the order. She also stated that the resident has an abdominal binder on as another measure to prevent the resident from pulling out her GT.

The facility violated the aforementioned regulation by failing to provide adequate supervision when transferring Resident D from her wheelchair to bed by the use of a Hoyer lift. As a result, Resident D fell from a Hoyer lift sling, hit her head and expired.Resident D was a ninety-six year old female, admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. organs), dementia (a decline of reasoning, memory and other mental abilities) and macular degeneration (eye disease). The annual comprehensive assessment dated [DATE] documented that she required total assistance of two plus person and a mechanical lift to transfer from wheelchair to bed. Resident D's closed record was reviewed on [DATE]. The nurses' notes dated [DATE] documented the following:1:30 p.m. - "Resident had a fall incident from the Hoyer lift while resident was lifted from the wheelchair... Resident was talking and verbally responsive... She had sustained an abrasion on the right side of her head w/ (with) minimal bleed. Abrasion approx (approximately) 0.3 x 0.5 cm, cleansed and treated."1:55 p.m. -"... resident became unresponsive with periods of apnea, turned cyanotic... O2 (oxygen) placed via non-breather mask... Pulse was still noted but can't be appreciated after 5 sec (seconds). While doing pulse vital signs 911 was called at the same time, no BP (blood pressure) appreciated via stet (stethoscope)." 2:00 p.m. - "911 arrive and took over" 2:11 p.m. - "911 staff called Dr. M and MD pronounced resident expired."On [DATE], the two CNAs (certified nursing assistances) J and C who cared for Resident D the day she expired were interviewed. CNA J, who was assigned to care for Resident D on the day of the fall, was interviewed at 1:10 p.m. She stated that after she connected the Hoyer lift to the wheelchair she went and asked CNA C for help. When CNA J started to lift the resident, CNA C told her to wait because she did not think the Hoyer lift sling was on properly. CNA C then told her to go ahead and lift the resident and removed the wheelchair then Resident D leaned forward and fell to the floor. She had blood on the right side of her head.CNA C was interviewed on [DATE] at 1:30 p.m. She stated that she assisted CNA J with placing the resident into the bed. When CNA J raised the resident from the wheelchair, she could see that the sling was up a little, so she pulled the sling down. CNA C stated that when CNA J lifted Resident D from the wheelchair, she pulled the wheelchair back, turning her back to the resident. CNA J turned the Hoyer lift to place Resident D onto the bed before CNA C returned to guide and assist in placing the resident on bed. CNA C told CNA J to wait. It was too late, Resident D fell face forward to the floor.During the transfer, the CNAs did not ensure that one of them was operating the Hoyer lift while the other was guiding the resident as she was lifted from the wheelchair and return to bed. CNA C turned away from the resident to move the wheelchair and CNA J that was operating the Hoyer lift did not wait for CNA C to return back and guide the resident onto the bed. Had CNA C been there to guide the resident onto the bed, the fall could have been prevented.Review of the facility investigation report stated that CNA J was operating the lift. CNA C was going to guide the patient into bed. "Pt (patient) leaned forward and slipped from the lift face down, hitting her head either on the foot of the lift or the floor."A copy of the Alameda County Sheriff's Office Coroner Investigator's Report was received on [DATE]. The coroner documented the cause of death was accident, Craniocervical trauma (injury to the head and neck). The Alameda County Sheriff's Office report attached to the coroner's report documented that it appeared that the sling was out of position and the resident slumped forward and struck her head on the floor or the foot of the lift. As a result of the facility's failure to provide adequate supervision when the resident was being transferred from the wheelchair to bed with a Hoyer lift the resident fell , hit her head and expired. ______________________________________________________________________ G Level Deficiency Based on observation, record record and staff interviews, the facility failed to provide supervision for one of one sampled residents (D) during transfer while using a mechanical transfer lift. Resident D fell from the lift and hit her head during the transfer from wheelchair to bed. This failure to supervise resulted in the fall injury and subsequent resident death. Findings: Resident D was a ninety-six year old female, admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. The annual comprehensive assessment dated [DATE] documented that she required total assistance of two plus persons and a mechanical lift to transfer from wheelchair to bed. Resident D's closed record was reviewed on [DATE]. The nurses' notes dated [DATE] documented the following: 1:30 p.m.- " Resident had a fall incident from the Hoyer lift while resident was lifted from the wheelchair ... Resident was talking and verbally responsive ... She had sustained an abrasion on the right side of her head w/ (with) minimal bleed. Abrasion approx. (approximately) 0.3 x 0.5 cm., cleansed and treated. " 1:55 p.m. -" ...resident became unresponsive with periods of apnea, turned cyanotic ... O2 (oxygen) placed via non-breather mask ... Pulse was still noted but can' t be appreciated after 5 sec (seconds). While doing pulse vital signs 911 was called at the same time, no BP (blood pressure) appreciated via stet (stethoscope). " 2:00 p.m.- " 911 arrive and took over " 2:11 p.m.- " 911 staff called Dr. M and MD pronounced resident expired. " On [DATE], the two CNAs (certified nursing assistants) J and C who cared for Resident D the day she expired were interviewed. CNA J, who was assigned to care for Resident D on the day of the fall, was interviewed at 1:10 p.m. She stated that after she connected the Hoyer lift to the wheelchair, she went and asked CNA C for help. When CNA J started to lift the resident, CNA C told her to wait because she did not think the Hoyer lift sling was on properly. CNA C then told her go ahead and lift the resident and removed the wheelchair, then Resident D leaned forward and fell to the floor. CNA C was interviewed on [DATE] at 1:30 p.m. She stated that she assisted CNA J with placing the resident into the bed. When CNA J raised the resident from the wheelchair, she could see that the sling was up a little, so she pulled the sling down. CNA C stated that when CNA J lifted Resident D from the wheelchair, she pulled the wheelchair back, turning her back to the resident. CNA J turned the Hoyer lift to place the resident on the bed. CNA C told CNA J to wait. It was too late, Resident D fell face forward to the floor. During the transfer, the CNAs did not ensure that one of then was operating the Hoyer lift while the other was guiding the resident as she was lifted from the wheelchair and returned to bed. CNA C turned away from the resident to move the wheelchair and CNA J that was operating the Hoyer lift did not wait for CNA C to return back and guide the resident on the bed. Had CNA C been there to guide the resident on the bed, the fall could have been prevented. Review of the facility investigation report stated that CNA J was operating the lift. CNA C was going to guide the patient into the bed. " Pt (patient) leaned forward and slipped from the lift face down, hitting her head either on the foot of the lift or the floor. " A copy of the Alameda County Sheriff ' s Office Coroner Investigator's Report was received on [DATE]. The coroner documented the cause of death was accident, craniocervical trauma (injury to the head and neck). The Alameda County Sherriff ' s Office report attached to the coroner' s report documented that it appeared that the sling was out of position and the resident slumped forward and struck her head on the floor or the foot of the lift.