Every finding on record at Delano District Skilled Nursing Facility

Based on interview and record review, the facility failed to ensure licensed nurses were monitoring an antidepressant's (medication used to treat depression [persistent feeling of sadness]) adverse reactions (undesired harmful effect from a medication) for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 having adverse reactions to Paxil (antidepressant).Findings:During a review of Resident 1's admission Record (AR), dated 4/8/26, the AR indicated, DIAGNOSIS. MAJOR DEPRESSIVE DISORDER (persistent, intense feeling of sadness).During a concurrent interview and record review on 4/2/26 at 2:10 p.m. with Director of Nursing (DON), Resident 1's Order Summary Report (OSR) dated 4/2/26, was reviewed. The OSR indicated, Paxil Oral Tablet 20 MG (milligrams - unit of mass) . one time a day for Depression m/b (manifested by) verbalization of sadness. The OSR indicated, there was no physician order to monitor Paxil's adverse reactions on Resident 1. DON stated Resident 1 had been on Paxil since 8/6/25 and there had been no monitoring of Paxil's adverse reactions on Resident 1 since 8/6/25. DON stated there should have been monitoring of Paxil's adverse reactions on Resident 1 every shift to ensure Resident 1 was not having adverse reactions to Paxil, and to notify the physician if Resident was having adverse reactions to Paxil.During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medications, dated 7/7/2009, the P&P indicated, Licensed nurses will. Observe for adverse reactions of the drug. If adverse reactions are noted, notify the physician. Document the reactions noted and the communication made with the physician regarding these reactions.

Based on interview and record review, the facility failed to ensure one of two sampled staff (Certified Nursing Assistant [CNA]) 1, completed annual abuse training. This failure had the potential to put residents at risk for abuse.Findings:During a review of Resident 1's IDT (Interdisciplinary Team- group of professionals from different disciplines who work together toward common, patient-centered goals) Notes dated 3/16/26, the IDT indicated, Responsible party.reported.(Resident 1) complained that a nurse (Certified Nursing Assistant [CNA] 1) from the NOC (night) shift was rude and mean.During a concurrent interview and record review on 3/17/26 at 1:55 p.m. with Human Resource Assistant (HRA), CNA 1's abuse training dated 2/7/23 was reviewed. The abuse training indicated CNA 1 last received training on 2/7/23 (more than three years prior) HRA was unable to provide more recent abuse training for CNA 1.During an interview on 3/17/26 at 2:05 p.m. with Administrator, Administrator stated that abuse training should have been completed annually.During an interview on 4/8/26 at 3:05 p.m. with Director of Staff Development (DSD), DSD stated abuse training should have been completed annually.During an interview on 4/13/26 at 4:15 p.m. with CNA 1, CNA 1 stated her last abuse training completed prior to the allegation was completed on 2/7/23. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention Program dated 7/22/2021, the P&P indicated, In-Service Training.All new employees are required to attend the facility's resident rights and abuse prevention in-service training during their orientation.Training shall be provided on an annual basis and as needed.

Based on observation, interview, and record review, the facility failed to:Supervise one of three sampled residents (Resident 1) after Resident 1 attempted to commit suicide (when a person intentionally harms themselves with the goal of ending their life, and they die as a result). This failure resulted in Resident 1's second suicide attempt.Follow their policy and procedure for Suicide Prevention Guidelines, to monitor one of three sampled residents (Resident 1) after Resident 1 attempted to commit suicide. This had the potential for Resident 1 to successfully kill herself and/or harm herself.Findings:During a review of Resident 1's admission RECORD (AR), dated 3/25/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (a chronic mental health condition which causes people to lose touch with reality, such as hearing voices or holding false beliefs, while also experiencing intense mood swings) bipolar type (a mental health condition characterized by extreme, often unpredictable shifts in mood, energy, and activity levels), cognitive communication deficit (difficulty with communication resulting from problems with memory, attention, or brain function), anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life), and major depressive disorder (a serious mental health condition characterized by persistent, overwhelming sadness and a loss of interest in activities, lasting at least two weeks).During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 1/15/26, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS score was 14 (cognitively intact status).During a review of the facility 5 Day Investigation Summary (5DIS), dated 3/19/25. the 5DIS indicated, Resident 1 required a foley catheter (FC - tube inserted into the body to drain urine) for a diagnosis of urinary retention (the inability to empty the bladder [[NAME] like portion of the body that holds urine] meaning urine stays trapped inside even when you feel the need to pee).1. During an interview on 3/24/26 at 1:05 p.m. with Director of Nursing (DON), DON stated Resident 1 attempted to commit suicide in her room on 3/14/26 (no approximate time given) by using her call light (corded device used to call nurses for assistance). DON stated Resident 1 was placed on every 30-minute visual checks on 3/14/26 and 3/15/26 to monitor for any further suicide attempts. DON stated on 3/16/26 (two days after the suicide attempt) she had Resident 1 placed on one-to-one visual monitoring (one staff member dedicated to watching one specific resident at all times) when staff informed her Resident 1 attempted another suicide using her FC (3/14/26). DON stated she changed the 30-minute visual checks to one-to-one visual monitoring because Resident 1 attempted to commit suicide twice, first time using her call light and second time using her FC to wrap around her neck the same day on 3/14/26.During a review of Resident 1's Progress Notes (PN), dated 3/16/26 at 9 a.m., the PN indicated, on 3/14/26 regarding (Resident 1's) attempt to harm herself by wrapping the call light and FC catheter (sic) tubing around her neck. (Resident 1) pulled out her foley catheter and used it to harm herself . (Resident 1) has been on suicide watch since 3/14/26. FC is necessary to manage her bladder function and prevent hydronephrosis (the swelling of a kidney [portion of the body that creates urine] caused by a backup of urine), urinary tract infection [an infection of the urine] and possible kidney injury. (Resident 1) was assigned a 1:1 sitter to monitor for any suicide attempts which includes monitoring any attempts of pulling out her foley catheter . The PN did not indicate Resident 1 had made several attempts to commit suicide. During an interview on 3/24/26 at 1:59 p.m. with Resident 1, Resident 1 stated I don't want to hurt myself, I want to kill myself . I want to hurt myself but don't know how, if I had a gun I could do itDuring an interview on 3/24/26 at 2:32 p.m. with Registered Nurse (RN)1, RN stated on 3/14/26 she was called (cannot recall at what time) by Certified Nursing Assistant (CNA) 1 regarding Resident 1 attempting to commit suicide using her call light and FC. RN 1 stated she went into Resident 1's room and heard Resident 1 stated she wanted to kill herself. RN 1 stated she notified the DON on 3/14/26, regarding the suicide attempt made by Resident 1 using her call light and FC.During an interview on 3/27/26 at 10:02 a.m. with CNA 1, CNA 1 stated on 3/14/26 she was working the p.m. shift (2 p.m. to 10:30 p.m.) and was assigned to Resident 1. CNA 1 stated at approximately 4:30 p.m. she entered Resident 1's room due to hearing Resident 1 screaming. CNA 1 stated she saw Resident 1 with her call light wrapped around her neck (first attempt) but not her FC. CNA 1 stated she reported this to Licensed Vocational Nurse (LVN) 1. CNA 1 stated LVN 1 and another nurse (not identified) went into Resident 1's room and asked her to attend to the other residents while they assessed Resident 1. CNA 1 stated approximately 10 minutes later (4:40 p.m.) she heard Resident 1 screaming again. CNA 1 stated she entered Resident 1's room and noticed there were no staff in the room and Resident 1 had removed her FC and placed it around her neck in order to try to kill herself (second attempt).During an interview on 4/9/26 at 3 p.m. with LVN 2, LVN 2 stated she had worked the night shift (10:30 p.m. to 7 a.m.) on 3/14/26. LVN 2 stated Resident 1 was on every 30-minute visual checks (not one-to-one monitoring) the night after attempting to commit suicide. LVN 2 stated she had wondered why Resident 1 was on 30-minute visual checks but not one-to-one due to her attempts of killing herself. LVN 2 stated Resident 1 was not placed on one-to-one monitoring until Monday (3/16/26).During an interview on 4/15/26 at 2:08 p.m. with LVN 1, LVN 1 stated she was assigned to Resident 1 on 3/14/26. LVN 1 stated she was called into Resident 1's room (cannot recall the time) by CNA 1 and found Resident 1 with her call light wrapped around her neck in an effort to kill herself the first time. LVN 1 stated she called RN 1 regarding the incident and both her and RN 1 removed the call light and any other string/cords in the room so Resident 1 could not use them to harm herself. LVN 1 stated she left Resident 1's room to continue her work with other residents, assuming Resident 1 would be supervised by RN 1 or CNA 1. LVN 1 stated some time had passed (does not recall how much time passed) and she heard CNA 1 yelling out for her again. LVN 1 stated when she reentered Resident 1's room she observed Resident 1 with her FC around her neck in an attempt to commit suicide a second time. LVN 1 stated she thought it was to her understanding CNA 1 or RN 1 would be told to stay in Resident 1's room to monitor Resident 1. LVN 1 stated I knew she (Resident 1) was a danger to herself and needed to be monitored to prevent from harming herself. I did not get confirmation on who was going to keep an eye on her. I felt she needed to go out to the hospital for evaluation for 5150 (process in which qualified individuals can determine a person is a danger to themselves and/or others and can have them detained [to be temporarily held] for up to 72 hours for mental health evaluation and/or treatment).During an interview on 4/15/26 at 3:08 p.m. with DON, DON stated she was not aware Resident 1 attempted to commit suicide twice on 3/14/26. DON stated she thought Resident 1's call light and FC were used at the same time and not on separate suicide attempts. DON stated if she knew about the FC and Resident 1 had attempted to kill herself twice, I would have placed her (Resident 1) on one-to-one that night (3/14/26.) DON stated Resident 1 was not placed on one-to-one monitoring until 3/16/26.2. During a concurrent interview and record review on 3/24/26 at 4:09 p.m. with DON, the facility document titled Observation of Resident: Suicidal Ideation/Suicidal Attempts (ORSISA), dated 3/21/26 was reviewed. The ORSISA on 3/21/26 indicated Resident 1 was to be monitored every 30 minutes. The ORSISA indicated Resident 1 was not monitored at 11 a.m., 3 p.m., and 3:30 p.m. DON stated Resident 1 should have been monitored at these times to ensure Resident 1 was not harming herself.During a review of the facility's policy and procedure (P&P) titled, Suicide Prevention Guidelines, dated 3/3/23, the P&P indicated, The facility must provide medically related social services to attain the highest practicable physical, mental, and psychosocial well-being of each resident. In this respect, residents who threaten to harm themselves will be provided immediate attention to prevent such an occurrence. Notice will be made immediately to the physician, family and/or legal representative when residents threaten or attempt to harm themselves. In the event of a suicidal ideation, threat, gesture, or attempt, the first responder shall ensure the safety of the resident and notify the Charge Nurse. The Charge Nurse shall notify the Director of Nurses (DON), Director of Social Services, Administrator, family, and the physician. If needed, the resident will be relocated to an area that is closely monitored by staff. Nursing staff will monitor the resident every 30 minutes and provide documentation utilizing Attachment A (ORSISA). Documentation will also include inspection of resident's room for harmful objects every shift. If suicide threats increase, resident will be closely monitored until physician has been contacted and orders have been received. Documentation will continue during the period that suicidal ideations, threats, gestures, or attempts have been reported. Documentation may discontinue after three days of no recorded behaviors if agreed by IDT or physician. Medical Records staff will monitor the end of the documentation period.

Based on interview and record review, the facility failed to ensure the follow-up investigation report was completed within five working days for an allegation of abuse for one of three sampled residents (Resident 1). This failure had the potential to result in an incomplete abuse investigation.Findings:During a review of the S (situation) B (background) A (appearance) R (review and report) communication form and progress note (SBAR-used to report change of condition to the physician) dated 2/21/26 at 6:54 p.m., the SBAR indicated, CNA (certified nursing assistant) reported verbal abuse from Daughter.Per CNA, overheard argument from resident's room during meal pass.this noted on 2/21/26 at 5:30 p.m.During an interview on 3/5/26 at 11:38 a.m. with Administrator, Administrator stated the Director of Nursing (DON) was responsible for completing the five-day report.During an interview on 3/5/26 at 11:51 a.m. (nine working days after the incident) with DON, DON stated the five-day report was not completed and should have been.During a review of the facility policy and procedure (P&P) titled, Abuse Prevention Program dated 7/29/2020, the P&P indicated, The final investigation report must be faxed and confirmed to the appropriate agency as indicated above within 5 working days from the time the incident occurred.

Based on interview and record review, the facility failed to ensure the Care Plan (CP), was implemented for one of three sampled residents (Resident 1) when wellness checks were not completed. This failure had the potential for staff to be unaware of Resident 1 experiencing an alteration in her well-being.Findings:During a review of the S (situation) B (background) A (appearance) R (review and report) communication form and progress note (SBAR-used to report change of condition to the physician) dated 2/21/26 at 6:54 p.m., the SBAR indicated, CNA (certified nursing assistant) reported verbal abuse from Daughter.Per CNA, overheard argument from resident's room during meal pass.During a review of Resident 1's CP dated 2/23/26, the CP indicated, Alteration in well-being related to.verbal altercation between (Resident 1) and her daughter.Interventions.Social Service Designee to conduct wellness check x (times) 72 hours.During a concurrent interview and record review, on 3/5/26 at 11:35 a.m. with Social Service Director (SSD), Resident 1's clinical record was reviewed. SSD was unable to provide documented wellness checks for Resident 1.During an interview on 3/5/26 at 11:38 a.m. with Administrator, Administrator stated Social Services should have monitored Resident 1 after the incident.During an interview on 3/5/26 at 11:39 a.m. with Director of Nursing (DON), DON stated Social Services should have done the 72-hour wellness checks after the incident.During a review of the facility's policy and procedure (P&P) titled Comprehensive Care Plans (CP) dated 11/2017, the P&P indicated, Update the comprehensive care plan to reflect changes to goals, approaches, as necessary.resulting from condition changes and needs.Interventions are instructions to one or a combination of disciplines to perform direct care or to provide assistance so that the resident may strive to achieve their established goals.

Based on interview and record review, the facility failed to ensure three of three sampled staff (Facility Staff [FS] 1, FS 2, and Activity Director [AD]), were competent to utilize the facility transport vehicle. This failure had the potential for residents to not be transported safely and for injuries to occur.Findings: During an interview on 12/18/25 at 12:10 p.m. with FS 1, FS 1 stated he provided transport to residents in the past, using the facility transport vehicle, when leadership (not identified) ask him to. During a review of the facility employee files (EF), not dated, the EF indicated FS 2 also used the facility transport vehicle to transport residents. During an interview on 12/18/25 at 2:05 p.m. with Director of Nursing (DON), DON stated the facility provided transport to residents to and from appointments as well as to go on outings for activities. During an interview on 12/18/25, at 2:32 p.m. with Director of Staff Development (DSD), DSD stated FS 1, FS 2, and staff in activities use the facility van to transport residents to appointments and/or to go on outings. DSD stated the facility did not have a process in place she was aware of indicating staff driving the facility transport vehicle were competent and safe to do so. During an interview on 12/18/25 at 2:37 p.m. with AD, AD stated she had worked for the facility for 15 years and transports residents on outings as part of her job. AD stated the facility had a transport vehicle that can accommodate nine residents on an outing including a hydraulic lift (a machine that uses pressurized fluid [usually oil] to easily raise or lower heavy objects) to place wheelchair bound residents into the vehicle and an ability to strap their wheelchairs down so they do not slide around when the van is transporting them (residents). AD stated she has not been required to show she is competent and/or safe to drive the facility van. During a concurrent observation and interview on 3/2/26 at 3:35 p.m. with DON in the facility parking area, the facility resident transport vehicle was observed. The facility transport vehicle had a hydraulic lift to raise wheelchair bound residents into the vehicle. The facility transport vehicle appeared to accommodate nine residents including residents that cannot be out of a wheelchair. DON stated the facility had not complete competencies for staff that drive the facility transport vehicle to ensure they were safe to do so. During a review of the facility's policy and procedure (P&P) titled, Competency Evaluation, dated 11/1/22, the P&P indicated, All staff members who provide patient care, treatment, or services are competent to perform their job duties and responsibilities. PURPOSE .To establish a standardized process for assessing and documenting staff competency at established times and intervals to minimize risk of harm to patients, maintain a consistently high quality of care, and to comply with laws and regulations. Applies to all staff members who provide care, treatment, or services in the organization. Competency -The demonstrated knowledge and skill necessary to perform a task or job safely, successfully, and efficiently.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse Prevention Program, when references were not checked prior to hire, orientation and abuse training were not provided for one of one sampled staff (certified nursing assistant [CNA 1]). These failures had the potential to place facility's residents at risk for abuse.Findings: During a concurrent interview and record review, on 1/15/26 at 10:45 a.m. with Director of Nursing (DON), CNA 1's employee file was reviewed. DON stated CNA 1 was from an agency, DON was unable to provide a hire date for CNA 1. During a concurrent interview and record review, on 1/15/26 at 12:32 p.m. with Director of Staff Development (DSD), CNA 1's employee file was reviewed. DSD stated the staffing agency ensured CNA 1 had all the training that was required. DSD stated the staffing agency performed all background checks and reference checks. DSD confirmed the facility does not provide training or reference checks for the agency staff. DSD stated she did not have an exact date of hire, but CNA 1 has worked at the facility for approximately a year, and CNA 1 works once or twice a week. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, revised 7/22/21, the P&P indicated, Screening .1. Potential employees will be screened for history of abuse, neglect or mistreatment of residents as defined by the applicable requirements utilizing the following tools: a. Reference checks with previous and or current employers. 1. All new employees are required to attend the facility's resident rights and abuse prevention in-service training during their orientation (which must occur within 60days of employment). Training shall also be provided on an annual basis and as needed.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) call light was placed within reach. This failure had the potential for Resident 1's unmet care needs.Findings:During a concurrent observation and interview, on 1/6/26 at 1:55 p.m. with Resident 1, in resident 1's room, Resident 1 was lying in bed with the head of the bed elevated. Resident 1 stated, They (certified nursing assistant [CNA]) do not give me my call light.During an observation on 1/6/26 at 2:36 p.m. outside of Resident 1's room, Resident 1 was heard yelling, CNA I don't have a call button. Resident 1 continued to call out for a CNA until 2:43 p.m.During a concurrent observation and interview, on 1/6/26 at 2:43 p.m. with CNA 4, in Resident 1's room, Resident 1 was lying in bed with the head of bed elevated. Resident 1's call button was looped to the bed rail but was hanging behind the top right-hand side of the mattress. CNA 1 stated Resident 1 could not reach the call light. CNA 1 stated the call light should be in easy reach for the residents. During a review of the facility's policy and procedure (P&P) titled, Call Light - Answering, reviewed 4/25/14, the P&P indicated, The purpose of this policy is to meet the residents' needs and requests within an appropriate time frame. It is the only mechanism at the resident's bedside whereby residents are able to alert nursing personnel to their needs. Each resident receives directions upon admission on how to use the call light system and where the call light is positioned at the bedside. All residents will have a call light in-place at all times.

Based on interview and record review, the facility failed to ensure allegations of abuse were reported and investigated timely for one of three sampled residents (Resident 1). This failure resulted in a delay in reporting and Resident 1 not to be protected from further abuse.Findings:During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 10/28/25, the MDS indicated, Resident 1' s BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness).During a review of Resident 1's SBAR (situation, background, appearance, and review) Communication Form, (SBAR) dated 12/21/25, the SBAR indicated, Attention brought by CNA (Certified Nursing Assistant) that resident sustained a skin tear (an acute, traumatic wound where the top layers of skin separate from the underlying tissue due to friction, shearing, or blunt force) while changing her and doing ADLs (Activities of Daily Living - basic self-care tasks like bathing, dressing, toileting, and eating), resident had accidentally was bumped on side rail.During a review of Resident 1's Special Problems, (SP) dated 12/21/25, the SP indicated, (Resident 1) screamed Ouch you (expletive) you hit me told her I didn't hit you, you hit yourself with the siderail the SP was signed by CNA 3.During a review of Resident 1's Nurse's Notes, (NN) dated 12/23/25, the NN indicated, SOC 341 was filled due to resident claiming that she was hit on the right hand and sustained a skin tear during ADLs.During a concurrent observation and interview, on 1/6/26 at 1:55 p.m. with Resident 1, Resident 1 stated on 12/21/25, two CNAs were providing care. Resident 1 stated one of the CNAs was gripping and told her she screamed too much, and she should say please and thank you. Resident 1 stated her hand was injured during care and she told the CNAs you hit me. Resident 1's right hand was noted with a scab the size of a dime over the pinky finger knuckle.During an interview on 1/6/26 at 3:30 p.m. with CNA 2, CNA 2 confirmed she cared for Resident 1 on 12/21/25. CNA 2 stated she requested CNA 3 to assist with care for Resident 1. CNA 2 stated during care Resident 1 was injured and stated Resident 1 hit herself on the bedrail causing a skin tear. CNA 2 stated, (Resident 1) told us (CNA 2 and CNA 3) ouch you hit me, and we (CNA 2 and CNA 3) just said we did not hit you.During an interview on 1/6/26 at 3:49 p.m. with the Director of Nursing (DON), DON stated Resident 1 made allegations to CNA 2 and CNA 3 that CNA 2 and CNA 3 hit Resident 1. DON stated CNA 2 and CNA 3 did not report Resident 1's allegations. DON stated CNA 2 and CNA 3 were trained on how to report allegations of abuse.During an interview on 1/7/26 at 1:54 p.m. with CNA 3, CNA 3 stated on 12/21/25 she assisted CNA 2 with Resident 1's care. CNA 3 stated Resident 1 was injured during care, and she made an allegation that CNA 2 and CNA 3 hit her. CNA 3 stated, (Resident 1) told us you hit me, we told her no we did not, you hit the rail. CNA 3 stated she did not report Resident 1's allegations of abuse because I know people her age say things and I felt like she was mad.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, revised 7/22/21, the P&P indicated, 4. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or physical abuse is reported, the Nursing Supervisor or Supervisor of the mandated reporter, shall notify the appropriate person and agencies as listed below: a. The Resident's Responsible Party; b. The Resident's attending physician; c. The Ombudsman or Local Law Enforcement; and d. CDPH . 5. Notices to the above agencies/individuals must be submitted by telephone or confirmed fax within 24 hours from the time the incident occurred utilizing the SOC 341 form. 13. A person shall not knowingly; . Fail to report an incident of mistreatment or other offense; . The facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, residents will be protected from harm by the following measures: a. Staff will ensure the immediate physical safety of the resident first by ensuring that the accused perpetrator is not near the resident. Staff will observe to ensure that both parties remain separated until further investigation. All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to the Ombudsman or law enforcement and CDPH as required by law and in accordance with this policy. If a Resident sustained no serious bodily injury: Within 24 hours: Report the incident by phone to law enforcement. Within 24 hours: Submit a completed SOC 341 to the Ombudsman, law enforcement, and CDPH.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) wound was treated by a licensed nurse. This failure had the potential for allergic reaction (an immune system [a complex network of cells tissues and organs that defend against bacteria] overreaction to a harmless substance, causing symptoms ranging from mild to severe, and life-threatening) and/or infection (occurs when harmful bacteria enter the body, multiply, and trigger an immune response) for Resident 1.Findings:During an interview on 1/6/26 at 3:30 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated during care Resident 1 got a skin tear (an acute, traumatic wound where the top layers of skin separate from the underlying tissue due to friction, shearing, or blunt force) and CNA 3 went to the treatment nurse and got a triple antibiotic ointment (a combination of three medications used to treat or prevent infections in minor cuts and scrapes, to promote faster healing by stopping bacterial growth) and a pad to clean the skin tear and a band aid. CNA 3 cleaned Resident 1's skin tear and applied the triple antibiotic ointment placed the band aid on Resident 1's skin tear.During an interview on 1/6/26 at 3:56 p.m. with Director of Nursing (DON), DON stated CNAs are not allowed to do wound treatments.During a review of Resident 1's Special Problems, (SP) dated 12/21/25, the SP indicated, accidently hitting her against the side rail went to get a bandage for her & some ointmen [sic] antibiotic & I apply it on (Resident 1) . signed by CNA 3.During an interview on 1/7/26 at 1:54 p.m. with CNA 3, CNA 3 stated Resident 1 received a skin tear during care. CNA 3 stated she went and told the treatment nurse; the treatment nurse gave her ointment and a band aid. CNA 3 stated she applied the ointment and the band aid to Resident 1's skin tear.During a review of the facility's policy and procedure (P&P) titled, Medication Administration Schedule, revised 10/19/22, the P&P indicated, Medications are administered as prescribed in accordance with manufacturers' specification, good nursing principles and practices only by persons legally authorized to do so. Medications are prepared only by the licensed nurse, pharmacy or other personnel authorized by the state regulations to prepare and administer medications.

Based on interview and record review, the facility failed to: 1. Complete reference checks for two of three sampled employees (Certified Nursing Assistant/CNA 1 and CNA 2) prior to employment and;2. Complete the background check for CNA 1.These failures had the potential to put the residents at risk for abuse.Findings:During a concurrent interview and record review on 12/12/25 at 12:20 p.m. with Director of Nursing (DON) and Human Resource Assistant (HRA), CNA 1's employee file was reviewed. CNA 1's employee file indicated CNA 1 was hired 3/25/25. There were no reference checks done or exclusion (office of inspector general) background check completed prior to employment. DON and HRA stated per policy the reference checks and background check should have been completed prior to employment.During a concurrent interview and record review on 12/12/25 at 12:20 p.m. with DON and HRA, CNA 2's employee file was reviewed. CNA 2's employee file indicated CNA 2 was hired 1/9/23. There was no reference checks done prior to employment. DON and HRA stated per policy the reference checks should have been completed prior to employment.During a review of the facility's (P&P) titled, Abuse Prevention Program dated 7/22/21, the P&P indicated, Screening.Potential employees will be screened for history of abuse, neglect or mistreatment of resident as defined by the applicable requirements utilizing the following tools.Reference checks with previous and/or current employers.Refer to Hiring Policy in Appendix for additional procedures regarding screening of potential employees.The following checks must be done for all employees and potential applicants.all the following must be checked per applicant.CA courts, which included supreme, 5th appellate district, Megan's law website, exclusion, L&C (licensing and certification) verification search.

Based on interview and record review, the facility failed to ensure two of two sampled employees, (Certified Nursing Assistant [CNA 1] and CNA 2), had the required criminal background checks prior to their date of hire. This failure had the potential to expose the residents to staff with criminal backgrounds and exposing residents to risks for abuse.Findings:During a concurrent interview and record review, on 11/20/25 at 1:22 p.m. with the Director of Nursing (DON), CNA 1 and CNA 2's employee files were reviewed. DON stated CNA 1's date of hire was 10/6/25, and CNA 2's date of hire was 8/19/24. CNA 1 and CNA 2's criminal background checks were reviewed. DON confirmed no dates were documented on CNA 1 and CNA 2's criminal background checks.During an interview on 11/20/25 at 1:51 p.m. with Human Resources (HR), HR stated criminal checks were completed before hire date. HR stated she takes screen grabs (picture of computer screen) of criminal background checks; HR confirmed no dates were captured on the screen grabs. HR stated she was unable to provide evidence that criminal background checks were completed before CNA 1 and CNA 2's date of hire. During a review of the facility's policy and procedure (P&P) titled, Hiring' effective date April 2023, the P&P indicated, I. HIRING The following process will be followed in the hiring of full-time and part-time positions, including temporary employees and per diem employees: . II. EMPLOYMENT ELIGIBILITY VERIFICATION . 3. Each applicant for employment will be screened for the following: criminal background, fraud, and sex offender checks via the internet through the following links California Court of Appeals - Supreme Court, California Court of Appeals - 5th District Court, Megan's Law and The Office of Inspector General. If the applicant's verification check reveals that the applicant has any documented actions against them, the applicant will not be considered for hire.

Based on interview and record review, the facility failed to:1. Provide discharge notice before discharging one of three sampled residents (Resident 1) to include the reasons for discharge. This failure had the potential for Resident 1 being discharged inappropriately and not prepared for his discharge.2. Send a copy of the notice of discharge to the Office of the State Long-Term Care Ombudsman (Ombudsman-an elderly advocacy agency) for 12 of 13 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11 and Resident 12). This failure had the potential to prevent the Ombudsman from assisting and advocating for Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11 and Resident 12 during their discharge process.Findings:During a review of Resident 1's admission Record (AR), printed 11/14/25, the AR indicated Resident 1 was [AGE] years old was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, difficulty walking, and unsteadiness on feet. The AR indicated Resident 1's Responsible Party (RP) (the person who makes medical decisions on behalf of the resident) was Family Member (FM) 1.During a review of Resident 1's Physician Order (PO), dated 11/7/25 at 3:57 p.m., the PO indicated: Discharge to home on [DATE] @ 9 AM with same meds [medications] and treatment with Around the Clock Home Health PT/OT/ST [Physical Therapy] [Occupational Therapy] [Speech Therapy].During a review of Resident 1's Notice of Proposed Transfer/Discharge (ND), dated 11/9/25, the ND indicated the Resident 1 was being discharged because the resident's health had improved sufficiently that he no longer needed the services provided by the facility. The ND indicated the ND was provided to FM 1 on 11/9/25 (on the day of discharge).During an interview on 12/22/25 at 9:30 a.m. with the Director of Nursing (DON), DON stated Resident 1discharge order was written on 11/7/25 and Resident 1 was discharged on 11/9/25. DON stated the ND was provided to FM 1 on 11/9/25.During an interview with the Social Services Assistant (SSA) on 12/22/25 at 10:07 a.m., SSA stated the ND was provided to FM 1 on 11/9/25 (the day of discharge) and not on 11/7/25 (the day Resident 1's physician signed his discharge order) because FM 1 was not at the facility on 11/7/25 and only came to the facility on [DATE]. SSA stated FM 1 was verbally informed of the discharge on [DATE] and on 11/5/25 when the Notice of Non Medicare Coverage (NUMNOC) was given to him.2. During a concurrent interview and record review with the SSA on 12/22/25 at 10:07 a.m., SSA stated she did not send copies of residents' ND's to the Ombudsman. SSA provided a copy of document titled Discharge Control and Task Log (Discharge Log) dated 11/14/25. The Discharge Log indicated the following:Resident 2 discharged on 11/1/25Resident 3 discharged on 11/3/25Resident 4 discharged on 11/4/25Resident 5 discharged on 11/4/25Resident 6 discharged on 11/4/25Resident 7 discharged on 11/5/25Resident 8 discharged on 11/5/25Resident 9 discharged on 11/6/25Resident 10 discharged on 11/7/25Resident 1 discharged on 11/9/25Resident 11 discharged on 11/10/25Resident 12 discharged on 11/11/25During a review of email communication dated 12/22/25 at 2:01 p.m., the Ombudsman stated they did not receive Resident 1's ND. The Ombudsman stated the facility did not send them the NDs. The Ombudsman denied informing the facility not to send them NDs. The Ombudsman stated the facility only sent them a list of residents discharged and list contained only the name, admission and discharged dates and where the residents were discharged to. The Ombudsman stated their office had previously notified the facility in writing to send them NDs of all residents to be discharged . The Ombudsman provided copy of a letter sent to the facility on 8/22/25 indicating the facility's requirement to send NDs of all discharged residents to the Ombudsman.During a review of facility policy and procedure (P&P) titled Transfer and Discharge Notice, dated 2/25/10, the P&P indicated: Facility-initiated Transfer and Discharges: Notice of Transfer/Discharge is required. a written notice of discharge must be provided to the resident and the resident representative with a copy to the State LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the Ombudsman must be sent at the same time notice is provided to the resident and resident representative.

Based on interview and record review, the facility failed to implement an effective discharge plan for one of three sampled residents (Resident 1) when Resident 1 was discharged home without home health services (where health care professionals provide health care services to the resident at his home) as ordered by the physician and failed to document a post-discharge plan of care in Resident 1's discharge summary. These failures had the potential to place Resident 1 at risk for not achieving his health care goals and preventable hospital and/or skilled nursing facility readmission.Findings:During a review of Resident 1's admission Record (AR), dated 11/14/25, the AR indicated Resident 1 was [AGE] years old, was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, difficulty walking, and unsteadiness on feet. The AR indicated Resident 1's Responsible Party (RP-the person who makes medical decisions on behalf of the resident) was Family Member (FM) 1.During a review of Resident 1's Physician Order (PO), dated 11/7/25 at 3:57 p.m., the PO indicated, Discharge to home on [DATE] @ [at] 9 AM with same meds [medications] and treatment with Around the Clock Home Health PT/OT/ST [Physical Therapy] [Occupational Therapy] [Speech Therapy] .During a review of Resident 1's Discharge Summary (DS), dated 11/9/25, the DS indicated, Your physician has requested the following as a part of your post-discharge treatment plan: PT [Physical Therapy] OT [Occupational Therapy] ST [Speech Therapy]. The DS indicated Resident 1 Requires Assistance with ambulation, transfers, toileting, dressing, bathing and grooming. The DS had no information how Resident 1 was to obtain PT/OT/ST. Resident 1's DS section titled Discharge Planning/Discharge Care Plan was blank.During a review of Resident 1's Progress Note (PN) dated 11/10/25 at 10:11 a.m., the PN indicated Follow up with [Home Health Agency].home health is unable to service resident's area.During a review of Resident 1's Progress Note (PN) dated 11/12/25 at 10:29 a.m., the PN indicated Resident 1's insurance informed they did not have in-network [contracted with them] home health agencies in the area Resident 1 lived in and that Resident 1 needs to go out of network with another doctor in his area so he can obtain home health services in his area. During an interview with FM 1 on 11/14/25 at 10:55 a.m. FM 1 stated Resident 1 had been discharged to his care and was living with him. FM 1 stated he could not care for Resident 1, that Resident 1 was physically weak and that Resident 1 could not independently complete activities of daily living. FM 1 stated Resident 1 stayed seated on a sofa chair in the living room the whole day. FM 1 stated nobody had come to provide any health care to Resident 1.During an interview on 12/22/25 at 9:30 a.m. with the Director of Nursing (DON), DON stated Resident 1 had been admitted [DATE] for PT/OT/ST and was discharged home on [DATE] because his health insurance denied skilled nursing facility coverage past 11/9/25. DON stated Resident 1's PO indicated Resident 1 to receive PT/OT/ST at home provided by a home health agency. DON stated the facility could not arrange home health services to Resident 1 because no home health agency provided services where Resident 1/FM 1 lived in. DON stated Resident 1 was discharged home on [DATE] with no home health care services.During an interview with the Social Services Assistant (SSA) on 12/22/25 at 10:07 a.m. SSA stated Resident 1 was ordered to be discharged with home health services, but she could not find a home health agency servicing the area Resident 1 lived in. SSA stated We tried home health, and nobody would service that area. SSA stated she contacted Resident 1's insurance company and was advised that Resident 1 needed to seek an out of network home health agency that serviced the area he lived in. SSA stated she informed FM 1 of the above but stated I don't think he understood. SSA stated Resident 1 was discharged to the care of FM 1 on 11/9/25 with no home health services.During a review of the facility's policy and procedure (P&P) titled, Discharge Documentation, dated 3/9/23, the P&P indicated, When a discharge is anticipated, the resident will have a discharge summary which includes a. a post-discharge plan of care. which will assist the resident to adjust to his/her new living environment.

Based on interview and record review, the facility failed to report an allegation of physical abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (CDPH). This failure had the potential for abuse to continue and had the potential for other residents to be abused.Findings:During a review of Resident 1's admission RECORD (AR), dated 8/5/25, the AR indicated, Resident 1 was a [AGE] year old male who admitted to the facility on [DATE] with a diagnosis of anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), muscle weakness, legal blindness, history of falling, and need for assistance with personal care. During a review of Resident 1's ED (Emergency Department) Physician Notes (EDPN), dated 7/14/25, the EDPN indicated Resident 1 arrived at the acute hospital emergency department stating, Needed to get out of truck and that they [unknown] were crossing the road, and the [facility] staff is abusing [Resident 1].During an interview on 8/5/25 at 2:05 p.m. with Administrator, Administrator stated he was the abuse coordinator (a designated staff member responsible for preventing and addressing abuse within the facility). Administrator stated on 7/14/25 he was called into Resident 1's room by staff (not specified who) due to Resident 1's behavior of purposely kneeling on the floor, refusing food and medication, and requesting to be sent to the acute hospital. Administrator stated Resident 1 told him, You guys [not specific which staff] are hitting and kicking me. Administrator stated a report for Resident 1's allegation of abuse was not submitted to the CDPH as of 8/5/25 despite the allegation of staff abusing Resident 1 being made on 7/14/25. Administrator stated there should have been a report of allegation of abuse submitted to the CDPH. During a review of the facility's policy and procedure (P&P) titled, Reporting Abuse to State Agencies, and Other Entities, undated, the P&P indicated, All alleged/suspected violations and all substantiated incidents of abuse will be promptly reported to the Ombudsman or law enforcement and CDPH (California Department of Public Health) as required by law and in accordance with this policy. If a Resident sustained no serious bodily injury . Within 24 hours.

Based on observation, interview, and record review, the facility failed to ensure for five of 72 sampled residents (Resident 47, Resident 86, Resident 96, Resident 105, Resident 92) call lights were answered promptly. This failure had the potential to result in residents' unmet needs. Findings: During a concurrent observation and interview on 2/4/25 at 9:30 a.m. in Resident 47's room, Resident 47's call light was on. Resident 47 stated she needed some help from her Certified Nursing Assistant (CNA) because she had a dirty brief. During a concurrent observation and interview on 2/4/25 at 9:31 a.m. in the hallway outside of Resident 47's room, a light was on above Resident 47's door indicating her call light was on. CNA 4 was observed walking past the call light and going in and out of rooms on the opposite side of the hallway. CNA 4 stated she was new to the facility and was not sure which CNA was assigned to Resident 47's side of the hallway. During an observation on 2/4/25 at 9:35 a.m., CNA 4 entered Resident 47's room, was heard telling Resident 47 give me one second, and left the room without changing Resident 47's brief. CNA 4 proceeded to get the Hoyer lift and walk into room [ROOM NUMBER] at the end of the hallway. During an observation on 2/4/25 at 9:40 a.m. in the hallway outside of Resident 47's room, Resident 47's call light was on and a nurse wheeling the medication cart passed the room without answering the call light. During a concurrent observation and interview on 2/4/25 at 9:43 a.m. in Resident 47's room, CNA 1 answered Resident 47's call light. CNA 1 stated CNAs try to get to residents as soon as possible but if another CNA can't get to them, we should get them whatever they need. CNA 1 stated residents with dirty briefs needed to be changed right away. During an interview on 2/4/25 at 10:35 a.m. with Resident 47, Resident 47 stated CNAs have told her she is too needy and should not ring her call light so much. Resident 47 stated CNAs have told her they have to spend all their time taking care of her, so they don't have time with other residents. 34510 During an interview on 2/4/25 at 10:22 a.m. with Resident 105, Resident 105 stated when the call light took too long for staff to answer, she felt desperate. During a review of Resident 105's Minimum Data Set (MDS- comprehensive assessment tool), dated 1/16/25, the MDS indicated, Resident 105 had a Brief Interview for Mental Status (BIMS- cognitive assessment) score of 15 (score of 13-15 means cognitively intact). Resident 105's MDS indicated, Resident 105 required partial/moderate assistance (helper does more than half the effort) with activities of daily living. During an interview on 2/4/25 at 10:22 a.m. with Resident 92, Resident 92 stated it takes staff more than 15 minutes for staff to answer the call light. Resident 92 stated she felt frustrated. During a review of Resident 92's MDS, dated [DATE], the MDS indicated, Resident 92 had a BIMS score of 15. Resident 92's MDS indicated, Resident 92 required supervision or touching assistance (helper provides verbal cues). 37797 During a concurrent observation and interview on 2/3/25 at 2:29 p.m. with Resident 96, Resident 96 stated she needed to be changed and pressed the call light. The call light was answered at 2:44 p.m. During an interview on 2/4/25 at 8:30 a.m. with Resident 86, Resident 86 stated she and other residents routinely waited 15 minutes or more for call lights to be answered, which was too long. During an interview on 2/6/25 at 2:36 p.m. with Administrator, Administrator stated, If you are passing a light, you should be answering that light. Administrator stated a 15-minute delay in answering a call light is not prompt. During a review of the facility's policy and procedure (P&P) titled, Call Light- Answering, dated 4/25/14, the P&P indicated, PURPOSE: The purpose of this policy is to meet the residents' needs and requests within an appropriate time frame. It is the only mechanism at the resident's bedside whereby residents are able to alert nursing personnel to their needs. PROCEDURE: NURSING ACTION . 5. Staff will observe call lights. 6. Answer all lights promptly, regardless of whose resident it is.

Based on interview and record review, the facility failed to ensure nine of nine employees' (Plant and Maintenance [PM], Housekeeper [HSK] 1, Certified Nursing Assistant [CNA] 1, CNA 2, Registered Nurse [RN] 2, Licensed Vocational Nurse [LVN] 1, Nursing Assistant [NA] 1, NA 2, and NA 3) Covid 19 (infectious respiratory illness) vaccination status were tracked and recorded. This failure had the potential to spread Covid-19 to residents, staff, and visitors. Findings: During a review of the facility's Employee Covid-19 Vaccination Log, (undated), the Employee Covid-19 Vaccination Log indicated, the following employees had no record of Covid-19 vaccination status: a) PM, hired on 7/16/24. b) HSK 1, hired on 11/14/24. c) CNA 1, hired on 8/12/24. d) CNA 2, hired on 8/15/24. e) RN 2, hired on 11/7/24. f) LVN 1, hired on 10/10/24. g) NA 1, hired on 1/2/25. h) NA 2, hired on 12/31/24. i) NA 3, hired on 1/2/25. During an interview on 2/5/25 at 9:05 a.m. with Infection Preventionist Nurse (IPN), IPN stated, The recently hired staff who have no Covid-19 vaccine immunization record were not recorded because when they were hired, it [Covid-19 vaccination] was not mandatory to get the Covid-19 vaccine. IPN stated, I don't ask them anymore. During an interview on 2/5/25 at 9:09 a.m. with Scheduler Personnel (SP), SP stated the employees who had no Covid-19 vaccination status record are currently employed. During a review of the facility's policy and procedure (P&P) titled, Mandatory Vaccination & Booster Policy, dated 1/1/22, the P&P indicated, All employees are required to report their vaccination status and to provide proof of vaccination to a member of the infection prevention team or human resources. Employees must provide truthful and accurate information about their Covid-19 vaccination status, and if applicable, their testing results.

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Three of three sampled personal laundry cart covers were soiled and discolored. This failure had the potential for contaminating clean linen and spread of infection to residents. 2. One of three sampled clean linen closets had a dark discolored floor with debris. This failure had the potential for contaminating clean linen and spread of infection to residents. 3. Two of two Registered Nurses (RN 1 and RN 3) failed to clean and disinfect glucometers (medical devices used to measure the amount of glucose[sugar] in the blood) according to facility policy and manufacturer's guidelines. after resident use. This failure had the potential to expose residents to bloodborne pathogens (microorganisms [bacteria or virus] in the blood that can cause life threatening disease). Findings: 1. During a concurrent observation and interview on 2/4/25 at 1:58 p.m. in the laundry room with Housekeeping and Laundry Aide ([NAME]), there were three personal laundry carts loaded with residents' clean personal clothes. The laundry carts' mesh covers were soiled and discolored. [NAME] stated, Those covers [personal laundry cart mesh covers] were white and now they are brownish tan. During an interview on 2/4/25 at 2 p.m. with Housekeeping and Laundry Supervisor (HLS), HLS stated the laundry carts' mesh covers needed to be replaced. HLS stated the clean laundry needed protection from dusts during transport. During a review of the facility's policy and procedure (P&P) titled, Handling Linen and Resident's Personal Laundry, dated 5/7/12, the P&P indicated, Purpose: To ensure linen is handled, stored and transported in a safe and sanitary manner to prevent cross contamination and the potential for disease transmission. B. Clean linen from the laundry room shall be delivered in clean covered laundry carts. 2. During a concurrent observation and interview on 2/4/25 at 2:12 p.m. with HLS in the clean linen closet, the clean linen closet floor had dark gray discolorations and debris. HLS stated, It [floor] has not been cleaned in a while. During a review of the facility's P&P titled, Environmental Services Infection Prevention & Control, dated 6/1/17, the P&P indicated, Floors will be cleaned using microfiber floor cleaning products daily using the detergent germicide. 37797 3. During a concurrent observation, interview, and record review on 2/4/25 at 3:25 p.m. with RN 1, RN 1 checked the blood sugar level of Resident 18 with a [NAME] True Metrix PRO (brand name) glucometer. After reading the results, RN 1 wiped the glucometer with a Super Sani-Cloth (brand name) Germicidal Disposable Wipe. The glucometer dried in fewer than 10 seconds. RN 1 stated the glucometer was disinfected and ready to be used for the next resident. The label of the Super Sani-Cloth Germicidal Disposable Wipe was reviewed. The label indicated Disinfects in 2 minutes. During an interview on 2/6/25 at 8:18 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated glucometers should be disinfected after each use using Super Sani-Cloth Germicidal Disposable Wipes. The IPN stated staff should keep the glucometer wet with the wipe's solution for at least three minutes to eliminate bloodborne pathogens. The IPN stated failure to follow the three-minute contact time could result in the transmission and infection of residents with bloodborne pathogens. 44134 During an observation on 2/5/25 at 12:19 p.m. in Resident 119's room, RN 3 used a glucometer to check Resident 119's glucose level. After use, RN 3 wiped the glucometer with one alcohol prep pad (a sterile gauze pad that is soaked in alcohol antiseptic[prevents the growth and action of microorganisms]) that measured approximately one inch by one inch. RN 3 cleaned the glucometer for less than 30 seconds. RN 3 then left Resident 119's room, walked into the hallway and placed the glucometer on top of a medication cart. During a concurrent observation and interview on 2/5/25 at 12:21 p.m. in the hallway near Resident 119's room, RN 3 picked up the glucometer that was sitting on top of the medication cart and placed it into the medication carts top drawer. RN 3 stated the glucometer had been cleaned with an alcohol prep pad in Resident 119's room, prior to placing it into the medication cart drawer. RN 3 stated she cleans the glucometers with alcohol prep pads after each use. RN 3 stated the facility policy is to clean the glucometers with alcohol after use. During an interview on 2/6/25 at 8:20 a.m. with IPN, IPN stated glucometers are to be cleaned for three minutes after each use with Sani-Wipes. IPN stated if the glucometers are not properly cleaned there was a risk for transmission-based infection. IPN stated it was not appropriate for staff to clean glucometers with alcohol pads. During a review of the [NAME] True Metrix PRO Glucometer manual, (undated), the manual indicated, Meter should be cleaned and disinfected between patients. To Disinfect: Using fresh wipes, make sure that all outside surfaces of the meter remain wet for 2 minutes . During a review of facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Glucometer, revised 7/15/21, the P&P indicated, Disinfect (after each use) after cleaning the exterior surfaces following the manufacturers' directions using a cloth/wipe with either and [sic] EPA-registered detergent/germicide with a tuberculocidal [kills pathogens] and HBV/HIV [bloodborne pathogen] label claim. Alcohol should not be used unless indicated by manufacturer's label and instructions.

Based on observation, interview, and record review, the facility failed to ensure professional standards for food service safety and sanitary kitchen conditions when: 1. Dented canned products were retained in dry storage for use. 2. Dry food storage container lid was not closed and secured per safe storage and guidelines. These failures had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) for at-risk vulnerable residents. Findings: 1. During a concurrent observation and interview on 2/3/25 at 8:59 a.m. with Dietary Manager (DM), in the dry food storage room (DFSR), multiple dented 50-ounce tomato soup cans were stored. DM stated the dented tomato soup cans shouldn't be in here, and needed to be removed. DM stated there were nine out of 12 tomato soup cans dented. DM stated the dented tomato soup cans posed a food safety risk. During a concurrent interview and record review on 2/3/25 at 2:16 p.m. with DM, the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL SUBJECT: CANNED AND DRY GOODS STORAGE, dated 2018 was reviewed. The P&P indicated, POLICY: all the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly. PROCEDURES. 10. Canned food items should be routinely inspected for damage such as dented. cans. These items should be set aside in a designated area for return to the vendor or disposed of properly. DM stated the P&P was not followed and should have been. DM stated the designated [dented can] place is in my office. 2. During a concurrent observation and interview on 2/3/25 at 9:09 a.m. with DM in the DFSR, the dry lentil beans 22-quart container was open. DM stated the lentil beans container lid should have been closed. DM stated, the open lid could cause food contamination or insects can go in. During a concurrent interview and P&P review on 2/3/25 at 2:19 p.m. with DM, the facility's P&P titled, SANITATION AND INFECTION CONTROL SUBJECT: CANNED AND DRY GOODS STORAGE, dated 2018 was reviewed. The P&P indicated, POLICY: all the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly. PROCEDURES. 9. Metal, plastic containers (with tight fitting lids). will be used. DM stated the kitchen staff were expected to follow policy.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of three of 27 sampled residents (Resident 93, Resident 128, and Resident 96) when: 1. Staff did not follow Resident 93's physician order to remove a Lidocaine patch (a pain medication applied directly to the skin) from Resident 93's back after 12 hours of application. This failure resulted in Resident 93 having Lidocaine applied for a period longer than prescribed. 2. Staff administered a Nifedipine Extended Release tablet (a medication to treat high blood pressure especially formulated to slowly release the drug into the bloodstream over an extended period and to be administered whole) crushed into a powder to Resident 128. This failure resulted in Resident 128 receiving Nifedipine at a higher dose than prescribed. 3. Staff failed to ensure Morphine and Methadone (controlled drugs with a high potential for abuse and addiction) prescribed for Resident 96 were properly accounted for. This failure resulted in Resident 96 at risk of having her Morphine and Methadone medications lost or diverted. 4. Staff failed to follow policy and procedure when the outgoing nurse of the East Wing signed the end of shift narcotic count sheet before the end of her shift and in the absence of the incoming nurse. This failure had the potential for residents having their controlled medications lost or diverted. Findings: 1. During a review of Resident 93's Admission Record (AR), dated 2/6/25, the AR indicated, Resident 93 was admitted on [DATE] with a principal diagnosis of dementia (decline in memory, thinking, and problem solving). During a review of Resident 93's Order Details (OD), (undated), the OD indicated, physician order dated 1/6/25 as follows: Lidocaine External Patch 4% (Lidocaine) Apply to LOWER BACK topically one time a day for PAIN (12 HOURS ON AND 12 HOURS OFF AND REMOVE PER SCHEDULE) and remove per schedule. During a review of Resident 93's Medication Administration Record (MAR), dated 2/1/25-2/28/25, the MAR indicated, Resident 93's Lidocaine Patch was to be applied daily at 8 a.m. and removed at 8 p.m. During a concurrent observation and interview on 2/5/25 at 8:26 a.m. with Registered Nurse (RN) 4, RN 4 stated she would apply Resident 93's Lidocaine Patch. RN 4 retrieved the Lidocaine patch from the medication cart. The label on the Lidocaine patch indicated, Apply 1 Patch to the affected area topically remove per schedule (12 hours on - 12 hours off). RN 4 raised Resident 93's shirt, exposed his back, stated let me remove the old patch, removed a patch of the same size and appearance from his lower back, and applied the Lidocaine patch to the same location. RN 4 stated the Lidocaine patch removed had been applied the previous day in the morning. During an interview on 2/6/25 at 9:10 a.m. with the facility's Consultant Pharmacist (CP), the CP stated staff should administer medications according to physician orders, and that Resident 93's Lidocaine patch should have been removed after 12 hours of application. During a review of facility's policy and procedure (P&P) titled, General Dose Preparation and Medication Administration, dated 1/27/21, the P&P indicated, . facility staff should . verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct time, for the correct resident, as set forth in the Facility Medication Administration Times Schedule . 2. During a review of Resident 128's AR, dated 2/6/25, the AR indicated Resident 128 was admitted on [DATE] with diagnoses including hypertension (high blood pressure) and dysphagia (difficulty swallowing). During a review of Resident 93's Medication Administration Record (MAR), dated 2/1/25-2/28/25, the MAR indicated, physician order dated 7/7/24 as follows: Crushed Medications according to facility policy and pharmacy recommendations and physician order dated 12/9/24 as follows: Nifedipine ER Osmotic Release Oral Tablet Extended Release 24 hours 30 MG (Nifedipine) Give 1 tablet by mouth one time a day . During a concurrent observation and interview on 2/5/25 at 8:38 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she was going to administer medications to Resident 128. LVN 5 removed a tablet from the medication cart with the label Nifedipine 30 mg EXTENDED RELEASE 24 HOURS. LVN 5 crushed the tablet into a powder and gave it to Resident 128 mixed with food. LVN 5 stated Resident 128 took all his medications crushed. During a concurrent interview and record review on 2/6/25 at 9:10 a.m. with the CP, the CP reviewed Resident 128's medication orders and stated Nifedipine Extended Release tablets are designed to slowly release the drug over an extended time and for this reason should not be crushed and should be taken whole. The CP stated crushing Nifedipine Extended Release resulted in the resident receiving a higher dose of the medication than intended. During a review of the Food Drug Administration (FDA) document titled, PROCARDIA XL (nifedipine) Extended Release Tablets For Oral Use NDA 19684/S-023, dated February 2010, the document indicated: Information for Patients: Procardia XL Extended Release Tablets should be swallowed whole. Do not chew, divide or crush tablets. During a review of the facility's policy and procedure (P&P) titled, General Dose Preparation and Medication Administration, dated 1/27/21, the P&P indicated, Facility staff should only crush oral medications that can be crushed. 3. During a review of Resident 96's AR, dated 2/6/25, the AR indicated, Resident 96 was admitted on [DATE] for palliative care (end of life care). During a review of Resident 96's OD, (undated), the OD indicated, the following two medication orders for pain control: Morphine Sulfate Oral Solution 100 mg/5 ml *Controlled Drug* Give 10 mg sublingually every 6 hours for pain management. and Methadose Oral Concentrate 10 MG/ML (Methadone HCL) *Controlled Drug* Give 0.5 ml by mouth two times a day for pain management. During a concurrent observation, interview, and record review on 2/5/25 at 10:52 a.m. with RN 3 and LVN 4, RN 3 and LVN 4 provided the Controlled Drug Record sheets (Narcotic Logs) for February 2025 for Resident 96's morphine and methadone. RN 3 and LVN 4 stated each time a nurse administered those medications they documented in the Narcotic Log the dose administered and how much was left in the vial. The Narcotic Log for Resident 96's morphine indicated, the last dose was given on 2/5/25 and there were 4.5 ml of morphine left in the vial. LVN 4 retrieved Resident 96's morphine vial from the medication cart and stated there were 9 ml left in the vial. A review of the Narcotic Log for Resident 96's methadone indicated the last dose was given on 2/5/25 and there were 10 ml of methadone left in the vial. RN 3 retrieved Resident 96's methadone vial from the medication cart and stated there were 16 ml left in the vial. During an interview on 2/6/25 at 1:35 p.m. with the Director of Nursing (DON), the DON stated there should be no discrepancies between what is documented in the Narcotic Logs and the controlled medications in the medication carts. During a review of facility's policy and procedure (P&P) titled, Controlled Medications, dated 3/18/18, the P&P indicated, The facility nursing staff and the pharmacy will follow procedure to assure that the controlled drugs are accounted for, and their use readily traceable. 4. During a concurrent interview and record review on 2/5/25 at 10:45 a.m. with RN 3, RN 3 provided the Shift Verification of Controlled Substances sheet (Verification Sheet) for the East Wing of the facility for February 5, 2025. RN 3 stated the Verification Sheet was used by nurses at shift change to document that all doses of controlled medications stored in the medication cart matched the doses documented on the Narcotic Log. RN 3 stated during each shift change, at 6:30 a.m., 2:30 p.m., and at 10:30 p.m., both the outgoing and the incoming nurses signed the Verification Sheet. The Verification Sheet for February 5, 2025, indicated it had already been signed by the outgoing nurse for the shift ending at 2:30 p.m., but was not signed by the incoming nurse. RN 3 stated both nurses had to sign the Verification Sheet at the same time during shift change. During an interview on 2/6/25 at 1:35 p.m. with the DON, the DON stated nurses should not sign the shift verification of controlled substances in advance. During a review of facility's P&P titled, Controlled Medications, dated 3/18/18, the P&P indicated, Controlled drug reconciliation every shift . controlled drug quantities will be verified and reconciled at the change of each nursing shift . at the completion of each nursing shift, the on-coming and off-going nurses will count and reconcile the controlled drugs . each nurse will sign that such count on the Verification of controlled substance sheet as accurate.

Based on observation, interview, and record review, the facility failed to provide physical assistance and/or use of transfer device during ambulation (walking) to ensure safety for one of three sampled residents (Resident 1), when the Director of Rehabilitation (DOR), who was assisting Resident 1 while walking, did not provide a hand support to Resident 1 due to DOR was holding a cellphone on her left hand and holding a wheelchair on her right hand. This failure resulted in Resident 1 falling, sustaining a right shoulder tendon (connective tissue that connects the muscle to the bone) tear, suffering from severe pain, and going to the general acute care hospital. Findings: During a review of Resident 1's SBAR (Situation, Background, Assessment, and Recommendation) Communication and Progress Note (SBAR), dated 5/15/24 at 1:40 p.m., the SBAR indicated, Patient [Resident 1]was being ambulated with the use of FWW [Front-Wheeled Walker] under rehab [rehabilitation] supervision while reaching back to her wheelchair to sit [sic], patient [Resident 1] loss of balance [sic] was eased down to floor by rehab staff [Director of Rehabilitation/DOR]. During a concurrent observation and interview on 6/4/24 at 10:55 a.m. in Resident 1's room, with Resident 1, Resident 1 was lying in bed. Resident 1's facial expression was grimacing. Resident 1 stated she is having a right shoulder pain due to the fall incident. Resident 1 stated DOR was on Facetime (video call) on her cellphone while DOR was assisting Resident 1while walking on 5/15/24. Resident 1 stated DOR was holding a cellphone with her left hand and using her right hand to hold the wheelchair. Resident 1 stated she told DOR she was feeling really dizzy. Resident 1 stated she tried to sit back onto the wheelchair, but the wheelchair was too far back and not within reach when attempting to sit back. Resident 1 stated she fell forward, face down onto the floor. Resident 1 stated DOR did not apply a gait belt (transfer belt is a device applied on a resident's waist who has mobility issues, by a caregiver prior to moving or walking the resident for safety), before assisting Resident 1 to walk on 5/15/24. During an interview on 6/4/24 at 12:15 p.m. with DOR, DOR stated she was holding a cellphone with her left hand and pulling Resident 1's wheelchair with her right hand. DOR stated she grabbed and held Resident 1's upper body to ease Resident 1 to the ground. DOR stated she did not apply a gait belt on Resident 1 prior to the fall incident on 5/15/24. During a concurrent interview and record review on 6/26/24 at 10:10 a.m. with Physical Therapist (PT), Resident 1's Physical Therapy Progress Report (PTPR), dated 5/15/24 was reviewed. The PTPR indicated, Patient [Resident 1] ambulated [walked] 25 feet x [times] 2 with recovery between gait distances with FWW with CGA [Contact Guard Assist-level of assistance in physical therapy where a caregiver places one hand on resident's body to help with balance or body stabilization] and cues [signal] for FWW management, posture, step strength, foot clearance, safety, and BOS (Base of Support), 2 turns CGA. PT stated Resident 1's Physical Therapy order were steady assist and CGA. PT stated CGA means have one hand on the resident to keep resident steady. During a review of Resident 1's Minimum Data Set (MDS-Assessment Tool), dated 5/6/24, the MDS indicated, Resident 1 requires the assistance of one staff with walking. During a review of Resident 1's Admission Record (AR), dated 5/1/24, the AR indicated, Resident 1 had diagnoses of difficulty in walking, unsteadiness on feet, and muscle weakness. During a review of the Resident 1's Care Plan (CP), dated 5/13/24, the CP indicated, The resident [Resident 1] is high risk for falls related to fall risk score 13 [total score of 10 or above means high risk], weakness; psychotropic [medications that affect mental state] drug use. Goal: The resident [Resident 1] will be free of falls or falls will be minimized through the review date. Intervention: One-person assist with transfer. During an interview on 6/13/24 at 1:25 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated she assisted Resident 1 after the fall on 5/15/24. CNA 1 stated while assisting Resident 1 off the floor and back onto bed, she stated she did not see Resident 1 with a gait belt on. During a review of Resident 1's Charting-Falls (CF), dated 5/16/24 (after the fall), the CF indicated, rt [right] knee pain rt ankle swelling, pain level 8/10 [level of 8-10 means severe pain]. Resident 1's CF dated 5/17/24 indicated, right and left upper chest with swelling, right knee and right ankle with swelling, pain level 9/10. Resident 1's CF dated 5/17/24 indicated, Resident [Resident 1] is scheduled for X-rays [imaging creates pictures of the inside of the body] this am [morning] due to c/o [complained of] severe pain: right and left shoulder, back of neck, right and left upper chest with swelling, right knee and right ankle with swelling, left knee, right and left foot. Resident with c/o severe pain. During a review of Resident 1's Hospital Discharge Summary (HDS), dated 5/22/24, the HDS indicated, admitted : 5/18/24. Right shoulder MRI [Magnetic Resonance Imaging-medical imaging technique used to form pictures of the inside the body] evidence of a full-thickness tear [completely detached from the bone] of the supraspinatus tendon [back of the shoulder] measuring 2.8 cm [centimeter] x 2.0 cm in axial dimension [line tear]. During a review of the facility's policy and procedure (P&P) titled, Ambulation Program, dated April 9, 2014, the P&P indicated, Equipment. Gait Belt. D. Observe correct guarding or spotting. 2. Use your other hand to support his/her shoulder or hip if needed. During a review of the facility's policy and procedure (P&P) titled, Use of Gait Belt, dated February 23, 2010, the P&P indicated, A gait belt will be used when ambulating or transferring a resident. E. Hold on to the gait belt firmly with one or both hands.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services for one of seven sampled residents (Resident 1) when Resident 1 experienced repeated seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness) and the Registered Nurse (RN 1) failed to identify the seizure activity, call the physician promptly, send Resident 1 out to a higher level of care promptly and ensure qualified staff monitored the resident when the resident was experiencing seizures. These failures resulted in a delay in receiving prompt medical attention and resulted in an overall decline in Resident 1 ' s physical condition. Findings: During a review of Resident 1 ' s Admission Record (AR) dated [DATE], the AR indicated, diagnoses including Unspecified convulsions (sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders), Muscle weakness, Chronic Obstructive Pulmonary Disease (disease that damages your lungs over time). During a review of Resident 1 ' s MDS (Minimum Data Set - an assessment tool) under Brief Interview for Mental Status (BIMS - an assessment tool for cognition [the mental processes that take place in the brain]) dated [DATE], the BIMS indicated, Resident 1 had a score of 15 out of 15 (intact cognition). During a concurrent observation and interview on [DATE] at 1:34 p.m. with Resident 1 outside the resident dining area, Resident 1 was tearful and had oxygen being delivered via nasal cannula (tube into your nose to deliver oxygen). Resident 1 stated he was sent to the acute hospital a few weeks ago ([DATE]) due to having multiple seizures. Resident 1 stated he was at the hospital for approximately five days. Resident 1 stated after returning from the acute hospital, he now required continuous oxygen and has had difficulty with swallowing. Resident 1 stated he was going to have a swallow evaluation to determine if he was at risk for choking. Resident 1 stated when he eats, he feels as if food is getting stuck in his throat. Resident 1 stated he was tearful due to all the medical issues he has had over the last few weeks. During an interview on [DATE] at 10:07 a.m. with RN 1, RN 1 stated on [DATE] she felt the resident was pretending to have seizures. During an interview on [DATE] at 11:13 a.m. with Director of Nursing (DON), DON stated Licensed Vocational Nurse (LVN 1) contacted her on [DATE] to obtain permission to send Resident 1 out to the acute hospital due to the resident having multiple seizures and RN 1 refusing to send him out to the hospital. DON stated she spoke with RN 1 as to the reason RN 1 would not send Resident 1 out on [DATE] and RN 1 stated she did not feel the resident was truly having seizures. DON stated since Resident 1 ' s return from the acute hospital his condition has changed. Resident 1 now required continuous oxygen and he was having difficulty with swallowing. He required a swallowing evaluation due to concerns with him choking when he eats. During an interview on [DATE] at 10:51 a.m. with LVN 1, LVN 1 stated she knew Resident 1 was having seizures on [DATE] as Resident 1 would become non-responsive and his upper body would shake. LVN 1 stated she timed the seizures, and each seizure was lasting seven to nine minutes each. LVN 1 stated Resident 1 had approximately six seizures in the facility hallway. LVN 1 stated LVN 2 gave Resident 1 his seizure medication (Valtoco - a prescription nasal spray rescue medication used for the short-term treatment of seizure clusters) at around 9:13 a.m. but it was ineffective. LVN 1 stated she and LVN 2 called RN 1 about Resident 1 ' s continuous seizures and to request RN 1 to send Resident 1 out to the acute hospital for higher level of care. LVN 1 stated RN 1 had staff place Resident 1 in his room and ordered all staff except for Certified Nursing Assistant (CNA) students to leave. LVN 1 stated Resident 1 continued to have multiple seizures while in his room. LVN 1 stated RN 1 then left Resident 1 in his room with CNA students and then went to other resident rooms searching for a hairdryer to dry her cell phone. LVN 1 stated RN 1 had spilled coffee on her cell phone. LVN 1 stated RN 1 was more concerned about her cell phone being wet and looking for a hairdryer than Resident 1 ' s medical condition. LVN 1 stated LVN 2 approached RN 1 and tried to convince her to send Resident 1 out to the acute hospital for higher level of care, but RN 1 screamed at LVN 2 and stated she would not send Resident 1 out. During an interview on [DATE] at 11:40 a.m. with LVN 2, LVN 2 stated she was assigned to Resident 1 on [DATE]. LVN 2 stated at approximately 9 a.m. Resident 1 began having seizures in the facility hallway. LVN 2 stated she and LVN 1 timed Resident 1 ' s seizures and seizures lasted approximately up to 10 minutes each. LVN 2 stated Resident 1 ' s seizures would present as him not being responsive, his eyes rolling in the back of his head and his whole body shaking. LVN 2 stated she contacted RN 1 about Resident 1 ' s continuous seizures. LVN 2 stated RN 1 instructed her to give Resident 1 his Valtoco. LVN 2 stated she informed RN 1 there was no more Valtoco medication available for Resident 1 after she gave the initial dose. RN 1 instructed the CNA students to monitor the resident in his room. RN 1 then began looking around the resident rooms and asking other residents for a hairdryer because RN 1 spilled coffee on her cell phone. LVN 2 stated RN 1 was more concerned about her cell phone and finding a hair dryer than Resident 1 ' s medical condition. LVN 2 stated she and LVN 1 attempted four times from 9 a.m. to 10:30 a.m. to get RN 1 to send Resident 1 to the acute hospital due to multiple seizures but RN 1 stated, Shut the [explicit] up you ' re stressing me out. LVN 2 stated Resident 1 had about five more seizures after being given the Valtoco. LVN 2 stated she called DON due to RN 1 ' s refusal to send Resident 1 to the acute hospital so she could be instructed on how to send Resident 1 on her own without RN 1. LVN 2 stated Resident 1 had approximately eight seizures one after the other in total before being sent out to the hospital by ambulance on [DATE] at approximately 12:40 p.m. During a review of Resident 1 ' s Order Summary (OS), dated [DATE], the OS indicated, Resident 1 doctor ordered Valtoco 15 milligrams (mg - a unit of measurement) to be given via nasal (nostril) route. One spray of the medication in the nostril every 10 minutes as needed for breakthrough seizures for two uses. During an interview on [DATE] at 10:06 a.m. with CNA 1, CNA 1 stated she was assigned to Resident 1 on [DATE]. CNA 1 stated Resident 1 was up in a chair in the hallway when he had his first seizure approximately after 9 a.m. CNA 1 stated Resident 1 ' s first seizure that day was noticed because his head tilted back, he was not alert and his left hand shook continuously. CNA 1 stated LVN 2 gave Resident 1 his Valtoco. CNA 1 stated the medication was only effective for about three minutes before Resident 1 began to have more seizures. CNA 1 stated RN 1 instructed the CNA students to monitor Resident 1 and no one else to be with him. CNA 1 stated the CNA students and their instructor stated they were not appropriate to monitor Resident 1 in his current condition. CNA 1 stated despite the verbalized concerns, RN 1 only allowed the CNA students to monitor Resident 1. CNA 1 stated Resident 1 ' s lips would turn purple, and he would cough continuously during his seizures. CNA 1 stated, It was not fair for [Resident 1] to be left like that. He had approximately seven seizures before being sent out [to the acute hospital]. We [facility staff] were worried about him and wondering why he was not being sent out. [RN 1] was saying he was just being anxious. During an interview on [DATE] at 10:58 a.m. with DON, DON stated her expectation for a resident who was experiencing continuous seizures and not responsive to medication, is for the nurse to complete a full assessment, to notify the doctor and send the resident out to the acute care for higher level of care need. DON stated, I would not leave a [CNA] student to monitor the resident [Resident 1] as they do not have the appropriate training nor knowledge. During a review of Resident 1 ' s clinical record, Licensed Vocational Nurse (LVN 2) Progress Notes (PN) dated [DATE] at 3:10 p.m. were reviewed. The PN indicated, Resident [1] began having seizures [at 9 a.m.] in the hallway during medication pass. Resident [1] was in the hallway with CNA [Certified Nursing Assistant - CNA 1] present. Seizures continued happening back-to-back less than 30minutes [sic] apart lasting ,d+[DATE] minutes at a time. Notified RN supervisor [RN 1] advised to give [seizure medication] nasal spray, informed RN [1] supervisor last dose was given . Medication ineffective. RN [1] had students and CNA [not identified] put resident [1] back to bed, and asked students to monitor resident. CNA ' s [not identified] and staff [not identified] urged RN [1] to let CNA [not identified] be at bedside while students took over section [due to] students not being comfortable initiating CPR [cardiopulmonary resuscitation - an emergency procedure to help sustain life] if needed. RN [1] stated was not necessary . Resident [1] continued having seizures RN [1] refused to send resident [1] out to ER [emergency room ]. Contacted [Director of staff Development] to obtain ok to send out resident [to the emergency room ] . Ambulance arrived and given report by myselfambulance [sic] [LVN 2] stated ' why was resident [1] not sent out sooner he could have lost oxygen to his brain having so many seizures like that back to back, you will be lucky if state doesn ' t get down on you for this ' . During a review of Resident 1 ' s Ambulance Service Report (ASR) dated [DATE] (time of report not indicated), the ASR indicated an ambulance arrived for Resident 1 at approximately 12:18 p.m. The ASR indicated, 70year old male, chief complaint . seizures . [Resident 1] seizures are lasting approximately 10 minutes each about 20 minutes apart. His [Resident 1] las [sic] seizure began at [12:38 p.m.] and [Resident 1] did not come out of this seizure while under [ambulance staff - unidentified] care. [Resident 1] was transported to the nearest hospital due to status. During a review of Resident 1 ' s acute hospital Discharge Summary (DS), dated [DATE], the DS indicated Resident 1 was sent from the local acute hospital emergency room to another acute hospital 31 miles away for higher level of care in which a neurologist (a physician that deals with managing disorders of the brain and nervous system) was required. The DS indicated Resident 1 was admitted on [DATE] and discharged [DATE]. The DS indicated, Discharge Diagnosis . recurrent breakthrough seizures . status epilepticus (a medical emergency when there is a continuous seizure lasting more than 30 min, or two or more seizures without full recovery of consciousness between any of them) . Acute encephalopathy (a change on how the brain functions) . patient [Resident 1] had multiple episodes of seizure in the hospital as well. EEG [electroencephalogram - an assessment device that records brain activity] showing 2 spike-wave discharges [abnormal result consistent with showing epilepsy in a patient] consistent with seizure focus [the site in the brain from which a seizure originates] . Please note that this is a prolonged hospitalization . During a review of Resident 1 ' s MDS under Section GG - Functional Abilities and Goals (GGF - an assessment tool used to evaluate a residents ' functional capabilities) dated [DATE] (prior to Resident 1 ' s [DATE] hospitalization ), the GGF indicated the following: a. Resident 1 was independent with oral hygiene. b. Resident 1 was independent with his toilet hygiene. c. Resident 1 was set up assistance to shower/bathe self. d. Resident 1 was independent with upper and lower body dressing. e. Resident 1 was independent with putting on/taking off his footwear. f. Resident 1 was independent with his personal hygiene. g. Resident 1 was independent with movement that required rolling left and right. h. Resident 1 was independent with sitting to lying. i. Resident 1 was independent with sitting on the side of the bed. j. Resident 1 was independent with sitting to standing. k. Resident 1 was independent with chair/bed transfer. l. Resident 1 was independent with toilet transfer. m. Resident 1 was independent with tub/shower transfer. n. Resident 1 was independent in walking 10 feet (a unit of measurement), 50 feet with two turns and walking 150 feet. During a review of Resident 1 ' s MDS under section GGF dated [DATE] (after his return from hospital on [DATE]), the GGF indicated Resident 1 had a change of condition from the previous GGF done on [DATE] in which: a. Resident 1 required set up or clean up assistance with oral hygiene. b. Resident 1 was dependent on staff for toilet hygiene. c. Resident 1 was dependent on staff to shower/bathe self. d. Resident 1 was dependent on staff for upper and lower body dressing. e. Resident 1 was dependent on staff for putting on/taking off his footwear. f. Resident 1 was dependent on staff for personal hygiene. g. Resident 1 required maximal assistance from staff to roll left and right. h. Resident 1 required maximal assistance from staff with sitting to lying. i. Resident 1 required maximal assistance from staff with sitting on the side of the bed. j. Resident 1 required maximal assistance from staff for sitting to standing. k. Resident 1 required maximal assistance from staff for chair/bed transfer. l. Resident 1 required maximal assistance from staff for toilet transfers. m. Resident 1 required supervision or touching assistance from staff for tub/shower transfer. n. Resident 1 required moderate assistance to walk 10 feet and was not able to walk 50 feet or 150 feet due to safety concerns. During a review of Resident 1 ' s OSR, dated [DATE] (prior to [DATE] hospitalization ), the OSR indicated, Resident 1 had a doctor ' s order placed on [DATE] for oxygen two liters (a unit of measurement) as needed for shortness of breath. During a review of Resident 1 ' s OSR, dated [DATE] (after [DATE] hospitalization ), the OSR indicated, Resident 1 was to have oxygen two liters continuously every shift. During a review of Resident 1's Order Summary Report (OSR), dated [DATE] (prior to [DATE] hospitalization ), the OSR indicated, Resident 1 had a diet order consisting of no added salt regular texture food with thin liquids. During a review of Resident 1 ' s Speech Therapy SLP (speech language pathologist) Evaluation and Plan of Care (SLPEC), dated [DATE], the SLPEC indicated Resident 1 diagnosis of epilepsy and dysphagia (difficulty swallowing). The SPLEC indicated Resident 1 is on a new puree (food that does not need to be chewed) diet. The SLPEC indicated, Reason for referral: [Resident 1] referred to [speech therapy] due to new onset of risk for aspiration [choking] and signs/symptoms of dysphagia . Clinical impression: [Resident 1] presents with [signs and symptoms] of esophageal [portion of body that connects from mouth to stomach] dysphagia with food getting stuck in the area of the UES [upper esophageal sphincter - area of the stomach where there is a passage that prevents stomach contents from going up]. During a review of the facility ' s job description (JD) titled, Charge Nurse/Supervisor, not dated, the JD indicated, The primary purpose of your job position is to provide direct care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, regulations that govern our facility, and as may be required by the Director of Nursing Services or Nurse Supervisor to ensure that the highest degree of quality care is maintained at all times .Duties and Responsibilities . Admit, transfer, and discharge residents as required . Provide direct nursing care . Monitor seriously ill residents as necessary. During a review of the facility ' s policy and procedure (P&P) titled, Change of Condition, dated [DATE], the P&P indicated, PURPOSE: To keep residents, family and physicians informed in a timely manner . Notify the attending physician promptly . when there is . A change in the resident ' s physical, mental or psychosocial status, (i.e. [id est - latin for that is] deterioration in physical, mental, or psychosocial status, life threatening condition or clinical complications .) . PHYSICIAN NOTIFICATION . In emergency/life threatening situations . RN Supervisor or charge nurse will assess the resident and immediately call the attending physician . For situations where the physician cannot be reached right away . call the ambulance of the emergency or 911 .

Based on interview and record review the facility failed to prevent abuse for one of three sampled residents (Resident 1). This failure resulted in Resident 1 crying, and stating she felt embarrassed, humiliated and hurt. Findings: During a review of the facility's Investigation of Abuse Report Form, dated 8/11/21 to 8/12/21, the Investigation of Abuse Report indicated, [Resident 1] stated the following: Yesterday 8/10/21 I was told by my CNA [Certified Nursing Assistant (CNA 1)] go outside and get out of my room. I was so confused; I didn't understand why she was telling me to leave my own room. The Housekeeper [HSK 1] was there when my CNA told me this and I asked her, why does she tell me to leave, I live here? I felt very humiliated and hurt. everyone [staff] took good care of me except for [CNA 1] when she was having her bad days like the other day. During an interview on 8/19/21, at 10:32 AM, with Social Services Director (SSD), SSD stated, Resident 1 said CNA 1 told her to, Go outside, why are you still here, go home. SSD stated, HSK 1 was present during this altercation. SSD stated, Resident 1 was visually upset, emotional, and crying when she was talking about the incident. SSD stated, Resident 1 told her CNA 1 would have bad days and then incidents would happen. During an interview on 8/19/21, at 10:49 AM, with Director of Nursing (DON), DON stated, CNA 1 had disciplinary action in the past for her behavior. During an interview on 8/19/21, at 11:47 AM, with HSK 1, HSK 1 stated, on 8/10/21, around 2:30 PM, she witnessed CNA 1 tell Resident 1 to get out of her room in a rude manner. HSK 1 stated, as Resident 1 walked out of her room, Resident 1 asked why she was being thrown outside. HSK 1 stated, CNA 1's tone of voice was inappropriate and elevated. HSK 1 stated, she felt CNA 1 had verbally abused Resident 1. During an interview on 8/19/21, at 1:23 PM, with Administrator, Administrator stated, Resident 1 was crying and felt embarrassed when she reported the incident on 8/11/21. During a review of CNA 1's Employee Counseling Record, dated 7/5/16, the Employee Counseling Record indicated, CNA 1 was counseled for Inappropriate Conduct Towards Others. The Employee Counseling Record indicated, There was a concern verbalized by a resident and his family member about [CNA 1's] attitude. It was stated that employee exhibited a negative attitude when dealing with the resident. The attitude that employee exhibited and the way you deal and take care of the residents need to improve. You are here to work with the residents professionally and treat all residents with respect. During a review of CNA 1's Employee Communication Notes, dated 8/29/19, the Employee Communication Notes indicated, There was a concern from one of the resident that was brought out to SSD. Resident Said [sic] that the CAN [sic] was too fast and aggressive when providing care. During a review of CNA 1's 2019-2020 Supplemental Evaluation Form, dated 1/16/20, the Supplemental Evaluation Form indicated, under the section for areas of improvement, Lower tone of voice when talking to resident [sic], its mistaken always [sic] that you are yelling to [sic] them. During a review of the facility's policy and procedure (P&P) titled, Definitions and Recognizing Signs and Symptoms of Abuse/Neglect, undated, the P&P indicated, The facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all staff are to report any signs and symptoms of abuse/neglect to the appropriate agency and/or facility management immediately. Abuse is defined as the willful infliction of injury; unreasonable confinement; intimidation; punishment with resulting physical harm, pain or mental anguish . Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance . Mental abuse is defined as, but not limited to humiliation, harassment, threats of punishment, or withholding of treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to perform a comprehensive assessment to identify immediate care needs, initiate monitoring, and develop and implement an individualized plan of care for one of 24 sampled residents (20), when Resident 20 had a significant change in condition secondary to binge drinking. Resident 20 had been a resident at the facility for over three years and had been prescribed with multiple Central Nervous System (a nervous system, includes brain and spinal cord, integrates information it receives from, and coordinates and influences the activity of all parts of the bodies, CNS) depressants. These failures resulted in Resident 20's two falls, vomiting, and two emergency room visits. Binge Drinking - according to the Center for Disease Control and Prevention- https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm binge drinking is the most common form of excessive drinking and is defined for women as consuming four of more drinks during a single occasion. A drink is considered 45 milliliters (ml) of 40% alcohol distilled spirits or liquor (gin, rum, vodka, whiskey). According to FDA.GOV (Food and Drug Administration) Central Nervous System (CNS) Depression - is specifically the result of inhibited brain activity that can lead to decreased rate of breathing, decreased heart rate, profound sedation, and loss of consciousness possibly leading to coma or death. CNS depression is generally caused by the use of depressant drugs such as [MEDICATION NAME] (alcohol), narcotic pain medications, anxiety medications, sleep medications, muscle relaxants, and antidepressant medications. Alcohol acts as a Central Nervous System (CNS) depressant and when a resident is seriously intoxicated may lead to falls, blur speech, or vomiting (https://www.atsdr.cdc.gov/csem/csem.asp?csem=12&po=9). Findings: During an observation and concurrent interview with Resident 20, on 6/5/17, at 9:19 AM, she stated, I messed up. I got drunk over the weekend and today. Resident 20 had a grimaced facial expression and was visibly upset as she sat in her wheelchair. During a review of the clinical record for Resident 20, the document titled Minimum Data Set (MDS, a standardized and comprehensive assessment tool), dated 4/13/17, indicated she had a Brief Interview for Mental Status (BIMS) score of 15 (the highest score possible, which indicated she was cognitively intact, and had the capability to appropriately process perception, memory, judgment, and reasoning). On 6/4/17, a Certified Nursing Assistant (CNA) documented on Special Problems at 5:30 AM. It indicated When checking on resident at around (5:30 AM) I noticed a bottle of vodka on the floor on the left side of her bed. I asked (Resident 20) if she had drank(sic) it but (Resident 20) didn't respond. Vodka bottle was empty. During a review of the clinical record for Resident 20, the document titled Licensed Nurses Progress Notes, dated 6/4/17, indicated the following entries: 7 AM: Reported that CNA (Certified Nursing Assistant) from the (night) shift saw empty bottle of Vodka on the floor . also (Resident 20) slept the whole night which is not her usual routine. 11:30 AM: Saw curling iron on . CNA told (Resident 20) if she will still use it. (Resident 20) was kind of sleepy and stated I don't know. 12:30 PM: DON (Director of Nursing) was notified of above concerns. 12:45 PM: (Resident 20) was up in W/C (wheelchair) . Told that she's taking a lot of medication which may interact (with alcohol). 3 PM: (Medical Doctor) aware. 6 PM: (Resident 20) still has vodka at bedside 1 1/2 bottle . Nurse went three times to talk to her, she doesn't listen. She looks like little drunk . The documentation indicated Medical Director (MD) 1 was not notified until nine and half hours after she was first found drunk and Resident 20 continued to drink. During an interview with Licensed Vocational Nurse (LVN) 5, on 6/7/17, at 3:08 PM, she stated Resident 20 went out on pass (she temporarily left the facility) on Saturday 6/3/17, and purchased vodka. Resident 20 was noted Sunday (6/4/17) morning in her room by the night shift CNA. LVN 5 stated, Sunday morning I checked her, she was drowsy. I found an empty bottle of vodka on the floor. Today (6/7/17) she vomited about twice. During a review of the clinical record for Resident 20 the documents titled Licensed Nurses Progress Notes, dated 6/5/17, indicated the following entries: 10:30 AM (T)old (Resident 20) that medication and alcohol doesn't mix. (Resident 20) respond don't give me medication then. Explained risk of taking alcohol (and) medication could possibly lead to death . 4 PM: s/p (status [REDACTED]. 6:35 PM: (Resident 20) found lying on the floor near her foot end of bed, her W/C (wheelchair) was next to her head when asked she said she didn't fall; leave me alone. She sounds drunk. She drink (sic) about 400 ml (milliliters - a unit of measurement) of vodka the one she keep at bedside. 400 ml of vodka is 220 ml more than what CDC classifies as excessive drinking. During a review of the clinical record for Resident 20 the document titled Interdisciplinary Form, dated 6/5/17, at 10:30 AM, indicated (Facility staff) was worried about her because of all the medications she is taking which includes but not limited to antidepressant, anti-anxiety, sleeping pills, and other medications that mixed with alcohol could be fatal . I asked her if she drank this morning because her speech was somewhat slurred and she said she didn't. However, when I got near her, she had the smell of alcohol. I continued on informing her of the risk of drinking which may even lead to death . During a review of the clinical record for Resident 20, the document titled Resident Accident/Incident Report and Investigation Report, dated, 6/6/17, indicated Resident 20's fall on 6/5/17 was related to [MEDICAL CONDITION]. The recommended actions and interventions indicated 1:1 observed drinking. There was no comprehensive assessment found in the resident's chart since the discovery of her alcohol intake. During a further review of the clinical record for Resident 20, the documents titled Medications Flowsheet, indicated Resident 20 received the following medications, all of which would depress the CNS according to the FDA: A. [MEDICATION NAME] (an anti-anxiety agent) 0.5 mg (milligrams - a unit of measurement) ordered to be given twice a day was administered on 6/4/17 at 4:30 AM, and 12 PM, on 6/5/17 at 4:30 AM, and on 6/6/17 at 4 AM and 12 PM. B. Tylenol with [MEDICATION NAME] (a narcotic pain medication) ordered to be given three times a day was administered on 6/4/17 at 4 AM, 10 AM, 4 PM, on 6/5/17 at 4 AM, and on 6/6/17 at 4 AM and 4 PM. C. [MEDICATION NAME] 5 mg (a medication that helps with digestion) ordered to be given once a day was administered on 6/4/17, 6/5/17, and 6/6/17 at 4 AM. D. [MEDICATION NAME] 5 mg (an allergy medication) ordered to be given once a day was administered on 6/4/17 and 6/6/17 at 8 AM. E. [MEDICATION NAME] 25 mg (an allergy medication) ordered to be given at bedtime was administered on 6/4/17 and 6/6/17 at 8 PM. F. [MEDICATION NAME] 25 mg (lowers blood pressure) ordered to be given once a day was administered on 6/4/17 and 6/6/17 at 8 AM. G. [MEDICATION NAME] 0.1 mg (lowers blood pressure) ordered to be given twice a day was administered on 6/4/17 at 8 AM and 5 PM, and 6/6/17 at 8 AM. H. [MEDICATION NAME] 10 mg (anti-depressant) ordered to be given once a day was administered on 6/4/17 and 6/6/17 at 8 AM. I. [MEDICATION NAME] 75 mg (pain reliever) ordered to be given twice a day was administered on 6/4/17 at 8 AM, 8 PM, and on 6/6/17 at 8 PM. J.[MEDICATION NAME] mg (helps to sleep) ordered to be given at bedtime was administered on 6/4/17 and 6/6/17 at 8 PM. K. [MEDICATION NAME] 10 mg (a muscle relaxer) ordered to be given at bedtime was administered on 6/4/17 and 6/6/17 at 8 PM. During a review of the Nurses Medication Notes dated 6/5/17 for Resident 20, the following entries were noted: 8 AM: a licensed nurse attempted to administer due medications to Resident 20, but the resident had refused to take them, which included [MEDICATION NAME], and [MEDICATION NAME]. 10 AM: a licensed nurse had attempted to offer Resident 20's routine Tylenol with [MEDICATION NAME] three times, but the resident refused. 12 PM and 2 PM: a licensed nurse attempted to administer Resident 20's schedule medications three times, which included [MEDICATION NAME], but Resident 20 refused. PM (evening shift): a licensed nurse attempted to administer Resident 20's scheduled medications three times during the evening, including Tylenol with [MEDICATION NAME] and [MEDICATION NAME], but Resident 20 again refused. The facility licensed staff acknowledged the interactions between alcohol and these prescribed medications, there was no documentation the licensed staff had assessed Resident 20's condition for signs or symptoms of CNS depression. The licensed staff continued offering Resident 20 the prescribed medications. During an interview with MD 1, on 6/8/17, at 12:16 PM, she stated the facility had called her associate over the weekend (the on call physician covering for MD 1 on 6/4/17 to provide him an FYI (for your information) and did not inform him of the seriousness in Resident 20's condition. MD 1 stated If (Resident 20) presented with signs and symptoms of [MEDICAL CONDITION], I (MD 1) would not have given her narcotics, sleepers, or muscle relaxers. (When) giving meds while intoxicated, there is a potential for [MEDICAL CONDITION] (temporary loss of consciousness), episodes of dizziness, coma, and up to death. (Resident 20) told me that she has been drinking again for the last two months. I would expect the nurses to use clinical judgement when administrating medication to residents. During a review of the clinical record for Resident 20 the document titled Special Problems, dated 6/6/17, at NOC indicated, (Resident 20) pressed her call light various times throughout the night, when answering (Resident 20) stated she needed help when answering what kind of help she stated I don't know at around (2:15 AM) (Resident 20) stated she was scared and wanted me to stay in the room with her for the remaining shift. (Resident 20) was told that I would check up on her but also other residents needed my help. (Resident 20) was assured she would be ok and I would check on her periodically. (Resident 20) continued to press her call light and only wanted me to attend to her. Charge nurse aware. There were no assessments completed by a licensed nurse found in her records. During a review of the clinical record for Resident 20 the document titled Licensed Progress Notes, dated 6/6/17, indicated the following entries: 6:30 AM: (W)as continuously on the light telling somebody need to stay (with) her and also she asking for bottle of wine. 6:45 AM: CNA told that she (Resident 20) wants to passed out .(Resident 20 stated) she feels dizzy, feels she's gonna passed out and she has pain on the back of her head. 6:50 AM: Resident 20 was sent to the Emergency Department via ambulance for fall and drunk confused. 10:45 AM: Resident 20 had returned from the Emergency Department for refusing treatment. 12:45 PM: Resident 20 vomited and requested to go back to the Emergency Department. 12:55 PM: Resident 20 was sent out via ambulance to the Emergency Department a second time that day. 4:40 PM: Resident 20 returned to the facility and continued to complain of nausea and anxiety. 6:03 PM: Resident 20 was found sitting on floor between beds in her room . slid (and) fell sitting on the floor. During an interview with LVN 2, on 6/7/17, at 3 PM, she stated Resident 20 was independent in meeting her needs, but over the last few days had a change in condition where she now required staff assistance. During a clinical record review for Resident 20, the Emergency Department document titled Physician, dated 6/6/17, at 8:43 AM, indicated Resident 20, states she had a fall yesterday and doesn't remember it, c/o (complains of) dizziness, feeling of passing out upon arrival and severe back of head pain, also c/o nausea at this time . The patient presents following fall and [MEDICAL CONDITION] . The document also indicated Resident 20's blood alcohol level was 92 or 0.092 percent. For reference, California law considers operating a motor vehicle with a blood alcohol concentration at .08 percent or higher as Driving Under the Influence because at this level or above, responses greatly slowed, behavior greatly affected, and at high risk of accident. During an observation and concurrent interview with Resident 20, on 6/7/17, at 3:16 PM, she stated I'm still vomiting. I bought a little bottle of vodka and a big one. I drank the small one first. I drank the big one on and off over the weekend after drinking the small one. I was drunk. The Facility Care Plan for alcoholism was finally initiated on 6/5/17, two days after she was found binge drinking. During an interview with the Director of Nursing (DON), on 6/7/17, at 3:35 PM, she stated Saturday night (6/3/17) I was called that (Resident 20) was drunk. The DON stated she was aware of Resident 20 being drunk on 6/4/17, falling and being drunk on 6/5/17, and continuously throwing up on 6/7/17. The DON stated, My expectation is that the nurses should have called the doctor and got the medications held. During an observation and concurrent interview with Resident 20 on 6/8/17, at 11:29 AM, she stated I feel lousy, I'm still nauseous. Resident 20 stated she had finished the big bottle of vodka on Monday morning (6/5/17), and I don't remember falling because I passed out drunk. On Monday (6/5/17), I refused to take the meds because I didn't want to mix it while I was drunk. Resident 20 stated nursing had continued to offer her medications throughout the day on 6/5/17, but she would refuse. Resident 20 was alone in her room, had a grimaced facial expression, and would rub her stomach area throughout the interview. She had a waste basket and small towels to her surrounding area to use while having episodes of nausea and vomiting. During an interview with Pharmacy Consultant 1, on 6/8/17, at 2:32 PM, he stated the medications administered to Resident 20 should not have been given while she was intoxicated, stating (T)hese medications could contribute to her fall and vomiting. The facility policy and procedure titled Change of Condition, dated 10/13/16, indicated Notify the attending physician promptly, representative or family member when there is . A need to alter treatment significantly, (i.e., . a need to discontinue an existing form of treatment due to adverse consequences or resolution, or to commence a new form of treatment).

Based on observation, interview, and record review, the facility failed to protect one of one sampled resident (1) from involuntary physical restraint when a staff tied Resident 1's legs together with a small blanket to prevent Resident 1 from getting out of bed for staff convince. This failure resulted in Resident 1 having emotional and psychosocial distress. Findings: During a review of the clinical record for Resident 1, the Licensed Nurses Progress Notes, dated 6/18/15, at 3:55 PM, indicated in part .Resident (1) is in bed noted that she is restless and with baby blanket tied to her legs/both lower leg. The Resident Admission Record, indicated Resident 1 was admitted [DATE], with the following Diagnoses: [REDACTED]. During an interview with the Director of Nursing, on 6/24/15, at 8:54 AM, when asked if there was a staffing issue, she stated, No staffing issue. During an observation on 6/24/15, at 9:05 AM, in Resident 1's room, Resident 1 was not in her room. Resident 1's bed had both 1/3 side rails up, beam alarm (wireless alarm) attached at the foot board, bed at a normal height, no bed sheets, and a small blanket on top of the bed. During an interview with Resident 1, on 6/24/15, at 9:15 AM, when asked if she remembered the day when someone tied her legs with a small blanket, she stated, They tied my legs because they don't want me to get out of bed. When asked how she felt about it, she stated, It's awful. When asked if she was scared of staff in general, she stated, Kind of. This is the only place I've been, I don't know if other places will also tie your legs. During an interview with Resident 1's daughter, on 6/24/15, at 9:28 AM, she stated, My Mom pulls all the blankets thinking someone will tie her legs again. During an interview with the Housekeeper, on 6/24/15, at 11:07 AM, when asked about the incident on 6/18/15, in Resident 1's room, she stated, I went to clean the room and I saw her (Resident 1) legs were tied so I ran outside (the room) and reported to the first person I saw (Activity Director). Resident (1) was crying and restless. During an interview with Certified Nursing Assistant (CNA) 1, on 6/24/15, at 3:10 PM, when asked what happened on 6/18/15, in Resident 1's room, she stated, Resident (1) was restless since the start of the shift. Resident (1) was in bed because her wheelchair was being washed. When asked what she did to Resident 1, she stated, I tied her legs with a small blanket, below her knees. When asked the reason for tying Resident 1 up, she stated, I just want to protect her (Resident 1) from falling, she was putting her legs down first. When asked if Resident 1 had fallen before, she stated, No. Resident (1) had never fallen out of bed. When asked what she did after tying Resident 1's legs, she stated, It was the end of the shift, I was behind with my charting. I left the resident (1) and went to the Nurses' station to do my paperworks. When asked if she asked for help when Resident 1 was restless, she stated, No. I did not think about that. When asked if she could get an extra wheelchair to replace Resident 1's while the wheelchair was being washed, she stated, I did not think of looking for one. CNA 1 stated, I'm sorry, Ma'am, I did not mean to hurt the resident (1). It was a mistake. The facility policy and procedure titled, Physical Restraints, dated 7/25/11, indicated in the Purpose: To ensure that written policies and procedures concerning the use of restraints and postural supports are followed and to establish guidelines for the use of restraints. To ensure residents' right to be free from any physical restraint imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Policy Statements: It is the policy of this facility that each resident reach his/her highest practicable well-being in an environment that prohibits the use of restrains for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Restraints: Any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Therefore, Resident 1 was restrained for staff convenience when CNA 1 tied Resident 1's legs to prevent her from getting out of bed, so that CNA 1 could complete her charting.

Based on interview and record review, the facility failed to adequately supervise one sampled resident (1) while in the dining room who was at high risk for falls. This failure resulted in Resident 1 falling and sustaining a fractured left hip. Findings: During a review of the clinical record for Resident 1, the "Admission Record," dated 10/31/14, included [DIAGNOSES REDACTED]. The document titled "Fall Risk Assessment" dated 11/1/14 indicated a score of 14 and on 2/6/15 indicated a score of 12 (total score of 10 or above represents High Risk for falls). The Minimum Data Set (MDS, assessment tool) dated 2/6/15 was reviewed. The "Brief Interview for Mental Status (BIMS-a brief screener that aids in detecting cognitive impairment)" score was 3 out of 15 (severe cognitive impairment). The "Functional Status" under the "Transfer...Self Performance..." was coded as 3 (extensive assistance-resident involved in activity, staff provide weight bearing support)..."Walk in Corridor...Self Performance..." was coded as 2 (limited assistance-highly involved in activity, staff provide weight bearing support)..."Support..." was coded as 3 (two or more persons physical assist)...". The care plan dated 2/6/15, indicated "Resident is at risk for falls secondary to weakness, impaired cognitive skills and safety judgement, gets up quickly without regards to safety. Resident is non compliant with care, does not call for help when resident needs something especially with transfer. Resident is high risk for fractures... Fall risk score: 12... Approach... Observe frequently and place in supervised areas when out of bed... Frequent staff monitoring for steadiness and balance... Frequent verbal reminder so (sic) safety issues and the complications of fall as well (sic) the importance of calling for help whenever resident needs anything...Staff awareness of resident's risk for falls and history of falls...". The "Plan of Care (Actual Fall)" dated 2/14/15, indicated "Resident with actual fall secondary to/Risk factors... Strength deficit/weakness... History of falls... Impaired cognitive skills and safety judgement... potential for: Fractures... Fall risk score: 14". The care plan dated 2/16/15, indicated "Resident has [DIAGNOSES REDACTED]. (status [REDACTED]. The "Licensed Nurses Progress Notes" dated 2/14/15, at 6 PM, indicated in part, "...Upon hearing an alarm in the dining room, I attended to the alarm and saw the resident out of her w/c, unattended, ambulating in the middle of the floor next to the dining room table. Resident fell on the floor next to the dining room table... assessed for any injuries. No injuries noted..." The "Investigation of unusual occurrence report... Time of investigation: 2/17/15 at 9 AM... Date incident occurred: 2/14/15 at 6 PM...", indicated in part "...Monday 2/16/15 - RNA's (restorative nursing assistants) were attempting to assist resident with ambulation when resident started complaining of pain to her left hip. Physician was notified who then ordered x-ray of the left hip. Results came back with "subcapital fracture of the left hip (a break at the top of the long thigh bone where it fits into the hip socket)... Summary of interview/Summary of investigator"s findings... She was up in the (wheelchair) in the dining room during dinner time, when (Licensed Vocational Nurse-LVN 1) heard the alarm and saw resident walking by the table. He was about within 10 feet from the resident, when resident fell and could not get to her on time...". During an interview with Certified Nursing Assistant (CNA) 1, on 3/2/15, at 3:35 PM, she stated, "(CNA 3) told (CNA 2) to pick up (assist the resident out of the dining room) resident (Resident 1) in the dining room because she was by herself". CNA 1 added, CNA 2 did not assist Resident 1 from the dining room so Resident 1 remained by herself in the dining room. During an interview with LVN 1, on 3/4/15, at 8:50 AM, he stated, "When I walked into the dining room, Resident 1 was already up in her wheelchair. Resident 1 got up by herself. She was all alone. I was around 7 feet away from her when she fell . I can't (sic) grab her to prevent the fall. While ambulating she fell on her left side". During an interview with Registered Nurse 1, on 3/4/15, at 9:08 AM, she stated, "There was no CNA in the dining room (when Resident 1 fell ). The dining room was in front of the nurses station. Her alarm went on. It happened so fast. We couldn't catch her. CNAs should not leave resident while eating". During an interview with CNA 2, on 4/20/15, at 5:05 PM, she stated she was told by another CNA to take Resident 1 out of the dining room. CNA 2 stated she went to check Resident 1. She saw she was still eating. She proceeded to help another resident. CNA 2 stated she did not take Resident 1 out of the dining room. She added, "I thought someone was still there (referring to the dining room)". The document "Diagnostic Laboratories" dated 2/16/15 indicated, "Exam: (Left) Hip...Pain Pelvis/Hip Upper Thigh... Results:... There is a subcapitellar fracture (a fracture located just below the head of a bone that pivots in a ball-and socket joint) at the left hip...". The facility policy and procedure titled "Fall Prevention" review dated 4/29/14, indicated "Purpose:...monitor residents who are risk for falls. The goal of this program is to reduce both incidences of falls and injuries that may accompany fall... Procedures:... 11...Based upon the Fall Risk Assessment, if the resident is assessed as a high risk (10 or above), the licensed nurse will:... implement a plan of care for falls... 111......A. The staff...will identify appropriate interventions to minimize incidence (sic) falls and reduce the risk of falls... E. Staff will identify and implement relevant interventions... to try to minimize serious consequences of falling..."