Every finding on record at Driftwood Healthcare Center - Santa Cruz

Based on interview and record review the facility failed to ensure to screen and submit a new pre-admission screening and resident review (PASRR- screening for residents with mental disorder and residents with intellectual disability) after significant change in mental condition (a condition that affect resident's mood, thinking, and behavior) for one of two sample resident (Resident 1). This failure had the potential for mentally ill sample Resident 1 not to receive benefit from specialized health care and services.Findings:During an observation of Resident 1 on 8/7/2026 at 9:45 a.m., noted Resident 1 was in bed with one on one staff monitoring. Review of Resident 1's face sheet (FS- a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to facility on 4/3/2025.Review of Resident's change of condition notes dated 8/4/2026 indicated Resident 1 expressed and attempted suicidal ideation. Further review of this notes indicated Resident 1 cut her left wrist and the intervention to put the resident on one to one person monitoring to prevent further suicidal attempts.Review of Resident 1's nurse practitioner (NP, an advanced practice registered nurse who provides comprehensive healthcare, diagnoses medical conditions, and prescribes medications to treat illnesses) progress notes dated 8/4/2026 indicated Resident 1 expressed suicidal ideation and self-inflicted injury.Review of Resident 1's PASRR indicated there was no documented evidence of new PASRR assessment completed and submitted to California Department of Health Care Services (DHCS, a state agency responsible for financing, providing physical and mental health services and support for low-income individuals and families in California) after Resident 1's significant change in mental condition noted on 8/4/2026 that required interventions with one on one monitoring 24/7 and mental health professional follow up visits for Resident 1. During an interview with facility's director of nursing (DON) on 8/25/2026 at 1:14 p.m., DON stated facility's unit manager/registered nurse (UM/RN) responsible to assess, complete and submit new PASRR with significant change for residents in facility.During an interview with UM/RN on 8/25/2026 at 2:54 p.m., UM/RN confirmed Resident 1's verbalization of suicidal ideation and attempted suicide were considered significant changes in mental condition that warrants a new PASRR assessment and submission. UM/RN also confirmed there was no new PASRR assessment completed and submitted to DHCS after Resident 1's significant change in mental condition. UM/RN stated she should have done for Resident 1.During an interview with DON on 8/25/2026 at 3:33 p.m., DON stated UM/RN should have completed and submitted a new PASRR after the significant change in mental condition noted for Resident1.Review of letter from DHCS to facility for Resident 1 dated 3/31/2025 indicated, The Preadmission Screening and Resident Review (PASRR) is a federally mandated program requiring a Resident Review if there is a significant change in condition of a current resident.

Based on interview and record review, the facility failed to provide care, services, and assistance for showering for two of three sampled residents (resident 1 and 2). This failure had the potential to affect the personal hygiene, comfort, skin concerns, health condition, and well-being for Residents 1 and 2. Findings:Review of Resident 1's face sheet (FS, document that gives resident's information at a quick glance) indicated Resident 1 was admitted to facility on 6/15/2026.Review of Resident 1's minimum data set (MDS, resident assessment tool) assessment dated [DATE], section GG for functional abilities indicated Resident 1 required moderate assistance (helper provided less than half the effort) during showers.Review of facility's shower list document indicated, Resident 1 was scheduled for showers during AM (morning) shift every Wednesday and Saturday.Review of Resident 1's point of care history (PCH) document for period of 6/15/2026 to 7/15/2026 for Resident 1's showers indicated, Activity did not occur on 7/11/2026, one out of nine scheduled shower days. During a concurrent record review of facility's shower list containing Resident 1's PCH documentation and an interview with certified nursing assistant A (CNA A) on 7/15/2026 at 12:53 p.m., CNA A confirmed a shower was not given to Resident 1 on 7/11/2026. CNA A stated documenting that the shower activity did not occur means a shower was not given to Resident 1, as scheduled on 7/11/2026. Review of Resident 2's FS indicated Resident 2 was admitted to facility on 4/11/2025.Review of Resident 2's MDS assessment dated [DATE], section GG for functional abilities indicated Resident 2 required set up assistance (helper sets up and/or cleans up for resident's activity) during showers.Review of facility's shower list document indicated, Resident 2 was scheduled for showers during AM shift every Wednesday and Saturday.Review of Resident 2's PCH documentation from 6/15/2026 to 7/15/2026 indicated, Activity did not occur on 6/17/2026, 6/24/2026, 7/1/20026, 7/4/2026, and 7/8/2026, five out of nine scheduled shower days.During a concurrent record review of facility's shower list containing Resident 2's PCH documentation and interview with CNA B on 7/15/2026 at 2:22 p.m., CNA B confirmed showers were not given to Resident 2 on 6/17, 6/24, 7/1, 7/4, and 7/8/2026. CNA A stated documentation that shower activity did not occur means showers were not given to Resident 2 as scheduled on these five days.During an interview with facility's director of nursing (DON) on 7/15/2026 at 2:47 p.m., DON confirmed Resident 1 and Resident 2 did not receive showers as scheduled. DON stated CNA staff should have offered and provided showers as scheduled for both residents.Review of facility's policy and procedure (P&P) titled, Activities of daily Living (ADLs), Supporting, undated, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing .) .

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (plan of care addressing individual care, treatments, which should be sensitive to a resident's cultural, personal values, and lifestyle) for activities of daily living (ADL, basic and routine tasks required for a resident) care for one of three sampled resident (Resident 1), when Resident 1's care plan lacked interventions for refusal of showers. This failure had the potential for the lack of participation in developing and implementing a person-centered plan of care for ADLs for Resident 1, especially regarding showering. Findings:Review of Resident 1's face sheet (FS, document that gives resident's information at a quick glance) indicated Resident 1 was admitted to facility on 6/15/2026.Review of Resident 1's minimum data set (MDS, resident assessment tool) assessment dated [DATE] indicated Resident 1's brief interview for mental status (BIMS) score indicated 15/15 (score of 0-7, severely impaired cognition, 8-12, moderately impaired cognition, 13-15, intact cognition).Review of facility's shower list document indicated, Resident 1 was scheduled for shower during AM (morning) shift on every Wednesday and Saturday.Review of Resident 1's ADL document for shower dated 6/15/2026 to 7/15/2026 (4 weeks period) indicated Resident 1 refused showers on 6/17/2026, 6/20/2026, 6/27/2026, 6/28/2026 and 7/1/2026, total 5 out of 9 days. Review of Resident 1's care plans indicated there was no documented evidence of person centered care plan for ADLs and refusal of showers.During a concurrent record review of Resident 1's care plans and interview with the facility's medical record director (MRD) on 7/15/20026 at 2:12 p.m., MRD reviewed all documented care plans for Resident 1 and confirmed there was no documented evidence of care plan for ADL care and refusal of showers for Resident 1.During an interview with facility's director of nursing (DON) on 7/15/2026 at 2:36 p.m., DON confirmed there was no care plan for ADLS and refusal of showers for Resident 1. DON stated license nursing staff were responsible to develop and implement care plans for residents. DON also stated license nursing staff should have developed and implemented a care plan for ADLS and refusal of showers for Resident 1.Review of facility's policy and procedure (P&P) titled, Comprehensive Plan of Care, undated, indicated, Reflect the company's efforts to provide alternative methods when a resident wishes to refuse certain treatments or services; Comprehensive Care Plan is completed within 7 days after completion of the comprehensive assessment (MDS). Maintain the comprehensive care plan in the resident's current electronic medical record.

Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served under sanitary conditions and failed to follow infection control protocols when:1. Five food items were not labeled with an open date, and three food items were expired in the walk-in refrigerator; 2. One food item in the dry storage room was not labeled with an open date; 3. Two trash cans in the kitchen were observed without lids when not in use; 4. Kitchen staff used contaminated gloved hands to touch the blender blade assembly; 5. Kitchen staff did not wash or replace the blender lid after it fell into the sink and continued to use it to prepare pureed Brussels sprouts; 6. Kitchen staff did not use tongs to distribute bread and instead used gloved hands that had touched multiple surfaces; and7. The ice machine was not cleaned properly according to the manufacturer's instructions.These failures had the potential to cause food contamination and spread foodborne illness (illness resulting from contaminated food) to 84 of 85 residents who received their food from the kitchen. During an observation on December 8, 2025, at 9:52 a.m., accompanied by the Dietary Services Manager (DSM), the kitchen walk-in refrigerator was inspected. It was identified that 5 items were not labeled with an open date, and 3 items were expired.Items without open dates:a. A jar of premium sweet pickle relish, received 11/20/2025b. A can of horseradish, received 11/10/2025c. A jar of Italian dressing, received 11/28/2025d. A bottle of base BBQ sauce, received 11/26/2025e. A Jar of heavy-duty mayonnaise, no open date and no received dateExpired items:f. A bottle of vinaigrette dressing, expired 11/11/2025g. A Jar of tartar sauce, expired 12/3/2025h. A Jar of honey mustard dressing, expired 10/8/2025During an interview with the DSM on December 8, 2025, at 10:14 a.m., the DSM confirmed the above observations and stated that all opened food items should be labeled with an open date and that expired items should be removed from the refrigerator to ensure food safety.2. During an observation on December 8, 2025, at 10:18 a.m., accompanied by the DSM, the dry storage room was inspected. One partially used bag of corn flakes was identified without an open date.During an interview with the DSM on December 8, 2025, at 10:22 a.m., the DSM confirmed the above observation and stated that the opened bag of corn flakes should have been labeled with the open date.3. During a concurrent observation and interview in the kitchen with the DSM on December 8, 2025, at 10:25 a.m., two trash cans were observed without lids while not in use. The DSM confirmed the observation and stated that all trash cans should be covered with lids to help prevent the spread of infection.During an interview with the Registered Dietitian (RD) on December 8, 2025, at 3:00 p.m., the RD stated that all food items in the refrigerator should be labeled with received, opened, and use-by dates. In addition, the opened bag of cornflakes should also be labeled with the open date to ensure food safety. the RD further stated that the trash can should have a lid for sanitation purposes. A review of the facility's policy and procedure titled Nutrition Therapy Essentials, inc. Food Service Policy and Procedures , Manual 2023, indicated . Refrigerators and Freezers .all food should be dated and labeled with received, open, and use by dates. this to assure that food is safe for consumption and any food-borne illness can be avoided . Garbage containers should always be closed .storage room .all food bins should be clean, labeled .4.During an observation on December 9, 2025, at 11:25 a.m., [NAME] A was observed wearing a pair of black gloves. He used the same gloves to touch a spoon, a knife, and the handle of the blender (an electric kitchen appliance used to mix, chop, puree, or liquefy food and liquids). He then placed the blade assembly ( the removable component inside a blender that contains the cutting blades and the parts that hold them in place) into the blender, using the same gloves to handle the cooked chicken and add it to the blender to prepare finely chopped chicken.During an observation on December 9, 2025, at 11:31 a.m., in the kitchen, [NAME] A used the same pair of gloves after touching a spoon and a knife, and after placing the blender on the machine. He then used the same gloves to touch the blade assembly and add Brussels sprouts into the blender to prepare pureed brussels sprouts.During an observation on December 9, 2025, at 11:39 a.m., in the kitchen [NAME] A continued to use the same gloves after touching multiple items and did not change gloves before handling bread and placing it into the blender to prepare pureed bread.During a concurrent observation and interview with the Registered Dietitian (RD) on December 9, 2025, at 11:57 a.m., the RD confirmed the above observations and removed three trays of contaminated food from the tray line, including finely chopped chicken, pureed bread, and pureed brussels sprouts.5.During an observation in the kitchen on December 9, 2025, at 11:38 a.m., the DSM took over for [NAME] A and continued blending brussels sprouts. During this process, the blender lid fell into the sink. The DSM placed the lid back on the blender without washing or replacing it and continued preparing the pureed brussels sprouts. The DSM confirmed this observation.During an interview with the Infection Preventionist (IP) on December 9, 2025, at 12:39 p.m., the IP stated that the cook should have changed to a new pair of gloves before and after directly touching the blade assembly to prevent infection. The IP further stated that if a blender lid falls into the sink, kitchen staff should replace it because the sink may contain contaminants, posing a risk for infection and cross-contamination.During an interview with the Registered Dietitian (RD) on December 9, 2025, at 2:10 p.m., the RD confirmed that the finely chopped chicken was prepared for eight residents and the pureed food was prepared for fourteen residents. The RD stated that all food equipment must be clean and sanitized, and staff should change to a new pair of gloves before directly touching food and food-contact equipment. The RD also stated that the blender lid that fell into the sink should be cleaned and sanitized, or replaced, before contacting food to prevent infection and food contamination.A review of the facility's undated policy and procedure titled Food Handling Practices indicated that .change plastic gloves as frequently as handwashing would indicate. change gloves before and after non-food contact and between contacts with raw and cooked food .6. During a tray line observation with the Registered Dietitian (RD) on December 10, 2025, at 12:03 p.m., [NAME] B was observed wearing a pair of gloves and touching multiple utensil handles. [NAME] B then used the same gloved hands to grab bread and place it on residents' lunch trays. The RD subsequently removed four trays containing bread.During an interview with the RD on December 10, 2025, at 4:00 p.m., the RD confirmed the above observations and stated that approximately 40 residents were scheduled to receive the bread. The RD further stated that the cook should have used tongs (a handheld kitchen utensil used to grip, pick up, and transfer food without directly touching it by hand) to distribute the bread rather than gloved hands that had already touched multiple other items and were no longer considered clean.A review of the facility's undated policy and procedure titled Food Handling Practices indicated that . use tongs in meal service to portion meats, bread, garnishes, baked potatoes, cookies, etc .7. During an observation on December 9, 2025, at approximately 3:00 p.m., in the kitchen, accompanied by the Registered Dietitian (RD) and the Maintenance Supervisor (MS), the facility's ice machine was inspected. The MS stated that the manufacturer's service staff are scheduled to clean the ice machine with chemicals every six months. Since the ice machine was newly installed in August 2025, the manufacturer's cleaning service had not yet occurred. The MS further stated that he cleans the ice machine monthly by spraying it with hot water and wiping it.During a concurrent interview and record review with the MS on December 9, 2025, at 4:00 p.m., the MS reviewed the ice machine's Installation, Operation, and Maintenance Manual and stated that he had used hot water to clean the ice machine. The MS acknowledged that, per the manufacturer's instructions, he should use three gallons (a unit of liquid volume) of warm water mixed with two ounces (units of mass, weight, or volume) sanitizer to properly clean the ice machine.A review of the facility's Ice Machine Monthly Cleaning Log indicated that the MS cleaned the ice machine on August 6, 2025; September 10, 2025; October 10, 2025; and November 10, 2025.A review of the facility's undated ice machine cleaning policy and procedure, titled Cleaning& Maintaining Ice Machines, indicated . following the manufacturer's guidelines for cleaning .A review of the ice machine's installation, operation and maintenance Manual, revision 11/12/2023, indicated mix a solution of sanitizer and lukewarm water (3 gal of water mixed with 2 oz of sanitizer), use half of the sanitizer/water solution to sanitize all removed components .use half of the sanitizer/water solution to sanitize all food zone surfaces of the ice machine and bin (or dispenser) .

Based on observation, interview and record review, the facility failed to ensure the proper use of bed rail (or side rail, adjustable rigid bars attached to the side of a bed) for 12 of 15 residents (64,11, 80, 51, 71, 8, 9, 14, 17, 26, 35, and 36) when there were no documented evidence that the side rail entrapment risk assessments for the 12 residents were completed.This failure had the potential to place the residents at risk of entrapment and serious injury. Findings: During an observation on 12/8/25 at 10:34 a.m., in Resident 64's room, Resident 64 had the bilateral (both) side rails in upright position. During a concurrent observation and interview with the Director of Nursing (DON) on 12/9/25 at 10:23 a.m., in Resident 64's room, Resident 64 had the bilateral upper side rails in upright position. The DON confirmed the observation. Review of Resident 64's Physician's order, dated 6/26/24, indicated Half side rails up bilateral when in bed to enable independent repositioning and transfers. Review of Resident 64's Side Rail Evaluation dated 4/5/25, with the DON on 12/12/25 at 12:46 p.m., the DON confirmed that the entrapment risk assessment was not done. The DON confirmed that the Siderail Evaluation does not indicate how the risk of entrapment was assessed. The DON also stated that maintenance staff does the entrapment risk assessment quarterly. During a concurrent observation and interview with the DON on 12/9/25 at 10:29 a.m., in Resident 71's room, Resident 71 had the bilateral side rails (grab bars) in upright position. The DON confirmed the observation. Review of Resident 71's Physician's order, dated 12/5/25, indicated Bil grab bars up when in bed to enable independent repositioning and transfers. During a concurrent interview and record review with the Maintenance Supervisor (MS), on 12/12/25 at 1:53 p.m., the MS stated Resident 71's entrapment risk assessment was not done. During a concurrent observation and interview with the DON on 12/9/25 at 10:24 a.m., in Resident 11's room, Resident 11 had the bilateral upper side rails in upright position. The DON confirmed the observation. Review of Resident 11's Physician's order, dated 2/24/25, indicated Half side rails up both when in bed to enable independent repositioning and transfers. Review of Resident 11's Side Rail Evaluation with the DON on 12/12/15 at 12:53 p.m., dated 3/11/25, the DON confirmed that the entrapment risk assessment was not done. During a concurrent observation and interview with the DON on 12/9/25 at 10:26 a.m., in Resident 80's room, Resident 80 had the bilateral side rails (grab bars) in upright position. The DON confirmed the observation. Review of Resident 80's Physician's order, dated 12/8/25, indicated Grab bar side rails up both when in bed to enable independent repositioning and transfers. During a concurrent interview and record with the DON, on 12/12/25 at 12:57 p.m., the DON stated side rail evaluation for Resident 80 was not done because grab bars was considered less restrictive. During a concurrent observation and interview with the DON on 12/9/25 at 10:28 a.m., in Resident 51's room, Resident 51 has the bilateral side rails in upright position. The DON confirmed the observation. Review of Resident 51's Physician's order, dated 12/10/25, indicated Half side rails up bil when in bed to enable independent repositioning and transfers. Review of Resident 51's Side Rail Evaluation, dated 10/21/25, with the DON on 12/12/25 at 1:02 p.m., indicated the resident does not require the use of side rails at the time of evaluation. No documented evidence of risk of entrapment assessment done on 12/5/25. During an interview with the MS on 12/12/25 at 2:43 p.m., the MS stated he does the entrapment risk assessment for all bed with or without residents annually. The MS also stated that he will attach the side rails for a new resident once nursing staff informed him. The MS further stated he will not do the entrapment risk assessment for the new resident after the side rails were attached. During an interview with Registered Nurse (RN) A on 12/12/25 at 4:25 p.m., RN A stated there was no checklist or form to fill out for entrapment risk assessment. RN A also stated they only check if the hand does not get trapped in the side rail or if the side rail restrict their movement. According to Food and Drug Administration's (FDA) A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health: The Facts, dated12/11/2017, indicated potential risks of bed rails may include: strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. According to FDA's Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, date 2003, indicated In creating a safe bed environment, the following general principles should be applied: Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards.Re-assess the patient's needs and re-evaluate. During an initial observation visit on 12/8/25 a. at 10:05 a.m. Resident 35's bed was observed with 1 side rail; b. at 10:08 a.m. Resident 14's bed was observed with 2 side rails; c. at 10:09 a.m. Resident 9's bed was observed with 2 side rails; d. at 10:10 a.m. Resident 36's bed was observed with 2 side rails; e. at 10:12 a.m. Resident 26's bed was observed with 1 side rail; f. at 10:20 a.m. Resident 6's bed was observed with 2 side rails; g. at 10:40 a.m. Resident 17's bed was observed with 1 side rail. During a concurrent interview and record review on 12/12/25 at 2:45 p.m. with the Director of Nursing (DON), Resident 35's Medical Record (EMR) was reviewed. The side rail documents were reviewed. Resident 35's order dated 8/7/25 indicated start date 8/7/25 End date: open ended. Half side rails up. Resident 35's ,Side rail Evaluation dated 2/3/25, indicated, Entrapment Risk completed. Side rail Evaluation dated 5/11/25 indicated, Entrapment Risk not completed. Side rail Evaluation dated 8/7/25, indicated, Entrapment Risk completed. The DON stated the Entrapment risk is completed by maintenance yearly. Side rail Evaluation dated 11/8/25 indicated, Does the Resident require .side rails at this time. No. Entrapment Risk: not applicable. The DON stated, there was no orders to discontinue or gap in orders for side rail use. Review of the side rail (non-restraint) care plan (CP), dated 8/5/25, the CP indicated, Check for any gaps between the bedside rail/rails and the bed mattress for the risk of entrapment and refer to maintenance staff for interventions. During a concurrent interview and record review on 12/12/25 at 2:50 p.m. with DON, Resident 14's Medical Record (EMR) was reviewed. The side rail documents were reviewed. Resident 14's order dated 9/17/25 indicated start date 9/17/25 End date: open ended. Transfer rails. Resident 14's Side rail Evaluation dated 3/4/25 indicated, Entrapment risk completed. Side rail Evaluation dated 5/31/25 indicated, Entrapment risk completed. Resident 14's Side rail Evaluation dated 8/7/25 indicated, Entrapment risk completed. Resident 14's Side rail Evaluation dated 8/31/25 indicated, Entrapment risk not applicable. Resident 14's Side rail Evaluation dated 11/29/25 indicated, Entrapment risk not completed. Review of the side rail (non-restraint) care plan, dated 12/2/24, the CP indicated, Check for any gaps between the transfer rails and the bed mattress for the risk of entrapment and refer to maintenance staff for interventions. During a concurrent interview and record review on 12/12/25 at 2:55 p.m. with DON, Resident 9's Medical Record (EMR) was reviewed. The side rail documents were reviewed. Resident 9's order dated 7/15/24 indicated start date 7/15/24 End date: open ended. Half side rails up both. Resident 9's Side rail Evaluation dated 2/3/25 indicated, Entrapment risk: completed. Side rail Evaluation, dated 5/4/25 Entrapment Risk not completed. Side rail Evaluation, dated 8/7/25 Entrapment Risk: completed. Side rail Evaluation dated 11/1/25 indicated, No side rails and Entrapment risk: not applicable. Review of the side rail (non-restraint) care plan, dated 9/17/25, the CP indicated, Check for any gaps between the bedside rail/rails and the bed mattress for the risk of entrapment and refer to maintenance staff for interventions. During a concurrent interview and record review on 12/12/25 at 2:58 p.m. with DON, Resident 36's Medical Record (EMR) was reviewed. The side rail documents were reviewed. Resident 36's order dated 7/1/25 indicated start date 7/1/25 End date: open ended. Half side rails up both.Resident 36's Side rail Evaluation , dated 2/24/25 indicated Entrapment risk completed. Side rail Evaluation , dated 3/11/25 indicated Entrapment risk completed. Side rail Evaluation , dated 8/7/25 indicated Entrapment risk completed. Side rail Evaluation , dated 12/8/25 indicated Entrapment risk completed. Review of the side rail (non-restraint) care plan, dated 8/5/25, the CP indicated, Check for any gaps between the bedside rail/rails and the bed mattress for the risk of entrapment and refer to maintenance staff for interventions. During a concurrent interview and record review on 12/12/25 at 3:00 p.m. with DON, Resident 26's Medical Record (EMR) was reviewed. The side rail documents were reviewed. Resident 26's order dated 9/24/24 indicated start date 9/24/24 End date: open ended. Half side rails up both. Resident 26's Side rail Evaluation dated 1/14/25 indicated, Entrapment risk: completed. Resident 26's Side rail Evaluation dated 4/1/25 [observed- completed 7/3/25] indicated, Entrapment risk: completed. Resident 26's Side rail Evaluation dated 7/4/25 indicated, Entrapment risk: not completed. Resident 26's Side rail Evaluation dated 8/7/25 indicated, Entrapment risk: completed. Resident 26's Side rail Evaluation dated 9/13/25 indicated, Entrapment risk: completed. Review of the side rail (non-restraint) care plan, dated 6/21/24, the CP indicated, Check for any gaps between the bedside rail/rails and the bed mattress for the risk of entrapment and refer to maintenance staff for interventions. During a concurrent interview and record review on 12/12/25 at 3:10 p.m. with DON, Resident 6's Medical Record (EMR) was reviewed. The side rail documents were reviewed. Resident 6's order dated 12/8/25 indicated start date 12/8/25 End date: open ended. Half side rails up both. Resident 6's Side rail Evaluation dated 3/4/25 indicated, Entrapment risk: completed. Resident 6's Side rail Evaluation dated 5/31/25 indicated, Entrapment risk: completed. Resident 6's Side rail Evaluation dated 8/7/25 indicated, Entrapment risk: completed. Resident 6's Side rail Evaluation dated 8/31/25 indicated, Entrapment risk: completed. Resident 6's Side rail Evaluation dated 11/29/25 indicated, Entrapment risk: completed. Review of the side rail (non-restraint) care plan, dated 4/5/24, the CP indicated, Check for any gaps between the bedside rail/rails and the bed mattress for the risk of entrapment and refer to maintenance staff for interventions. During a concurrent interview and record review on 12/12/25 at 3:15 p.m. with DON, Resident 17's Medical Record (EMR) was reviewed. The side rail documents were reviewed. Resident 17's order dated 10/3/24 indicated start date 10/3/25 End date: open ended. Half side rails up both. Resident 17's Side rail Evaluation dated 2/24/25 indicated, Entrapment risk: completed. Resident 17's Side rail Evaluation dated 3/26/25 indicated, Entrapment risk: completed. Resident 17's Side rail Evaluation dated 6/7/25 indicated, Entrapment risk: completed. Resident 17's Side rail Evaluation dated 8/7/25 indicated, Entrapment risk: completed. Resident 17's Side rail Evaluation dated 9/13/25 indicated, Entrapment risk: completed. Review of the side rail (non-restraint) care plan, dated 10/3/24, the CP indicated, Check for any gaps between the bedside rail/rails and the bed mattress for the risk of entrapment and refer to maintenance staff for interventions. During an interview on 12/12/25 at 4:10 p.m. with the Maintenance Supervisor (MS), the MS indicated the entrapment assessment is completed by nursing, he completed the yearly maintenance checks and maintenance as needed. During an interview on 12/12/25 at 4:20 p.m. with Registered Nurse A (RN), RN A stated there are no resources for checking Residents for entrapment from side rails. RN A was not able to provide evidence of what specific assessments are included in the entrapment assessments. During an interview on 12/12/25 at 4:27 p.m. with Registered Nurse D (RN), RN D stated, maintenance places the side rails and a supervising nurse will do the entrapment assessment. No evidence provided on what is included in the entrapment assessment.

Based on observation, interview, and record review, the facility failed to ensure puree food recipes were followed during cooking for 14 of 84 residents.This failure had the potential to compromise the health and safety of 14 residents who receive pureed diets. During an observation in the kitchen on December 9, 2025, at 11:39 a.m., [NAME] A was observed adding hot water from the kitchen faucet to the blender to prepare pureed bread without measuring the amount added.During an observation in the kitchen on December 9, 2025, at approximately 11:50 a.m., [NAME] A was observed adding 1 scoop (4 ounce) of food thickener to the pureed Brussels sprouts and adding approximately 21/2 scoops (10 ounce) of food thickener to the pureed bread.During an interview with [NAME] A on December 10, 2025, at 11:54 a.m., [NAME] A confirmed that he added water from the kitchen faucet instead of using a measuring cup and used a 4-ounce scoop to add food thickener. He further confirmed that he added approximately 21/2 scoops (10 ounces) of thickener to the pureed bread and approximately 1 scoop (4 ounces) of thickener to the pureed Brussels sprouts. [NAME] A admitted that he added more thickener than required by the recipe and acknowledged that he should have followed the recipe when preparing pureed foods.During a concurrent interview and record review with the Registered Dietitian (RD) on December 10, 2025, at 4:00 p.m., the RD reviewed the recipe titled Wheat Bread Conv PU and confirmed that, according to the recipe for 14 residents (15-serving recipe), the preparation required a total of 13/4 cups plus 2 tablespoons [15 ounces (units of mass, weight, or volume)] of water and 3 tablespoons plus 21/2 teaspoons (approximately 1.9 ounces) of food thickener. The RD stated that [NAME] A added approximately 10 ounces of thickener to the pureed bread, which was not consistent with the recipe.The RD further reviewed the recipe titled Brussels Sprouts FZN PU and confirmed that, according to the recipe for 14 residents (15-serving recipe), the preparation required a total of 1/4 cup plus 1 tablespoon of food thickener. The RD stated that [NAME] A added 4 ounces of food thickener, which exceeded the amount required by the recipe.A review of the facility's policy and procedure titled Nutrition Therapy Essentials, Inc. Food Service Policy and Procedures, Manual 2023, indicated: .pureed food preparation (follow menu recipes). pureed foods should be prepared to the consistency and thickness of mashed potatoes rather than a gravy or watery texture. use product guidelines for thickening to achieve appropriate consistency .

Based on observation, interview, and record review, the facility failed to ensure proper infection prevention techniques were followed when:1. For one of three residents (Resident 36) the licensed nurse failed to wear gloves when giving an injection2. The Certified Nursing Assistant (CNA) B failed to wear the proper Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illness)) when providing care to one of seven residents (Resident 71) on Enhanced Barrier Precautions (EBP, infection control guidelines, primarily for nursing homes, that require staff to wear gowns and gloves during high-contact resident care activities to prevent the spread of multidrug-resistant organisms [MDROs, microorganisms that are resistant to many common antibiotics]).3. The Licensed Vocational Nurse (LVN) C failed to change gloves during tube feeding for 1 of 1 resident (Resident 11).These deficient practices had the potential for contamination and spread of infection. Findings: 1. 1. During a medication pass observation on 12/10/25 at 11:52 a.m., with Licensed Vocational Nurse (LVN) F, LVN F was observed giving Resident 36 an injection without wearing gloves. During a concurrent interview at 11:55 a.m. LVN F stated, usually I wear gloves. During a review of the facility's policy and procedure (P&P) titled, Subcutaneous Injection, dated (undated), indicated .Procedure: .put on gloves. 2. Review of Resident 71's Physician's order, dated 12/8/25, indicated Place resident on Enhanced Barrier Precautions (EBP) due to use of medical device (IV to left hand). Wear gloves, mask, gown for contact and resident activities: Dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs and assist with toileting. During an observation on 12/9/25 at 9:41 a.m., in Resident 71's room, Resident 71 was lying in bed when CNA B removed the blanket and heel booties (heel protectors) of the resident. CNA B was not wearing the yellow gown. During a concurrent observation and interview with the Medical Records Director (MRD), in the hallway outside of Resident 71's room, on 12/9/25 at 9:47 a.m., the MRD pointed with his hand to the PPE hanging by the door of Resident 71 and stated something in Spanish to CNA B. The MRD confirmed that he did point at the PPE and that CNA B was not wearing yellow gown. The MRD stated that CNA B was getting ready to do patient care and reminded her to wear the PPE. During an interview with CNA B, on 12/9/25 at 10:21 a.m., CNA B confirmed that she was not wearing the yellow gown when she started providing care to Resident 71. CNA B stated should wear the yellow gown. During an interview with the Infection Preventionist (IP), on 12/9/25 at 12:40 p.m., the IP stated the staff have to put on the PPE for any type of patient care for residents on EBP. The IP also stated the staff have to wear the mask, gloves and yellow gown when removing the socks or heel booties of residents. 3. Review of Resident 11's Physician's order, dated 11/12/25, indicated Formula: Twocal HN (a high-calorie, high-protein nutritionally complete liquid formula used for tube feeding [liquid nutrients given through a tube inserted in the stomach] via enteral pump (a medical device that delivers liquid nutrition via a feeding tube). Review of Resident 11's Physician's order, dated 6/18/25, indicated Enhanced barrier precautions due to presence of indwelling device: GT feeding. Wear gloves and gowns for the ff: High-contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. Device care: central line, urinary catheters, feeding tube and wound care. During a concurrent observation and interview with LVN C, on 12/10/25 at 2:45 p.m., LVN C was performing tube feeding on Resident 11. LVN C put on gloves and yellow gown. Then prepared the tube feeding formula and the enteral pump. LVN C then changed the gloves and pulled up Resident 11's dress and checked the residual amount (the amount of formula or fluid left in the stomach). LVN C then flushed the G-tube (gently pushing water through the Gastrostomy tube, a feeding tube inserted through the abdomen directly into the stomach with a syringe to keep it clear of blockages), turned on the enteral pump and entered the settings. Then LVN C primed the enteral pump tubing (filling the line with fluid to flush out the air before connecting to the patient) and connected it to the G-tube. LVN C then started the pump and then removed the gloves. LVN C confirmed she did not change the gloves before checking the residual and before connecting the pump tubing to the G-tube. LVN C also stated she should have changed gloves. During an interview with the IP, on 12/11/25 at 4:01 p.m., the IP stated the LVN should change the gloves before checking the residual and again before connecting the tubing to the G-tube because the LVN touched other things. During a review of the facility's Policy and Procedures (P&P), titled Enhanced Barrier Precautions (EBP), undated, indicated EBP shall be used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that may result in transfer of MDROs to staff hands and clothing .For residents for whom EBP are indicated, EBP shall also be used when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, e.g., central line, urinary catheter, feeding tube .

Based on observation, interview, and record review, the facility failed to ensure four of five Residents (8,18,40,44) eye drops medications were appropriately stored and labeled. This failure placed residents at potential risk for receiving the wrong medication and expired medications, which could lead to medication ineffectiveness and medication adverse reaction.Findings:During an observation and concurrent interview on 12/11/25 at 2:15 p.m. with Registered Nurse (RN) D, medication carts one, two and three were inspected. In medication cart one there were three of four bottles of artificial tears (over-the-counter eye drops, gels, or ointments that mimic natural tears to add moisture, lubricate, and soothe dry, irritated eyes)(Resident 18, 40, 44) with the box identified with the name, date opened and room number, no Resident identifiers on the bottle. In medication cart three there was one box of artificial tears (Resident 8) with only a room number identifier and date opened on the box and no identifier on the bottle.During a follow up interview on 12/12/25 at 8:57 a.m. with RN D, RN D confirmed, there is a potential for error with only the boxes having Resident identifiers.During an interview on 12/12/25 at 2:28 p.m. with the Pharmacist (RPH), the RPH stated, [eyedrops] should have a label on the container incase the box is lost and for infection prevention so not using the wrong [eyedrops] container on Residents.During a review of the facility's policy and procedure (P&P) titled, Guidelines for Labeling and Disposing Multi-Dose Medications, not dated, the P&P indicated, . Each multi-dose container must have: the resident's name, the medication name, dose, route dispensing pharmacy label, expiration date .

Based on interview and record review, the facility failed to ensure accurate documentation of the administration of controlled medications (narcotics, including potential opioids for pain management) for two of eight sampled residents (Resident 7, 37), by failing to document the administration and refusal of Resident 7's and 37's medications on the Medication Administration Record (MAR - a report detailing the medications administered to a resident by the licensed nurse in the facility).This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drug).Findings:On 12/10/25 at 12:52 p.m., during the inspection of Medication cart 1, with Licensed Vocational Nurse C (LVN C), an audit of controlled drug records and medication administration records was completed.During the concurrent interview and record review on 12/10/25 at 12:52 p.m., with LVN C Resident 7's Controlled Drug Record (CDR) (a record of narcotic medication counts) for hydrocodone-apap (generic for Norco, a potent opioid for pain management) 5-325 milligram (mg a unit of measure) was reviewed. The CDR indicated a dose of Norco was removed on 12/10/25 at 8:28 a.m. However, a concurrent count of the medication package indicated the Norco medication was still in the package and therefore not administered to Resident 7. Review of Resident 7's MAR for December 2025 indicated the medication [Norco] was administered 12/10/25 at 8:28 a.m.During a follow up interview, on 12/10/25 at 3:27 p.m. with LVN C, LVN C stated, she had forgotten the resident refused the medication, she gave all the other medications, and signed them all off as given, she should have signed off the Norco as refused.During a concurrent interview and record review on 12/11/25 at 11:41 a.m. with the Director of Nursing (DON), Resident 37's CDR for Oxycodone HCL 5 mg and MAR dated 9/2025 was reviewed. The CDR indicated a dose of Oxycodone HCL 5 mg was removed on 9/1/25 at 12 MN and 9/25/25 at 2:00 p.m. However, a review of Resident 37's 9/2025 MAR indicated there was no evidence documented that Resident 37 was administered the medication Oxycodone HCL 5 mg.During a review of Resident 37's physician orders dated 8/4/25 for Oxycodone 5 mg indicated Oxycodone HCL 5 mg, Give 1 tablet every 6 hours as needed for moderate to severe pain.During a review of the facility's policy and procedures(P&P), titled Medication Pass Guidelines, undated, indicated .Record the results of medication administration as necessary. Record the name, dose, route, and time of medication on the Medication Administration Record [MAR].initial the record after the medication is administered to the resident. Use the electronic health record system.During a review of the facility's policy and procedures (P&P), titled Refusal of Treatment, undated, indicated .Refusal of treatment includes, but is not limited to, refusal of the following: Medications. At a minimum, the following must be recorded in the nursing progress notes: the date and time the treatment/medication administration was attempted; the treatment/medication administration attempted; the residents response and reasons for refusal.documentation each time the resident refused .treatment/medication.

Based on observation, interviews, and record review, the facility failed to implement their abuse policy and procedures for one of three sampled residents (Resident 1) when the facility did not report Resident 1's allegation of abuse. This failure resulted in Resident 1's allegation of abuse not reported to required agencies California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman). This failure had the potential to compromise the safety of the residents in the facility.During an interview on 5/15/25 at 1:11 p.m., with Resident 1. Resident 1 stated she has a concern about a gentleman that comes in her door, she stated she is afraid for other residents what the gentleman can do to them. Resident 1 stated the gentleman's room was two doors next to hers. Resident 1 stated she filed a grievance for that, and social services knows. During a review on 5/15/2025 of Resident 1's Face sheet (FS, document that summarizes a person's information such as medical history), the FS indicated Resident 1 was initially admitted on [DATE] to the facility with diagnoses including urinary tract infection, anxiety disorder unspecified (a mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), and major depressive disorder (a serious mood disorder characterized by persistent feelings of sadness, loss of interest or pleasure, and other symptoms that impair daily functioning).Review of Resident 1's admission minimum data set (MDS, a resident assessment tool) dated 4/8/2025, indicated Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition level) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During an interview on 5/15/25 at 3:31 p.m., with the Social Service Director (SSD), the SSD stated she met with Resident 1. The SSD stated Resident one invited Resident 2 to her room, and they talked about spouses then Resident 1 asked Resident 2 to leave the room because it made her uncomfortable.During a review of Facility's Grievance (a standardized document that an individual, typically an employee, uses to formally report a complaint or concern about unfair treatment, a policy violation, or a breach of their employment contract or collective bargaining agreement) Form dated 4/28/25, it indicated, Resident states she invited resident [room AA] into her room-Started talking about his wife and children. He came towards me and feeling my leg. At- Which point I quickly escorted him out of the Room.During a concurrent interview and record review on 5/16/25 at 3:22 p.m. of Resident 1's grievance form dated 4/28/25., with the SSD, the SSD stated Resident 1 came to her office and she helped Resident 1 fill up the grievance form. The SSD further stated those are Resident 1 words she just helped her write it. During the follow-up interview on 5/16/25 at 2:43 p.m., with Resident 1, she stated she was sitting in her bed, then Resident 2 came forward to her, and started talking about his family. He [Resident 2] started stroking her right leg, she pushed him away and yelled at him, he back away and started making mouth gestures. Resident 1 stated she reported it to the night nurse and the night social worker on Friday. Resident 1 stated she was told this gentleman will leave on Tuesday. Resident 1 stated she felt like she was violated, and she didn't give him consent to touch her. During an interview on 5/16/25 at 3:44 p.m., with the Director of Nursing (DON), the DON stated it's not reported, from her understanding she [Resident 1] invited him [Resident 2] to her room so it's consensual, the DON further stated she only talked to Resident 2, and he denied it on 5/1/25.During an interview on 5/16/25 at 3:55 p.m., with the Administrator (ADM), The ADM stated there was no further concern from Resident 1. ADM stated Resident 1 was okay that Resident 2 will be discharged the following day. The ADM stated they thought it was not abuse, and she (Resident 1) just wanted to let them know.During an observation on 5/15/2025 at 12:50 p.m., noted Resident 2 was still in the facility. During another observation on 8/22/2025 at 11:25 a.m., Resident 2 was observed still in the facility but has been moved to another room further away from Resident 1. During a review of Resident 2's clinical records on 8/22/2025, Resident 2's clinical records indicated he was admitted on [DATE] with diagnoses including cerebral infarction unspecified (a medical term that refers to a stroke where the specific cause of the blockage in a brain artery is unknown) and type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) without complications and he was never discharged from the facility as of 8/22/2025. A Review of Facility's Five Day summary dated 5/20/2025 indicated Based on initial and further investigation beginning on 4/28/25 that included interviews with staff and residents, the facility was unable to substantiate the allegation of abuse.During a concurrent interview and record review on 8/22/25 at 12:18 p.m., with the Nurse Supervisor (NS), the NS reviewed Resident 1's progress notes from 4/21/25 to 4/30/25, she confirmed that there was no documentation the allegation was reported to CDPH, Ombudsman, and Law enforcement. The NS further stated she did the SBAR and progress notes about this allegation of abuse between Resident 1 and Resident 2 only on 5/15/2025 and reported it to CDPH, Law enforcement and Ombudsman only on 5/15/25. During a review of the facility's policy and procedure titled, Abuse Investigation & reporting, undated, indicated, All allegations of resident abuse, neglect, exploitation, misappreciation of resident property, mistreatment and/or injuries of unknown source( abuse) shall be promptly reported to the appropriate local, state and/or federal agencies (as defined by current regulations) and thoroughly investigated by Company management. Findings of abuse investigations will also be reported to local law enforcement and the Office of Ombudsman .2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately but no later than: a) Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or b) Twenty-four (24) hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury.

Based on observation, interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) when Resident 1 got out of the facility without supervision. This failure put Resident 1 at risk for accidents. Findings: During an observation on 9/23/24 at 4 p.m., Resident 1 walked towards her room using a walker unassisted and was able to sit on the bed unassisted. Resident 1 stated she walked out of the facility on 9/20/24. During a concurrent observation and interview on 9/23/24 at 4:05 p.m. with Resident 1 and Resident 1's relative (RR), the RR stated she was called by the facility on 9/20/24 at night and informed that Resident 1 went out of the facility. When Resident 1 was asked how she got out of the facility, Resident 1 led the surveyor to her room's sliding door that opened to a patio. Resident 1 pointed at the right side of the patio where a closed wooden door was sighted. Resident 1 stated she opened the wooden door on 9/20/24 to get out of the facility. The RR pushed the wooden door and it opened to the street in front of the facility. During a concurrent observation and interview on 9/23/24 at 4:15 p.m. with the Registered Nurse (RN), the RN confirmed the wooden door had no lock and had no alarm. The RN stated it should be locked or must have an alarm. During a concurrent observation and interview on 9/23/24 at 4:27 p.m. with the RN, the RN confirmed the glass door near room AA was ajar (slightly open). The RN closed the door to check if door alarm was on, the RN opened the glass door and no alarm was triggered. The RN stated the door should be closed at all times and the alarm must be on. During an interview on 9/23/24 at 4:29 p.m. with the Director of Nursing (DON), the DON stated that an unlocked door put residents at risk for accidents. The DON stated door alarms must be on at all times. During a concurrent interview and record review on 10/2/24 at 2:15 p.m. with the Regional Director for Maintenance (RDM) and the Supervisor of Maintenance (SM), the SM stated doors were checked daily, every morning, afternoon and before leaving the facility. The SM stated doors were ensured locked from the outside and alarms were functioning. The RDM stated that the wooden door was not part of the monitoring prior to Resident 1 getting out of the facility. The SM confirmed the Exit Door monitoring log for September 2024 started on 9/23/24. The SM confirmed there was no logs prior to 9/23/24. A review of facility's policy and procedure (P&P) titled Wander/Elopement Alarm System Testing with an approval effective date of 10/9/23, the P&P indicated, Door Monitor Test 1. Inspect and test each door monitor daily . Policies on accident hazards were requested but were not provided.

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The registered dietician (RD) walked in the hallway to the big dining room with gloves on; 2. The rehab director (RHD) checked the residents' lunch tickets on the lunch trays, passed lunch trays to certified nursing assistant N (CNA N) and certified nursing assistant O (CNA O) to bring to the residents in their rooms without sanitizing her hands; CNA N and CNA O carried lunch trays to the residents without sanitizing their hands; licensed vocational nurse A (LVN A) checked the residents' lunch tickets on the lunch trays and opened the lids of the lunch trays to check on the food without sanitizing her hands; and the infection preventionist (IP) checked the residents' lunch tickets on the lunch trays, opened the lids of the lunch trays to check on the food, and passed the lunch trays to CNAs to bring them to the residents in their rooms without sanitizing her hands; 3. The activity director (AD) and certified nursing assistant L (CNA L) went into the isolation room for Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus which can spread from an infected person's mouth or nose in small liquid particles when they cough, sneeze, speak, sing or breathe) wearing surgical mask, and certified nursing assistant M (CNA M) went in the isolation room for COVID-19 not wearing a gown; 4. Resident 38's oxygen tubing was undated, and Resident 38's and Resident 72's filters of oxygen concentrators were dusty; 5. Registered nurse K (RN K) picked up sterile Alginate dressing (highly absorbent dressing) and clean gauzes with her contaminated gloved hands when doing the treatment for Resident 64's wounds; 6. Restorative nurse assistant (RNA) did not perform hand hygiene in between Resident 2 and Resident 4's meal assistance; 7. Certified nursing assistant Q (CNA Q) did not wear a face mask when she entered the facility with COVID-19 outbreak; and 8. CNA O touched the shared bathroom doorknob with dirty gloves, in Resident 31's room, placed the clean washcloth in the sink, used the same washcloth during incontinent care with Resident 31 and used dirty gloves to place a clean disposable brief on Resident 31. These failures had the potential to spread infection in the facility. Findings: 1. During an observation on 6/17/24, at 12:37 p.m., the registered dietician (RD) was walking in the hallway to the big dining room with gloves on. During a concurrent interview, the RD stated he just came out of the kitchen and forgot to remove the gloves. The RD acknowledged that he should remove gloves before walking out in the hallway. During an interview with the director of nursing (DON) on 6/24/24, at 1:45 p.m., she stated the RD talked to her about that, and she told him that he should remove gloves before walking out in the hallway. Review of the facility's undated policy, Standard Precautions, indicated Remove gloves promptly after use, and wash hands immediately . 2. During an observation on 6/17/24, at 12:45 p.m., the rehab director (RHD) came to lunch cart 1, checked the residents' lunch tickets on the lunch trays, passed lunch trays to certified nursing assistant N (CNA N) and certified nursing assistant O (CNA O) to bring to the residents in their rooms without sanitizing her hands, and CNA N and CNA O carried lunch trays to the residents without sanitizing their hands. During an interview with the RHD, CNA N, and CNA O on 6/17/24, at 1:06 p.m., the RHD acknowledged that she should sanitize her hands before checking the tickets on the lunch trays and passing the lunch trays to CNAs to bring to the residents; CNA N and CNA O stated they should sanitize their hands before carrying the lunch trays to the residents. During an observation on 6/17/24, at 1 p.m., licensed vocational nurse A (LVN A) came to lunch cart 1, checked a resident' lunch ticket on the lunch tray and opened the lid of the lunch plate to check on the food without sanitizing her hands. During an interview with LVN A on 6/17/24, at 1:14 p.m., she acknowledged that she should sanitize her hands before checking the lunch ticket on the lunch tray and opening the lid of the lunch plate to check on the food. During an observation on 6/17/24, at 1:35 p.m., the infection preventionist (IP) pushed the lunch cart 2 over, opened the lunch cart 2, checked residents' lunch tickets on the lunch trays, opened the lids of the lunch plates to check on the food, and passed the lunch trays to the CNAs to bring to the residents in their rooms without sanitizing her hands. During an interview with the IP on 6/17/24, at 1:44 p.m., the IP stated she should sanitize her hands before checking residents' lunch tickets on the lunch trays, opening the lids of the lunch plates to check on the food, and passing the lunch trays to the CNAs to bring to the residents. During an interview with the director of nursing (DON) on 6/24/24, at 1:45 p.m., the DON stated staff should sanitize their hands before checking the meal ticket on the meal tray, opening the lid of the meal plate to check on the food, passing the meal tray to the CNA, and carrying the meal tray to the resident. 3. During an observation on 6/17/24, at 10:15 a.m., the activity director (AD) went in Resident 33's room which was a COVID-19 isolation room to answer his call light wearing a surgical mask. During a concurrent interview, the AD stated she should wear a N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) instead of a surgical mask when entering a COVID-19 isolation room. During an observation on 6/17/24, at 11:12 a.m., certified nursing assistant M (CNA M) went in Resident 58's room which was a COVID-19 isolation room to give him ice water without wearing a gown (a personal protective equipment used to provide broad barrier protection). During a concurrent interview, CNA M acknowledged she should put on a gown before entering Resident 58's room. During an observation on 6/17/24, at 11:40 a.m., CNA L went in Resident 54's room which was a COVID-19 isolation room wearing a surgical mask. During a concurrent interview, CNA L stated she should wear a N95 mask instead of a surgical mask when entering Resident 54's room. During an interview with the infection preventionist (IP) on 6/17/24, at 10:15 a.m., she stated staff should wear N95 when entering COVID-19 isolation room, and on 6/18/24, at 10:10 a.m., the IP stated staff should put on a gown before entering COVID-19 isolation room. Review of the facility's undated policy, COVID-19 Using Personal Protective Equipment (PPE), indicated . 3. a. Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection adhere to enhanced transmission-based precautions and use a N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. 4. Review of Resident 38's Admission Record indicated she was admitted to the facility on [DATE] with dependence on supplemental oxygen diagnosis. Review of Resident 38's physician order indicated she had an order, started on 1/5/24, for continuous oxygen at 3 liters (L, a metric unit of volume) per minute. During an observation and interview with the infection preventionist (IP) on 6/17/24, at 1:25 p.m., Resident 38 was on supplemental oxygen. Her oxygen tubing was undated, and the filter of her oxygen concentrator was dusty. The IP stated the oxygen tubing should be dated and changed every week, and the filter of the oxygen concentrator should be kept clean. Review of Resident 72's Admission Record indicated he was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, lung diseases that block airflow and make it difficult to breathe) diagnosis. Review of Resident 72's physician order indicated he had an order, started on 3/21/24, for continuous oxygen at 3 L per minute. During an observation and interview with the infection preventionist (IP) on 6/17/24, at 1:30 p.m., Resident 72 was on supplemental oxygen, and the filter of his oxygen concentrator was dusty. The IP stated the filter of the oxygen concentrator should be kept clean. During an interview with the IP on 6/17/24, at 4:40 p.m., she stated the filter of oxygen concentrator should be cleansed every week. Review of the facility's undated policy, Cleaning Respiratory Equipment, indicated Supplies: 1. Replace masks and/or cannulas used by an individual resident within 7 days, . Oxygen Tanks, Connectors, and Concentrators: . 2. Clean oxygen concentrator filters weekly. 5. Review of Resident 64's Admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 64's 6/2024 Treatment Administration Record (TAR) indicated he had wounds on his left and right gluteal folds (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks). During an observation on the treatment for Resident 64's wounds with registered nurse K (RN K) on 6/20/24, at 11:12 a.m., RN K prepared the supplies for the treatment. RN K washed her hands, put on gloves, opened the treatment cart, opened the drawers looking for supplies, got the treatment creams to the medication cups, then opened the Alginate dressing packet and picked up the sterile Alginate dressing and picked up the clean gauzes with the same gloved hands that she opened the treatment cart, opened the drawers looking for supplies, and got the treatment creams to the medication cups. During an interview with RN K on 6/20/24, at 11:45 a.m., she acknowledged that she should not picked up the sterile Alginate dressing and clean gauzes with her contaminated gloved hands. Review of the facility's undated policy, Standard Precautions, indicated . 4. Gloves: . Remove gloves promptly after use, and wash hands immediately before touching non-contaminated items . 44583 6. During lunch observation on 6/18/2024 at 1:02 p.m., inside the big dining room, RNA was observed seated between Resident 2 and Resident 4. RNA touched Resident 2's adaptive utensils, which was already used by Resident 2, and handed them to Resident 2's hands. RNA turned to her right-side assisted Resident 4 in opening his drinks without performing hand hygiene. During an interview with RNA on 6/18/2024 at 1:24 p.m., RNA confirmed above observations. RNA stated she should have performed hand hygiene in between meal assistance with two residents. During an interview with DON on 6/24/2024 at 12:02 p.m., DON stated staff should perform hand hygiene in between residents' meal assistance. During review of the facility's undated policy and procedure titled, Assisting the Resident to Eat, indicated, Wash your hands if you will be assisting the resident to eat. Review of the Centers for Disease Control and Prevention's (CDC) guidelines, titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/24/2024, indicated, All healthcare personnel should understand how to care for and clean their hands .Know when to clean your hands .After touching patient or patient's surroundings . 7. During a concurrent observation and interview with CNA Q on 6/18/2024 at 1:15 p.m., inside Resident 41's room, CNA Q was observed assisting Resident 41 with meals without wearing a face mask. When Resident 41 was finished with lunch, CNA Q went out of Resident 41's room, without a face mask, walked towards the empty lunch cart which was passed nurse Station AA and went back to Resident 41's room. CNA Q confirmed above observation and stated she should have worn a face mask upon entry to the facility because they were having some COVID-19 cases. During an interview with receptionist (RECP) on 6/18/2024 at 1:19 p.m., RECP stated staff should grab a mask before entering the facility. RECP further stated all staff should wear a face mask because their facility had COVID-19 outbreak. During an interview with DON on 6/20/2024 at 10:36 a.m., DON stated, staff should wear surgical mask or N95 (a mask or device worn over the mouth and nose to protect the respiratory system by filtering out dangerous substances [such as dusts, fumes, or bacteria] from inhaled air) since we have COVID-19. During a review of the facility's undated policy and procedure titled, COVID-19 Using Personal Protective Equipment (PPE), indicated, One of the following is worn for source control while in the facility and for protection during resident care encounters: (1) An N95 respirator .(3) A well-fitting facemask . 8a. During an observation on 6/24/2024 at 9:31 a.m., inside Resident 31's room, Resident 31 was positioned on his left side lying facing CNA O. CNA O opened Resident 31's disposable brief and noticed Resident 31 had a bowel movement. RN K started cleaning Resident 31 with CNA O's assistance. RN K asked CNA O to get clean washcloths because the disposable wipes were not enough to remove the sticky stool from Resident 31's skin. CNA O grabbed the bathroom doorknob with dirty gloves to open it, then removed her dirty gloves inside the bathroom. 8b. During a follow up incontinent care observation on 6/24/2024 at 9:37 a.m., inside Resident 31's room, CNA O went back inside Resident 31's room with clean washcloths. CNA O placed the clean washcloths on top of the shared residents' sink, beside the faucet and turned on the faucet. The contaminated washcloths were used to clean Resident 31. 8c. During the same observation on 6/24/2024 at 9:40 a.m., CNA O tried to use the wet washcloth to remove some dried stool from Resident 31's scrotal area. CNA O was observed rolling and folding the same washcloth to remove more dried stool on Resident 31's scrotal area. After cleaning Resident 31, CNA O put on a new disposable brief on Resident 31 with the same dirty gloves. During an interview with CNA O on 6/24/2024 at 10:20 a.m., CNA O confirmed above observations. CNA O stated she preferred to use disposable wipes during incontinent care. During an interview with DON on 6/24/2024 at 12:02 p.m., DON stated clean wash cloth should not be placed on top of the sink. DON confirmed staff should not touch anything with dirty gloves. DON stated staff should remove their dirty gloves, wash their hands before touching any resident surface or belongings. DON mentioned staff should change used wet wash cloth and they should not fold the used washcloth and used it again. During a review of the facility's undated policy and procedure titled, Standard Precautions, indicated, All employees are expected to practice standard precautions to reduce both the risk of transmitting infections .Wash hands after touching or coming in contact with blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, before and after resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments .Handle resident care equipment that is soiled with .excretions in a manner that prevent skin and mucous membrane exposure .transfer of microorganisms to other residents and environment. 48935

Based on observation, interview, and record review, the facility failed to monitor, evaluate and managed residents' behavior for one of two sampled residents (Resident 285) when Resident 285 had episodes of screaming which sounded like a baby crying. The failure had the potential for Resident 285, not attaining her highest practicable physical, mental, and psychosocial well-being and caused discomforts to other residents in the same hallway (Residents19 and 61). Findings: During an observation on 6/17/2024 at 10:29 a.m., inside Resident 285's room, Resident 285 was lying in bed and her bed had two upper bed rails in upright position. Resident 285 was awake and quiet. During a concurrent observation and interview on 6/17/2024 at 12:44 p.m., inside Resident 19's room, Resident 19 was sitting at the edge of her bed. Resident 19 complained about the screamer, pointing towards Resident 285's room. Resident 19 stated, it was hard for her to sleep at night because of the screamer. During a concurrent observation and interview on 6/17/2024 at 3:50 p.m., inside Resident 61's room, Resident 61 was seated on his four wheeled walker and heard Resident 285 screamed. Resident 61 sounded irritated from the sound of Resident 285's scream, shook his head and stated, Can you please make that person stop? During an observation on 6/18/2024 at 9:40 a.m., in Station AA's hallway, Resident 285 could be heard screaming and sounded like a baby crying. Resident 285 was screaming continuously. None of the nurses or certified nursing assistant stopped to checked Resident 285. Review of Resident 285's face sheet ((summary page of a patient's important information), indicated, Resident 285 was admitted on [DATE] with diagnoses including sepsis (blood poisoning due to an infection), anemia (a condition in which the body does not have enough healthy red blood cells), type 2 diabetes mellitus with diabetic polyneuropathy (occurs when the body is unable to regulate glucose [sugar] in the blood, with nerve damage), unspecified dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning), dysphagia (difficulty swallowing), and gastrostomy status (G-tube or GT, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). Review of Resident 285's admission minimum data set (MDS, an assessment tool) dated 6/18/2024, indicated Resident 285 was usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversation). Further review of Resident 285's MDS indicated, Resident 285's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 6 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview with licensed vocational nurse D (LVN D) on 6/19/2024, in Station AA's hallway, Resident 285 could be heard screaming intermittently. LVN D confirmed Resident 285 had periods of screaming. LVN D stated, Resident D screamed mostly when she wanted to eat. LVN D confirmed Resident 285 had GT and her next feeding would be at 12:00 p.m. During a concurrent interview with director of nursing (DON) and record review on 6/20/2024 at 10:26 a.m., DON reviewed Resident 285's clinical records. DON confirmed the following: Resident 285 did not have an admission care conference, the behavior was not addressed, care plan regarding the behavior was not developed, and a risk meeting was done by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents), but they did not address the behavior. DON stated Resident 285's behavior should have been monitored and managed with a plan of care. During an interview with the social services director (SSD) on 6/21/2024 at 10:50 a.m., SSD confirmed Resident 285's behavior of screaming should be addressed. SSD further confirmed the IDT did not discuss their plan of care about Resident 285's behavior. During a review of the facility's undated policy and procedure titled, Behavior Assessment, Intervention and Monitoring, indicated, Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations .The nursing staff will identify, document, and inform the physician about the specific details regarding changes in an individual's mental status, behavior, and cognition .The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. The care plan will incorporate findings from the comprehensive assessment .The resident and family or representative will be involved in the development and implementation of the care plan.

Based on observation, interview, and record review, the facility failed to provide an appropriate social services (SS) support for four of six residents (Residents 61, 63, 75 and 285) when: 1. There was no documentation of timely SS support following Resident 61's complaint of missing money; 2. There was no SS support following an alleged abuse to Resident 63 and no documentation on SS follow up to address Resident 63's psychosocial needs; 3. There was no SS support following an alleged abuse to Resident 75 and no documentation on SS follow up to address Resident 75's psychosocial needs; and 4. There was no SS follow up to address Resident 285's behavior. These failures resulted in a lack of timely social services interventions and had the potential not to address Residents 61, 63, 75, and 285's psychosocial needs. Findings: 1. Review of Resident 61's face sheet (summary page of a patient's important information) indicated, Resident 61 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe), unspecified asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath), and pain in right shoulder. Review of Resident 61's admission minimum data set (MDS, an assessment tool) dated 4/21/2024, indicated Resident 61's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 12 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Review of Resident 61's SBAR-GENERAL [Situation, Background, Assessment, and Recommendation - an assessment tool used to facilitate prompt and appropriate communication of a problem] dated 6/10/2024, indicated Resident 61 was angry and stated someone stole his money from his wallet. Review of the IDT note for Resident 61's missing money, dated 6/11/2024, indicated, the IDT discussed Resident 61's missing money. Further review indicated, IDT will continue to monitor and follow up with plan of care as needed. During an interview with Resident 61 on 6/17/2024 at 3:50 p.m., Resident 61 reported someone stole his money worth $260. Resident 61 stated, I don't want to know who took it. During an interview with social services director (SSD) on 6/19/2024 at 10:10 a.m., SSD stated she received a report about Resident 61's missing money on 6/10/2024. SSD confirmed she was not able to monitor and follow up Resident 61 to address possible psychosocial effects of the missing money. During a concurrent interview with director of nursing (DON) and record review on 6/19/2024 at 11:19 a.m., DON reviewed SSD's progress notes. DON confirmed SSD's follow up documentations about Resident 61's missing money was just dated 6/19/2024 for both 6/10 and 6/11/2024 follow up. This surveyor started the investigation of Resident 61's missing money on 6/17/2024. 2. Review of Resident 63's face sheet indicated, Resident 63 was admitted to the facility with diagnoses including sepsis (blood poisoning due to an infection, causing the organs to work poorly), candidiasis (an infection caused by an overgrowth of yeast [Candida]), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and multiple sclerosis (a disabling disease of the brain and spinal cord). Review of Resident 63's admission MDS dated [DATE], indicated Resident 63's BIMS score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Review of Resident 63's SBAR-GENERAL dated 6/19/2024, indicated, Resident alleged roommate verbally abused her. Review of the IDT note for Resident 63's allegation of abuse by roommate dated 6/19/2024, indicated, IDT recommends and SOC 41 filed, notification to sheriff, ombudsman and CDPH, SBAR, COC, alert charting for emotional distress x (for ) 72 hours, SSD (social services director) to follow up with residents, psych [psychological or psychiatric] eval [evaluation], and on monitoring for emotional distress, resident was offered a room change but declined. During a concurrent observation and interview on 6/20/2024 at 1:27 p.m., inside Resident 63's room, Resident 63 was in bed, eating lunch. Resident 63 confirmed her roommate (Resident 75) called her very bad words. Resident 63 stated, she's (Resident 75) just very aggressive, verbally but not physically. During an interview with SSD on 6/21/2024 at 9:58 a.m., SSD stated her role as the SSD of the facility was to look after the psychosocial wellbeing of the residents. SSD further stated, her other role was to put out fire, and did some problem solving. During a concurrent interview with SSD and record review on 6/21/2024 at 10:41 a.m., SSD reviewed the IDT note on Resident 63's allegation of abuse by roommate dated 6/19/2024. SSD confirmed she did not implement the plan of care which was to follow up with Resident 63 for psych eval and on monitoring for emotional distress. SSD stated she should have followed up with Resident 63 as soon as she received the report on alleged abuse. 3a. Review of Resident 75's face sheet indicated, Resident 75 was admitted to the facility with diagnoses including fracture (broken bone) of left femur (thighbone), complete traumatic amputation (the loss of a body part, usually a finger, toe, arm, or leg, that occurs as a result of an accident or injury) of two or more left lesser toes, person injured in unspecified motor-vehicle accident, traffic, nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain) and nontraumatic subdural hemorrhage (a type of bleeding in which a collection of blood gathers between the inner layer of the meninges [the three thin layers that cover and protect the brain and spinal cord] surrounding the brain). Review of Resident 75's admission MDS dated [DATE], indicated Resident 75's BIMS score was 13 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Review of Resident 75's SBAR-GENERAL dated 6/13/2024, indicated, Allegation of Physical Abuse. Further review of the SBAR indicated, Resident 75 reported to staff a certified nursing assistant (CNA), threw her in her wheelchair and that he verbally abused her telling her she is loud and an old lady that talks to much. The SBAR indicated, the incident happened on 6/5/2024. Review of the IDT notes related to alleged physical and verbal abuse, dated 6/13/2024, indicated some recommendations, will continue and intervene accordingly . During a concurrent interview with SSD and record review on 6/19/2024 at 9:51 a.m., SSD reviewed her documentations related to the incident. SSD confirmed there was no documentation of SS three day follow up with Resident 75. During a concurrent interview with DON and record review on 6/19/2024 at 11:15 a.m. DON reviewed Resident 75's clinical records. DON confirmed there was no SS follow up with Resident 75's alleged abuse. DON stated, there should be SS follow up to check if Resident 75 was having emotional distress. 3b. Review of Resident 75's SBAR-GENERAL dated 6/14/2024, indicated, Alleged financial abuse. Per resident she had $1000 in her purse in a wallet and last seen it at 1100 am, she went to take money out of her wallet at 1700 and money was missing . During a concurrent observation and interview with Resident 75 on 6/18/2024 at 8:59 a.m., in the patio outside Resident 75's room, Resident 75 was having breakfast. Resident 75 had anger outburst (a sudden violent expression of strong feeling) to this surveyor, and stated they robbed me, they're incompetent . Review of Resident 75's clinical records, it did not indicate any SS follow up regarding the alleged financial abuse. 3c. Review of Resident 75's SBAR-GENERAL dated 6/19/2024, indicated, Resident 75 was accused of being verbally abusive and went through her roommate's belongings. Review of the IDT notes related to Resident 75's being accused of verbally abusive to roommate, dated 6/19/2024, indicated, SSD to follow up with residents, psych eval. During a concurrent observation and interview with Resident 75 on 6/18/2024 at 8:59 a.m., in the patio outside Resident 75's room, Resident 75 was having breakfast. Resident 75 had anger outburst (a sudden violent expression of strong feeling) to this surveyor, and stated they robbed me, they're incompetent . During an interview with SSD on 6/21/2024 at 10:44 a.m., SSD confirmed she did not follow up with Resident 75 about the accusation of being verbally abusive to her roommate (Resident 63). 4. During an observation on 6/17/2024 at 10:29 a.m., inside Resident 285's room, Resident 285 was lying in bed and her bed had two upper bed rails in upright position. Resident 285 was awake and quiet at this time. During a concurrent observation and interview on 6/17/2024 at 12:44 p.m., inside Resident 19's room, Resident 19 was sitting at the edge of her bed. Resident 19 complained about the screamer, pointing towards Resident 285's room. Resident 19 stated, it was hard for her to sleep at night because of the screamer. During a concurrent observation and interview on 6/17/2024 at 3:50 p.m., inside Resident 61's room, Resident 61 was seated on his four wheeled walker and heard Resident 285 screamed. Resident 61 sounded irritated from the sound of Resident 285's scream and stated, Can you please make that person stop? During an observation on 6/18/2024 at 9:40 a.m., in Station AA's hallway, Resident 285 could be heard screaming and sounded like a baby crying. Resident 285 was screaming continuously. Review of Resident 285's face sheet ((summary page of a patient's important information), indicated, Resident 285 was admitted on [DATE] with diagnoses including sepsis (blood poisoning due to an infection), anemia (a condition in which the body does not have enough healthy red blood cells), type 2 diabetes mellitus with diabetic polyneuropathy (occurs when the body is unable to regulate glucose [sugar] in the blood, with nerve damage), unspecified dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning), dysphagia (difficulty swallowing), and gastrostomy status (G-tube or GT, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). Review of Resident 285's admission minimum data set (MDS, an assessment tool) dated 6/18/2024, indicated Resident 285 was usually understood (difficulty communicating some words or finishing thoughts but is able if prompted or given time) and usually understands (misses some part/intent of message but comprehends most conversation). Further review of Resident 285's MDS indicated, Resident 285's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 6 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview with licensed vocational nurse D (LVN D) on 6/19/2024, in Station AA's hallway, Resident 285 could be heard screaming intermittently. LVN D confirmed Resident 285 had periods of screaming. LVN D stated, Resident D screamed mostly when she wanted to eat. LVN D confirmed Resident 285 had GT and her next feeding would be at 12:00 p.m. During a concurrent interview with director of nursing (DON) and record review on 6/20/2024 at 10:26 a.m., DON reviewed Resident 285's clinical records. DON confirmed the following: Resident 285 did not have an admission care conference, the behavior was not addressed, care plan regarding the behavior was not developed, and a risk meeting was done by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents), but they did not address the behavior. DON stated Resident 285's behavior should have been monitored and managed with a plan of care. During an interview with the social services director (SSD) on 6/21/2024 at 10:50 a.m., SSD confirmed Resident 285's behavior of screaming should be addressed. SSD further confirmed the IDT did not discuss their plan of care about Resident 285's behavior. SSD stated she did not address Resident 285's behavior issue. SSD further stated the only assessment and conversation she did for Resident 285 was related to possible long term stay at the facility. During a review of the facility's undated job description titled, SOCIAL SERVICES - SALARIED, indicated, Has administrative authority and accountability for the provision of psychosocial needs of the residents and patients. Acts as a Resident Advocate. ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned .Collects and assesses data relevant to patients' psychosocial needs, risk factors for psychosocial deterioration and responses to interventions. Implements social service interventions that achieve treatment goals, address resident needs, link social supports, physical care and physical environment to enhance quality of life.

Based on observation, interview, and record review, the facility failed to provide appropriate pharmacy pharmaceutical services when: 1. A medication, Lamictal (a medication used to treat conditions such as bipolar disorder and seizure disorders) 200 milligrams (mg, unit of measure), was not available for one out of six residents (Resident 8), 2. There were discrepancies between the controlled drug (those with high potential for abuse and addiction) record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for four out of four residents (Residents 3, 22, 40, and 51), 3. A controlled substance medication was wasted without a witness for Resident 41, 4. The controlled substances medication destruction records did not have a registered nurse (RN) signature for three out of three residents (Residents 82, 335, and 336), and, 5. There was no CDR started for two controlled substances for Resident 47. These failures had the potential for Resident 8 to suffer from withdrawal symptoms; and resulted in the facility not having accurate accountability of controlled medications, which had the potential for misuse or diversion. Findings: 1. During a medication pass observation on 6/17/24 at 9:47 AM with Licensed Vocational Nurse (LVN) A, LVN A stated she did not have Lamictal 200 mg on hand to give to Resident 8. During the administration, LVN A administered two 25 mg tablets (50 mg total) to Resident 8 but did not administer a 200 mg tablet. During a concurrent interview and inspection of the medication cart with LVN A on 6/17/24 at 10:01 AM, LVN A stated the Lamictal 200 mg dosage was not in stock, and that she reordered the medication from pharmacy the previous day. LVN A also stated only one dose of the medication was missed, which was today's dose. A review of Resident 8's physician orders, dated 06/15/2023, indicated Resident 8 was to receive Lamictal, one 200 mg tablet plus 50 mg (total of 250 mg) once a day at 9:00 AM for bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a follow-up interview and cart inspection with LVN E on 6/18/24 at 10:01 AM, LVN E stated Lamictal 200 mg was still not available yet, and that pharmacy will send the refill today, I'm holding them to it. A review of Resident 8's June 2024 MAR indicated the resident did not receive Lamictal 200 mg dose at 9 AM on 6/17/24 and 6/18/24. A review of the facility's policy titled Pharmaceutical Services, dated 1/9/24, indicated: Medications shall be administered in a safe and timely manner, and as prescribed. 2. During the survey, four random CDRs for four residents (Residents 3, 22, 40 and 51) were requested for review. On 6/18/24 at 10:19 AM, a review of the residents' physician orders, the CDRs and MARs indicated the following: a. Resident 3 had a physician order, dated 3/25/24 for hydrocodone-acetominophen (Norco, a potent narcotic for pain) 5 mg-325 mg 1 tablet every 6 hours PRN (as needed). Resident 3 had six instances which were recorded in the CDR but not documented as given in the MAR: on 4/7/24 at 12:00 AM, 4/14 at 8:21 AM, 4/26 at 10:30 AM, 5/31 at 12:00 PM, 6/11/24 at 1:00 AM and 11:00 PM. b. Resident 22 had a physician order, dated 6/17/24, for oxycodone (a potent narcotic for pain) 10 mg 1/2 tablet every 8 hours PRN. Resident 22 had three instances which were recorded in the CDR but not documented as given in the MAR: on 5/31/24 at 11:00 AM, 6/5/24 at 11:08 AM, and 6/12/24 at 5:00 AM. c. Resident 40 had a physician order, dated 3/14/24, for oxycodone 5 mg 1 tablet every 12 hours PRN. Resident 40 had six instances which were recorded in the CDR but not documented as given in the MAR in the MAR: 5/19/24 at 6:00 AM, 5/25/24 at 5:45 AM, 5/29/24 at 1:05 PM, 6/5/24 at 9:00 AM, 6/11/24 at 6:30 PM and 6/15/24 at 9:00 AM. d. Resident 51 had a physician order, dated 3/14/24, for hydrocodone-acetaminophen (Norco) 5 mg-325 mg 1 tablet every 8 hours PRN. Resident 51 had six instances which were recorded in the CDR but not documented as given in the MAR: 5/19/24 at 1:00 AM, 5/21/24 at 12:30 AM, 6/1/24 at 10:00 AM, 6/5/24 at 2:30 PM, 6/14/24 at 9:15 AM, and 6/15/24 at 7:30 AM. During a concurrent interview and record review with the director of nursing (DON) on 6/18/24 at 10:53 AM, the DON reviewed the residents' respective CDRs and MARs and verified the above findings, and stated she expected the nurses to sign out a medication in the CDR and record administration of the medication in the MAR. The DON also stated, It is important to document in both places because you don't want to be questioned by anyone about a mismatch, and to do it right. During an interview with Licensed Vocational Nurse (LVN A) on 6/19/24 at 10:50 AM, LVN A stated four out of six signatures on the CDR were hers for Resident 51, Resident 40, and Resident 3, and two out of three signatures were hers for Resident 22. LVN A also stated We have to be doing both, documenting controlled substance medication on the count sheet and the MAR. During an interview with LVN D on 6/19/24 at 11:02 AM, LVN D stated one out of three signatures on the CDR were hers for Resident 22, and one out of six signatures were hers for Resident 51 and Resident 40. LVN D also stated I was in a hurry. I can't really excuse not recording it in the MAR. I am usually pretty careful with that. Review of facility policy titled Medication Administration-Controlled Substances, dated November 2017 indicated 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose. 5. Administer the controlled medication and document dose administration on the MAR. 3. During an interview on 6/18/24 at 10:53 AM, the DON stated two licensed nurses must sign off that a controlled substance medication was wasted, and both nurses must destroy the medication before disposing. During a concurrent interview and record review on 6/18/24 at 3:51 PM with the DON, the DON stated Resident 41 had a blister pack of Norco 5mg/325 mg for 10 doses. One dose was wasted on 5/18/24 at 5:00 PM, with the signature of only one registered nurse (RN). The DON verified that there should have been two nurses' signatures when a controlled medication is wasted Review of facility policy titled Medication Administration-Controlled Substances, dated November 2017, indicated When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to policy and the disposal documented on the accountability record on the line representing that dose. 4. A review of three randomly chosen controlled drug record (CDR) papers for Residents 82, 335, and 336 indicated their respective controlled medications were destroyed on 5/14/24 but there were no signatures from a registered nurse (RN) There were only signatures from the consulting pharmacist (CP). During an interview with the DON on 6/19/24 at 10:38 AM, the DON verified that the CDR did not contain a RN signature for Residents 82, 335 and 336. The DON also stated either she can sign the Disposition of Remaining Doses with the CP or the NS can sign it. Review of Resident 82's physician orders dated from 4/1/24 to 4/8/24 indicated oxycodone 5 mg 2 tablets every 4 hours PRN (as needed). Review of Resident 335's physician orders dated from 4/25/24 to 5/1/24 indicated lorazepam 0.5 mg 1 tablet every 8 hours PRN. Review of Resident 336's physician orders indicated no active order. Review of the CDR indicated a past order for Oxycontin ER 10 mg 1 tablet twice daily. A review of facility policy last revised in January 2024 titled Disposal of Medications, Syringes and Needles-Disposal of Medications indicated .these controlled substances shall be disposed of by the nursing care center in the presence of appropriately titled professsionals .Licensed nurse employed by the nursing care center and a pharmacist . 5. During a concurrent medication cart inspection and interview with LVN C on 6/17/24 at 10:05 AM, a vial containing 10 tablets of lorazepam (a controlled medication for anxiety) 0.5 mg and a 30-mL bottle containing morphine 20 mg/milliliter (mL) were identified in the locked compartment of the medication cart. LVN C reviewed the binder containing the CDRs for controlled medications and stated they did not have the CDRs for Resident 47's lorazepam and morphine. LVN C stated a CDR sheet should have been put in the log to keep count of the medications. During an interview with the DON on 6/18/24 at 10:53, the DON stated controlled medications must be signed out in the CDR and administration must be recorded in the MAR. Review of Resident 47's physician orders indicated lorazepam 0.5 mg 1 tablet every six hours PRN and morphine concentrate 100 mg/5 mL 0.25 mL every three hours PRN. Review of facility policy, dated November 2017 titled Medication Administration-Controlled Substances indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage .a. Date and time of administration. b. Amount administered. c. Signature of the nurse administering the dose .

Based on observation, interviews and record review, the facility failed to ensure 3 of 18 sampled residents (Residents 2, 41, and 59) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 2 received five psychotropic medications without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) and without documented clinical rationale why the GDR was contraindicated (advised against in specified cases or under specified conditions); 2. Resident 41 received Seroquel (generic name: quetiapine, an antipsychotic medication) without specific and documented indication, and without an initial AIMS (abnormal involuntary movement scale, a rating scale designed to measure involuntary movements known as tardive dyskinesia, a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment; and 3. For Resident 59, the GDR assessment for the use of Seroquel did not have a physician-documented clinical rationale why the GDR was contraindicated. The failures resulted in unnecessary medications for the residents, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: 1. A review of Resident 2's medical record indicated she was admitted to the facility with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and brief psychotic disorder (sudden onset of psychotic behavior that lasts less than one month followed by complete remission with possible future relapses). A review of Resident 2's physicians orders indicated the following psychotropic medications: a. Clonazepam (a medication to treat agitation and anxiety) 0.5 milligrams (mg, unit of measure) at bedtime for anxiety manifested by inability to relax such as repetitive calling out since 8/18/22 (almost 2 years ago); b. Fanapt (iloperidone, an antipsychotic medication) 2 mg twice daily for schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior) manifested by (m/b) thinking that someone is after her, since 8/18/2022; c. Divaproex (Depakote, medication to treat mood disorder) 500 mg twice a day for bipolar disorder m/b mood swings since 8/18/23 (almost a year ago); d. Lamictal (lamotrigine, a medication for mood disorder) 100 mg, 1 tablet twice daily for Mood stabalization since 8/18/2023; e. Zoloft (sertraline, an antidepressant) 150 mg once daily for depression m/b sad facial expressions, dated 05/19/2023. A review of the monthly psychotropic medication evaluations, dated 1/31/24, 4/3/24, 5/3/24, and 6/2/24, indicated Resident 2 had zero (0) behaviors for the previous months. In other words, during a 6-month period from December 2023 to May 2024, the Resident 2 had not exhibited any behaviors for which the above medications were indicated. During the survey, Resident 2 was observed on 6/20/24 at 10:15 AM and 06/20/24 at 11:52 AM during which she was very pleasant, quiet, and without any agitation or distress. During an interview with Certified Nursing Assistant (CNA) F on 6/20/24 at 11:39 AM, she stated Resident 2 was often confused but had no mood changes, calling out, or anxiety/inability to relax. During an interview with Licensed Vocational Nurse (LVN) C on 6/20/24 at 11:47 AM, she stated Resident mumbles when she talks . makes noises and asks for help when she doesn't need help but had no mood changes or anxiety/inability to relax. In an interview with CNA G on 6/6/20/24 at 12:06 PM, she stated she had never observed Resident 2 with mood changes or anxiety, or any delusion thinking that someone is after her. During an interview with CNA H on 6/20/24 at 12:47 PM, she stated Resident 2 sometimes cries but not often. She stated she never witnessed Resident 2 exhibiting mood changes or thinking someone is after her. Despite the lack of behaviors, there were no documented evidence in the medical record the facility attempted the GDR for any of the medications since their respective ordered dates. A review of the physician's progress notes, written by Resident 2's physician (MD), indicated the following statements on the following dates: - 12/07/2023, The patient was seen for psychotropic meeting. The patient is on clonazepam, valproic, Fanapt, lamotrigine, sertraline. GDR is contraindicated. We will continue at this point. - 3/27/2024, The patient was seen for the psychotropic gradual drug reduction. GDR was contraindicated, clonazepam, valproic, Vimpat [an anticonvulsant which is also used for mood disorder], lamotrigine and sertraline. - 5/22/2024, The patient was seen for psychotropic meeting. GDR is contraindicated. During a concurrent interview and record review with the director of nursing (DON) and the nursing supervisor (NS) on 6/20/24 at 4:06 PM, they confirmed there had been no GDR attempts for the above medications since their respective ordered dates. They also confirmed there were no documented risk versus benefit assessment why the resident did not benefit from a GDR, nor was there a clinically pertinent explanation for why the GDR is contraindicated. A review of the facility's undated policy and procedure titled Psychotropic Medication Assessment and Monitoring indicated: Dosage reduction or re-evaluations are provided (follow regulations) - Reductions or re-evaluations are not necessary if, within the last reduction time frame, the resident has had a gradual dose reduction and the dose has been reduced to the lowest possible dose to control the symptoms, and the physician documents this information. In the facility-provided undated document titled Gradual Dose Reduction: Implication for Prescribers, it indicated the GDR for psychotropic medications may be contraindicated if the continued use is in accordance with relevant current standards of practice AND the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would likely impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. 48935 2. Review of Resident 41's clinical document titled Resident Face Sheet indicated Resident 41 was admitted on [DATE] with diagnoses including periprosthetic fracture (broken bone) around internal left hip joint, unspecified dementia (a disease that negatively affects brain function), and hypothyroidism (diseased caused by low thyroid hormone). Review of Resident 41's physician order dated 6/14/24 indicated quetiapine 25 mg 1 tablet at 7:00 PM. The indication given was Psychotic Disorder. According to the National Library of Medicine, psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality. They include mental illnesses such as schizophrenia, schizoaffective disorder, bipolar disorder, etc. (https://medlineplus.gov/psychoticdisorders.html; accessed 6/26/24) Review of Resident 41's medical record indicated there was no AIMS measurement documented anywhere in the electronic chart. During a concurrent interview with the DON on 6/19/24 at 1:39 PM, the DON stated the diagnosis of psychotic disorder is not specific indication as it could mean any serious mental illness. She also stated the AIMS is done on initiation and then every 6 months after that. The DON also stated that she could not find a documented AIMS in Resident 41's medical record. Review of facility undated policy titled Antipsychotic Medication Use indicated Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat specific condition as diagnosed and documented in the clinical record . Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. 3. A review of Resident 59's clinical document titled Resident Face Sheet indicated Resident 59 was admitted on [DATE] with diagnoses including history of traumatic brain injury, unspecified mood disorder and type 2 diabetes (disorder in regulation of blood sugar levels). Review of Resident 59's physician order, dated 1/16/24, indicated for quetiapine 50 mg 1 tablet at 9:00 AM; and another order, dated 3/27/24, for quetiapine 200 mg 1 tablet at 9:00 PM for psychosis. Review of the medical director (MD)'s progress note dated 5/22/24 indicated The patient was seen for psychotropic meeting. On Seroquel 50 mg q.a.m. and 200 mg q.h.s. [at bedtime]. GDR is contraindicated. During an interview with the DON on 6/20/24 at 1:02 PM, the DON stated there needs to be a given reason for why a gradual dose reduction (GDR) is contraindicated. The DON also stated, I argued with [MD] about the contraindication for gradual dose reduction, about how she should write why it is contraindicated. Because how can I explain to the family? Review of facility undated policy titled Antipsychotic Medication Use indicated The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweighs the risks or suspected or confirmed adverse consequences.

Based on interview and record review, the facility failed to ensure three of four residents (39, 48, and 64) had informed consents (written permission before implementing a healthcare intervention) prior to initiating psychotropic medication (medication capable of affecting the mind, emotions, and behavior). These failures resulted in the residents receiving psychotropic medications without being informed about their risks and side effects. Findings: Review of Resident 39's Admission Record indicated he was admitted to the facility on [DATE] with diagnoses including psychosis (a mental disorder characterized by a disconnection from reality) and depression (a persistent feeling of sadness and loss of interest). Review of Resident 39's physician orders indicated he had orders, started on 3/18/24, for olanzapine (used to treat several mental health conditions) 2.5 milligrams (mg, a metric unit of mass) every day and 5 mg at bedtime for psychotic disorder and trazodone (used to treat depression) 50 mg at bedtime for depression. However, there were no informed consents for these medications found in Resident 39's clinical record. Review of Resident 48's Admission Record indicated he was admitted to the facility on [DATE] with diagnoses including psychosis and mood disorder (a mental health condition that causes intense shifts in mood, energy levels, thinking patterns and behavior). Review of Resident 48's physician orders indicated he had orders, started on 3/8/24, for Depakote (used to treat certain psychiatric conditions) 500 mg twice a day for mood disorder and olanzapine 5 mg three time a day for psychosis. However, there were no informed consents for these medications found in Resident 48's clinical record. Review of Resident 64's Admission Record indicated he was admitted to the facility on [DATE] with psychotic disorder. Review of Resident 64's physician order indicated he had an order, started on 6/1/24, for valproic acid (used to treat certain psychiatric conditions) 250 mg three time a day for schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). However, there was no informed consent for this medication found in Resident 64's clinical record. During an interview with the director of nursing (DON) on 6/24/24, at 1:35 p.m., she reviewed Resident 39's, Resident 48's, and Resident 64's clinical records and was unable to locate the informed consents for Resident 39's olanzapine and trazodone, Resident 48's olanzapine and Depakote, and Resident 64's valproic acid. The DON stated that she would check with medical records. During an interview with the DON on 6/24/24, at 4 p.m., the DON was unable to provide the informed consents for Resident 39's olanzapine and trazodone, Resident 48's olanzapine and Depakote, and Resident 64's valproic acid. Review of the facility's policy, Health Information/Record Manual, dated 9/2021, indicated The Licensed Nurse carrying out the Physician's order for use of a psychotropic will verify with the Physician to make certain that an informed consent has been obtained by the Physician with the resident or resident representative. The Licensed Nurse will document such information and in the Informed Consent form.

Based on interview and record review, the facility failed to ensure care plans related to alleged abuse were reviewed and updated by the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) for three of six residents (Residents 61, 63, and 75). This deficient practice had the potential to place the residents at risk of psychosocial and emotional distress. Findings: 1. Review of Resident 61's face sheet (summary page of a patient's important information) indicated, Resident 61 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe), unspecified asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath), and pain in right shoulder. Review of Resident 61's admission minimum data set (MDS, an assessment tool) dated 4/21/2024, indicated Resident 61's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 12 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Review of Resident 61's SBAR-GENERAL [Situation, Background, Assessment, and Recommendation - an assessment tool used to facilitate prompt and appropriate communication of a problem] dated 6/10/2024, indicated Resident 61 was angry and stated someone stole his money from his wallet. Review of the IDT note for Resident 61's missing money, dated 6/11/2024, indicated, the IDT discussed Resident 61's missing money. Further review indicated, IDT will continue to monitor and follow up with plan of care as needed. Review of Resident 61's care plan titled, Missing Money, dated 6/11/2024, the goal indicated, Resident will have minimal complications related to missing money. Further review of the care plan's approach indicated, Md (physician), SOC 341 [a form uses to report a suspected elder abuse] complete, SBAR, COC [change of condition], Ombudsman notified, sheriff and CDPH (California Department of Public Health) notified. No other approach added to address how to meet their goal. During an interview with Resident 61 on 6/17/2024 at 3:50 p.m., Resident 61 reported someone stole his money worth $260. Resident 61 stated, I don't want to know who took it. During a concurrent interview with director of nursing (DON) and record review on 6/19/2024 at 11:19 a.m., DON reviewed Resident 61's care plan related to missing money. DON confirmed the care plan should have been updated based on their IDT meeting to reflect interventions to prevent any complications related to missing money. 2. Review of Resident 63's face sheet indicated, Resident 63 was admitted to the facility with diagnoses including sepsis (blood poisoning due to an infection, causing the organs to work poorly), candidiasis (an infection caused by an overgrowth of yeast [Candida]), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and multiple sclerosis (a disabling disease of the brain and spinal cord). Review of Resident 63's admission MDS dated [DATE], indicated Resident 63's BIMS score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Review of Resident 63's SBAR-GENERAL dated 6/19/2024, indicated, Resident alleged roommate verbally abused her. Review of the IDT note for Resident 63's allegation of abuse by roommate dated 6/19/2024, indicated, IDT recommends and SOC 41 filed, notification to sheriff, ombudsman and CDPH, SBAR, COC, alert charting for emotional distress x (for ) 72 hours, SSD (social services director) to follow up with residents, psych [psychological or psychiatric] eval [evaluation], and on monitoring for emotional distress, resident was offered a room change but declined. Review of Resident 63's care plan titled, Alleged Verbal Abuse by roommate, dated 6/19/2024, indicated, Goal: Resident will have minimal emotional distress related to alleged related to alleged verbal abuse by roommate. Further review of the care plan reflected, Approach: MD aware, SBAR, COC, ALERT CHARTING, CDPH, OMBUDSMAN AND SHERIFF AWARE, REFUSED ROOM CHANGE. No other approach added to address how to meet their goal. During an interview with nursing supervisor (NS) on 6/21/2024 at 11:46 a.m., NS confirmed Resident 63's care plan related to an alleged abuse by her roommate should have been updated after their IDT meeting to reflect the plan of care. 3a. Review of Resident 75's face sheet indicated, Resident 75 was admitted to the facility with diagnoses including fracture (broken bone) of left femur (thighbone), complete traumatic amputation (the loss of a body part, usually a finger, toe, arm, or leg, that occurs as a result of an accident or injury) of two or more left lesser toes, person injured in unspecified motor-vehicle accident, traffic, nontraumatic subarachnoid hemorrhage (bleeding in the space that surrounds the brain) and nontraumatic subdural hemorrhage (a type of bleeding in which a collection of blood gathers between the inner layer of the meninges [the three thin layers that cover and protect the brain and spinal cord] surrounding the brain). Review of Resident 75's admission MDS dated [DATE], indicated Resident 75's BIMS score was 13 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Review of Resident 75's SBAR-GENERAL dated 6/13/2024, indicated, Allegation of Physical Abuse. Further review of the SBAR indicated, Resident 75 reported to staff a certified nursing assistant (CNA), threw her in the wheelchair and that he verbally abused her telling her she is loud and an old lady that talks to much. The SBAR indicated, the incident happened on 6/5/2024. Review of the IDT notes related to alleged physical and verbal abuse, dated 6/13/2024, indicated some recommendations, will continue and intervene accordingly .Updated plan of care and reviewed with direct care staff. Review of Resident 75's care plan titled, Allegation of physical and verbal abuse, dated 6/13/2024, did not indicate interventions on how to minimize signs and symptoms of emotional distress. 3b. Review of Resident 75's SBAR-GENERAL dated 6/14/2024, indicated, Alleged financial abuse. Per resident she had $1000 in her purse in a wallet and last seen it at 1100 am, she went to take money out of her wallet at 1700 and money was missing . Review of Resident 75's care plan titled, Alleged financial abuse, dated 6/14/2024, did not reflect interventions to minimize signs and symptoms of emotional distress. 3c. Review of Resident 75's SBAR-GENERAL dated 6/19/2024, indicated, Resident 75 was accused of being verbally abusive and went through her roommate's belongings. Review of the IDT notes related to Resident 75's being accused of verbally abusive to roommate, dated 6/19/2024, indicated, SSD to follow up with residents, psych eval. Review of Resident 75's care plan titled, Resident was accused of being verbally abusive to roommate. The care plan's approach only had one intervention and did not reflect the planned recommendation by the IDT. It indicated, MD aware, SBAR, COC, ALERT CHARTING, CDPH, OMBUDSMAN AND SHERIFF AWARE. During a concurrent interview with NS and record review on 6/21/2024 at 12:04 p.m., NS reviewed Resident 75's three care plans related to the incidents mentioned above. NS confirmed all three care plans were not updated to reflect the plan of care as indicated in the IDT notes. During a review of the facility's undated policy and procedure titled, Comprehensive Plan of Care, indicated, Re-evaluate and modify care plans: as necessary to reflect changes in care, service and treatment. During a review of the facility's undated policy and procedure titled, Care Plan Essential (CPE), indicated, During the morning meeting and any types of care conferences with the company's Interdisciplinary Team (IDT), the resident's CPE will be reviewed and updated accordingly.

Based on observation and interview the facility failed to ensure food served was palatable and attractive. This failure had the potential to affect the amount of food residents consume, which could decrease their food intake and lead to poor nutrition and health outcomes. Findings: As a result of multiple resident complaints about the food, in particular complaints about the meats served being hard and dry, a test tray evaluation was conducted during the lunch service on 6/18/24 at 1:35 p.m. The consultant dietary manager (CDM) was in attendance when the test tray contents were sampled by four surveyors. One meat item served on the test tray was a breaded chicken fillet. The fillet was thin and covered in a breading crust. The breaded chicken fillet was very hard and difficult to cut. The breading was dark brown and appeared to be overcooked. The meat inside was dry. All 4 of the surveyors who tasted the chicken concurred that the meat was hard, dry, and overcooked. The CDM stated the chicken tasted fine. A review of the facility document titled, Job Description: Cook, revised 4/30/17, indicated the cook prepares palatable, nourishing, well-balanced meals to meet the daily nutritional and special dietary needs for each resident. A review of the facility document titled, Job Description: Registered Dietician, undated, indicated the essential duties and responsibilities may include supervising food preparation using techniques that conserve nutritional value, flavor, and appearance.

Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for five (Residents 81, 285, 22, 26, and 28) of 14 residents (residents who used bed or side rails) when: 1. Residents 81 and 285 had side or bed rails even when their siderail evaluation revealed both residents did not require the use of siderails; 2. Residents 22 and 28 had side or bed rails even when their siderail evaluation revealed both residents did not require the use of siderails; and Residents 22 and 26 did not have a documented physician's order for the use of siderails. These failures had the potential to place the residents at risk of entrapment and serious injury. Findings: 1a. During an observation on 6/17/2024 at 10:18 a.m., inside Resident 81's room, Resident 81 was seated on a wheelchair and her bed was observed with right bed rail in upright position while the left bed rail was not raised up. During a concurrent observation and interview with director of nursing (DON) on 6/20/2024 at 10:05 a.m., inside Resident 81's room, Resident 81's right bed rail was in upright position while the left bed rail was not raised up. DON confirmed the observation. During a concurrent interview with DON and record review on 6/20/2024 at 10:13 a.m., DON reviewed Resident 81's siderail evaluation dated 5/28/2024. DON confirmed Resident 81's siderail evaluation revealed Resident 81 did not require the use of siderails. DON further confirmed there were no documentations indicated alternatives were offered, no physician order and consent were obtained and care plan for side rail used was not developed prior to Resident 81's used of side rail. 1b. During an observation on 6/17/2024 at 10:29 a.m., inside Resident 285's room, Resident 285 was lying in bed and her bed had two upper bed rails in upright position. During a concurrent observation and interview with DON on 6/20/2024 at 10:11 a.m., Resident 285 was lying in bed and her bed had two upper bed rails in upright position. DON confirmed the observation. During a concurrent interview with DON and record review on 6/20/2024 at 10:23 a.m., DON reviewed Resident 285's siderail evaluation dated 6/14/2024. DON confirmed Resident 285's siderail evaluation revealed Resident 285 did not require the use of siderails. DON further confirmed there were no documentations indicated alternatives were offered, no physician order and consent were obtained and care plan for side rail used was not developed prior to Resident 285's used of side rail. DON stated there should be no bed rails installed upon residents' admission. During a review of the facility's policy and procedure titled, Side Rails, indicated, Requirements are the same as for other physical restraints, whether or not the side rails enable mobility: Nursing completes Side Rail Evaluation form, with input from IDT [interdisciplinary team, a group of health care professionals from diverse fields who work toward a common goal for residents] as indicated. Complete Informed Consent, reviewing risks and benefits with responsible party, including risk for entrapment (restraint or not a restraint). Obtain MD [medical doctor] order, including diagnosis/medical necessity for use of restraint .Care plan. 37409 2. During an observation on 6/18/24, at 9:08 a.m., Resident 22, Resident 26, and Resident 28 had bilateral bed side rails. Review of Resident 22's clinical record indicated she had no physician order for bed side rails, and her Siderail Evaluation, dated 4/9/24, indicated she did not require the use of side rails and the siderail evaluation did not proceed. Review of Resident 26's clinical record indicated he had no physician order for bed side rails. Review of Resident 28's Siderail Evaluation, dated 5/6/24, indicated she did not require the use of side rails and the siderail evaluation did not proceed. During an observation on Resident 22's, Resident 26's, and Resident 28's beds and interview with the director of nursing (DON) on 6/24/24, at 11:30 a.m., she confirmed that Resident 22, Resident 26, and Resident 28 had bilateral bed side rails. The DON reviewed Resident 22's, Resident 26's, and Resident 28's clinical records and confirmed that Resident 22 did not have physician order for bed side rails, and her 4/9/24 Siderail Evaluation indicated that she did not require the use of side rails and the siderail evaluation did not proceed; Resident 26 did not have physician order for bed side rails; and Resident 28's 5/6/24 Siderail Evaluation indicated that she did not require the use of side rails and the siderail evaluation did not proceed. The DON stated the resident should have physician order and Siderail Evaluation done for the use of bed side rails.

Based on interview and record review, the facility failed to provide adequate supervision to prevent unauthorized drug use for one of two sampled residents (Resident 1) when: 1. The interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) did not conduct an IDT meeting to discuss Resident 1's concerns regarding unauthorized drug use of fentanyl (an opioid drug to treat pain); 2. The care plan for unauthorized drug use was not updated; 3. The care plan for alcohol abuse (overuse of alcohol), opioid abuse (overuse of a broad range of drugs used to reduce pain, including illegal drugs), and/or non-compliance behavior of unauthorized drug use was not developed; 4. The elopement risk assessment was not accurate about medical history and did not develop a care plan for elopement risk; and 5. Resident 1's physician's order for Narcan (a medication for opioid overdose treatment) from the emergency room (ER) dated 2/15/23 was not clarified with his attending physician and transcribed for use if needed. These failures resulted in Resident 1's continued use of unauthorized drugs that required acute hospital transfer on 2/07/2023 and 2/15/2023 due to a change in Resident 1's level of consciousness when he was found by staff unresponsive on 2/15/23, 2/20/2023, and 3/10/2023. Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE] and had diagnoses including major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest), alcohol abuse with alcohol-induced mood disorder, and opioid abuse. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 2/08/2023, indicated he had a brief interview for mental status (BIMS, a structured cognitive [relating to the mental process involved in knowing, learning, and understanding things] test) score of 15 (cognitively intact). The MDS indicated Resident 1's active diagnoses included alcohol abuse with alcohol-induced mood disorder, and opioid abuse. Review of Resident 1's assessment of self-administration of medication dated 2/04/2023, indicated that Section 1 asked if the resident has expressed a desire to take his/her own medication(s) and was marked No (if No, do not proceed). 1. Review of Resident 1's Physician's Admission Notes, dated 2/08/2023 indicated the resident had a past history of alcohol disorder, substance abuse (fentanyl), and opioid dependence. The note also indicated that the resident admitted having half a gallon of vodka daily, his last drink was a day before admission, along with fentanyl. Review of Resident 1's Nurse's progress notes dated 2/07/2023 at 3:12 p.m. indicated Resident took off around 11 a.m. without letting the nurse know or signing out, apparently picked up by his brother. Resident came back around 2 p.m. Reminded him that he has no pass to go out. Review of Resident 1's Nurse's progress notes dated 2/07/2023 at 5:06 p.m. indicated Patient came back to the facility after signing AMA (against medical advice) form and wants to be readmitted . Patient sent to ER for evaluation for safe return. Review of Resident 1's ER discharge instructions dated 2/07/2023, indicated that the reason for the visit was a medical screening exam, and the discharge diagnosis was chronic pain, substance abuse, and fentanyl dependence. The instructions included that it was the facility's policy that if someone leaves, they need to be evaluated in the emergency department (ED) prior to returning, and the resident has admitted to the fentanyl abuse. Review of Resident 1's Nurse's progress notes, dated 2/15/2023 indicated the resident was found unresponsive in the bathroom, had a lighter on his hand and a piece of foil, paramedics arrived and administered Narcan, and was sent to the ER. Review of Resident 1's ER Discharge instructions dated 2/15/2023, indicated that the discharge diagnoses were accidental fentanyl overdose and opioid overdose. The ER discharge instructions included the physician's order for Narcan 4 milligrams (mg, a measurement unit dose)/0.1 milliliters (ml, a measurement unit dose) 1 spray as directed, may repeat every 2 to 3 minutes until the patient responds. During an interview on 1/31/2024 at 2:27 p.m. with Licensed Vocational Nurse A (LVN A), LVN A stated that one staff (could not remember exactly the identity) reported to her that Resident 1 was found sitting on his bathroom floor on 2/15/2023. LVN A stated she went to check Resident 1 and found him unresponsive and holding a lighter and a piece of foil in his hand. Review of Resident 1's Nurse's progress notes, dated 2/20/2023, indicated, the resident was found by a Certified Nursing Assistant (CNA) to be sedated in bed with foil in one hand and possible drug paraphernalia (equipment) in the other, the resident was having whole body tremors and was verbally nonresponsive, fire and paramedics came to the facility, the resident became less sedated and was verbally responsive and refused multiple times to go to the ER, the resident admitted to using drugs. Review of Resident 1's Nurse's progress notes, dated 2/25/2023, indicated the resident was found by a CNA inside the toilet with foil in one hand, possibly drug paraphernalia. Review of Resident 1's Nurse's progress notes, dated 3/10/2023, indicated the resident was found again by a CNA inside his room with foil and a lighter in his hands, seemed he was doping, and he was sedated, and he refused to call paramedics. During an interview on 1/31/2024 at 3:42 p.m. with LVN B, he stated that he was the charge nurse for Resident 1 on 2/25/2023 and 3/10/2023. LVN B stated Resident 1 was drowsy and holding a foil in his hand when he found him sitting on the bathroom toilet, almost falling to the floor, on 2/25/2023. LVN B stated Resident 1 was drowsy and holding a lighter and foil in his hand when he found him on his bed on 3/10/2023. LVN B further stated he was aware of Resident 1's drug overdose history, but there was no adequate supervision provided to the resident. During an interview and record review on 10/20/2023 at 11:50 a.m. with the Director of Nursing (DON), the DON confirmed she did not find any documentation regarding an IDT completed to address Resident 1's drug use overdose. The DON also stated an IDT care conference for unauthorized drug use should have been conducted and documented. The DON further stated that the facility provided 1:1 supervision for 3 days of his stay and needed to start 1:1 supervision earlier to prevent the repeated drug use. During an interview on 3/19/2024 at 11:55 a.m. with the unit manager (UM), the UM stated Resident 1 should have received 1:1 supervision since the facility was aware that he had this behavior of unauthorized drug use to prevent his unauthorized drug use. 2. Review of Resident 1's care plan for behavioral symptoms, created on 3/13/2023, indicated Resident was suspected use of drugs in the facility, and the problem start date was 2/10/2023. The interventions in the care plan included an IDT care conference were done, and risk versus (vs, against) benefits were discussed. The care plan was not updated with the repeated unauthorized drug use to prevent further unauthorized drug use. During an interview and record review on 9/07/2023 at 1:30 p.m. with the UM, she confirmed that Resident 1's care plan for the suspected drug use was not updated to include new interventions when Resident 1 had repeated episodes of drug use on 2/15/23, 2/20/23, 2/25/23 and 3/10/23. 3. Review of Resident 1's care plans indicated there was no care plan for alcohol abuse, opioid abuse, or non-compliance behavior of unauthorized drug use. During an interview and concurrent record review with the UM on 9/07/2023 at 1:30 p.m., the UM reviewed Resident 1's medical record and did not find any care plan for the non-compliance behavior on unauthorized drug use. The UM also stated the non-compliance behavior care plan should have been developed. During a follow up interview and concurrent record review with the UM on 11/03/2023 at 12:50 p.m., the UM confirmed the care plan for alcohol abuse, opioid abuse or non-compliance behavior of unauthorized drug use was not developed for Resident 1. The UM acknowledged that a care plan for alcohol abuse, opioid abuse and non-compliance behavior of unauthorized drug useshould have been developed. 4. Review of Resident 1's elopement risk assessment dated [DATE] indicated Resident 1 had no substance abuse/psych (involving mental illness) history and was considered not at risk. During an interview and concurrent record review on 10/20/2023 at 11:50 a.m. with the DON, she confirmed that Resident 1's elopement risk assessment dated [DATE] was not accurate because Resident 1 had diagnoses including major depressive disorder, alcohol abuse with alcohol-induced mood disorder, and opioid abuse. During an interview and concurrent record review with the UM on 11/03/2023 at 11:40 a.m., the UM confirmed Resident 1 eloped from the facility on 2/07/2023 and came back the same day. The UM confirmed there was no care plan developed regarding Resident 1's elopement episode that happened on 2/07/23. The UM acknowledged that a care plan for elopement should have been developed. 5. Review of Resident 1's ER Discharge instructions dated 2/15/2023, included the physician's order for Narcan 4 milligrams (mg, a measurement unit dose)/0.1 milliliters (ml, a measurement unit dose) 1 spray as directed, may repeat every 2 to 3 minutes until the patient responds. During an interview and concurrent record review with the UM on 11/03/2023 at 12:00 p.m., the UM confirmed Resident 1 had a physician's order of Narcan spray when he came back from theER on [DATE]. The Narcan order was not carried out in the facility. The UM acknowledged that the order should have been carried out. During a follow-up interview with the UM on 3/7/2024 at 2:05 p.m., the UM stated, the physician's order for Narcan spray dated 2/15/23 from the ER was not clarified with Resident 1's attending physician and was not transcribed for Resident 1's use if needed. During a review of the facility's policy and procedure (P&P) titled Care Planning-Interdisciplinary Team, approved 12/2020, the P&P indicated, Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. During a review of the facility's undated policy and procedure (P&P) titled Risk Meeting, the P&P indicated, The risk meeting is designed to bring current resident issues to the interdisciplinary team for discussion, potential alterations to the care plan, notification to all disciplines regarding current status of residents, and to develop proactive approaches designed to prevent acute episodes from occurring. During a review of the facility's undated policy and procedure (P&P) titled Behavior Assessment, Intervention and Monitoring, the P&P indicated, Assessment: as part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder. During a review of the facility's undated policy and procedure (P&P) titled Resident Elopement, the P&P indicated, The facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document patients at risk for elopement. Upon return of the resident, the Director of Nursing or charge nurse will update the resident's care plan with preventive interventions for elopement. During a review of the facility's undated policy and procedure (P&P) titled Comprehensive Plan of Care, the P&P indicated, Each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial (involving both psychological and social factors) needs identified during the comprehensive assessment. The comprehensive plan of care must address the resident's individual needs, strengths, and preferences; be periodically reviewed and revised by the interdisciplinary team as changes in the resident's needs. Develop goals and approaches for each problem and/or condition. Re-evaluate and modify care plans as necessary to reflect changes in care, service and treatment.

Based on interview and record review, the facility failed to assign the recommended one-on-one staff to one of 2 sampled residents (Resident 1) for adequate monitoring, as was indicated in the plan of action of the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients), following an incident on 6/9/23 where Resident 1 was found to have consumed an un-prescribed (not prescribed by a medical practitioner) Diazepam [Valium; a controlled medication to treat anxiety, alcohol withdrawal, and seizures (convulsions)]. [A controlled medication is a drug or substance that is tightly controlled by the government because of their abuse potential or risk, these medications are primarily active in the central nervous system (brain and spinal cord) and can cause physical and mental dependence leading to addiction, they can also have significant harmful health consequences at high doses]. This failure resulted in a subsequent incident where Resident 1 was found to have overdosed on un-prescribed Diazepam and was sent to the hospital on 6/12/23 via emergency medical services (EMS, a system that provides emergency medical care). Findings: Review of Resident 1's face sheet (summary page of a patients' important information) indicated, Resident 1 was admitted on [DATE] with diagnoses included idiopathic progressive neuropathy (nerve damage that interferes with the functioning of the peripheral nervous system); emphysema (a lung condition that causes shortness of breath); spinal stenosis, cervical region (is when the neck area of your spine is narrow); spinal stenosis, lumbar region [lower back] without neurogenic claudication (the narrowing of the spinal canal in the lumbar region but is not causing the typical leg symptoms while walking or standing); generalized anxiety disorder (persistent and excessive worry that interferes with daily activities); major depressive disorder, recurrent (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/23/2023, indicated Resident 1's Brief Interview for Mental Status (BIMS, a cognitive assessment) score was 15 (a score of 15 indicates resident has intact cognition). Review of Resident 1's Nurses Progress Notes, dated 6/9/2023 at 6:16 a.m., indicated, Charge nurse went into residents' room to check vital signs (an objective measurement of the body's most basic functions) and resident noted to have a bubble pack of Diazepam 10 milligrams (mg, unit of measure) on side of his pillow. There is 11 pills missing out of a pack of 20. Resident noted sedated. Vitals stable and WNL (within normal limits). Resident noted arrousdable (typo arousable). Md (Medical doctor) was contacted, message was left awaiting further orders. Review of Resident 1's Observation Detail List Report: Risk Meeting Notes Initial Week One, dated 6/9/23, .Resident consumed medication that was not prescribed . On 6/9/23 at 0600 the Charge nurse went into residents' room to check vital signs and resident noted to have a bubble pack of diazepam 10 mg on side of his pillow. The nurse immediately confiscated the pills and secured them in a locked narcotics drawer (drawer to keep controlled drugs). The resident was assessed. All Vitals stable and WNL (within normal limits). The Doctor was notified .IDT Plan of action: 1) Monitor resident for the next 72 hours for any s/sx (signs and symptoms) of being under the influence of illicit drug use. 2) Staff do thorough sweeps (search) of the room q (every) shift for any non-prescribed drugs. 3)recover and confiscate any drugs if found. Monitor resident q (every) shift for any signs or symptoms of illicit drug use. 4) monitor resident for any attempts to receive non prescribed drugs from any source .7) One on one to monitor resident . Review of Resident 1's Nurses Progress Notes, dated 6/12/2023 at 1:31 p.m., indicated, RESIDENT NOTED TO BE SEDATED AND SLURRING HIS WORDS. CHARGE NURSE WENT TO ASSESS RESIDENT FURTHER AND RESIDENT NOTED WITH A PACKET OF DIAZEPAM AT BEDSIDE PACK OF 20 WITH 3 LEFT IN PACKAGE. AS CHARGE NURSE WALKED IN RESIDENT 2 IN ROOM A WAS IN RESIDENT 1 ROOM AND RESIDENT 2 HANDED RESIDENT 1 A PILL AND RESIDENT 1 SWALLOWED IT AS NURSE ASKED FOR IT. MD (medical doctor) WAS CONTACTED AND ORDER TO SEND TO ER (emergency room ) FOR FURTHER EVAL (evaluation) WAS GIVEN. Review of Resident 1's Nurses Progress Notes, dated 6/12/2023 at 3:16 PM, indicated, Staff contacted 911 for this resident due to overdose of medication labeled as Diazepam. This resident has a documented DX (diagnosis) of depression and a history of suicidal ideation (thoughts and preoccupation with death and dying). The resident's VS (vital signs, an objective measurement of the body's most basic functions) were low per his baseline; BP 95/57 (blood pressure, the measurement of the pressure or force of blood inside your arteries, between 90/60 and 120/80 mmHg (millimeters of mercury) is considered ideal), RR 16 (respiratory rate, rate of breathing, normal rate is 12-18 breaths per minute for adults at rest) and O2 Sat 90% (oxygen saturation,indicates the percentage of oxygen in the blood and provides information about the functioning of the lungs, normal rate is 95% or higher) on rm (room) air (air we breathe which has 21% of oxygen). Staff assessed and determined the resident to be altered, drowsy but rousable. Resident stated he felt awful and dizzy. Staff was unable to determine with absolute certainty exactly what and how much drugs this resident consumed. The EMT's (Emergency medical technicians, provide life-saving care to patients at the scene of an emergency and during transportation in an ambulance during transport to a hospital) assessed the resident and transferred him out as a 5150 (allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) for further monitoring and evaluation . Review of Resident 1's ED (Emergency Department) Physician Notes, dated 6/12/23, indicated: Arrival mode: Ambulance History of Present Illness: The patient presents with benzodiazepine (medication that produce sedation and hypnosis, relieve anxiety, and muscle spasms, and reduce seizures) overdose. This is a [age]-year-old male BIBA (brought in by ambulance) from [SNF name] to the ED (emergency department) on a 5150 hold .after a suspected 17mg ingestion of Valium around 1400 today. Per EMS (Emergency Medical Services), patient was seen by staff with the Valium bottle that originally contained 20 tablets and only 3 were left when they looked. Staff is not sure if the 20 tablets was the original amount of Valium. Patient is not prescribed the Valium . Patient states he did not take the Valium. Per staff, patient is normally more alert and oriented, but is more lethargic (drowsy & lack of energy and mental alertness, a decrease in consciousness) Resp Rate (Monitor) rate 10 Breaths/Min (minute) (respiration; breathing, how the air moves into and out of lungs. A normal respiration rate is 16 to 20 breaths per minute). During an interview with licensed vocational nurse A (LVN A) on 8/31/23, at 2:55 p.m., the LVN A stated she was the charge nurse when Resident 1 had an episode of medication overdose on 6/12/23. The LVN A stated Resident 1 had a small box of Diazepam found on his bedside table. The LVN stated it's not the same bubble pack (type of medication package) from the facility, and Resident 1 looked sedated that time. During a phone interview and concurrent record review with the staffing coordinator (SC) 12/5/23, at 2:05 p.m., the SC stated she assigns the one-on-one staff as communicated by the director of nursing (DON). The SC reviewed the Nursing Staffing Assignment and Sign-in sheet dated 6/9/23, 6/10/23, 6/11/23, and 6/12/23. The SC confirmed there was no one-on-one staff assigned to Resident 1 on these days. The SC stated that she did not assign a one-on-one staff for Resident 1 because she was not instructed to assign a one-on-one staff for Resident 1. The SC stated it is the DON who communicates with the SC (her) which residents need a one-on-one. During an interview and concurrent record review with the Director of Nursing (DON) on 12/8/23, at 12:00 p.m., the DON reviewed the Risk Meeting IDT notes dated 6/9/23. The DON confirmed the IDT's plan of action after Resident 1's suspected medication overdose on 6/9/23, included one-on one monitoring for Resident 1 and that there was no one-on-one staff assigned to Resident 1 following the suspected overdose episode on 6/9/23 until 6/12/23 when Resident 1 was transferred to the hospital for evaluation. The DON stated Resident 1's first episode of medication overdose occurred on 6/9/23 on a Friday. The DON stated the one-on-one monitoring IDT recommendation was not assigned timely. The DON stated it should be implemented because another medication overdose incident happened so quickly. The DON instructed the nursing staff (CNAs, charge nurses) to check Resident 1's room for medications and instructed CNAs to monitor the resident for anything suspicious. The DON stated the monitoring that was provided by the CNAs was on and off, in between their patient care duties. The DON stated it might not provide the same level of monitoring and supervision provided by the one-on-one staff who stay with and watch the resident all the time. The DON also stated Resident 1 was already being monitored for falls, sleep, pain, behavior, which the DON felt was already enough at that time. Upon review of the Alert charting notes and Nurse's progress notes, the DON confirmed there was no proof of documentation that the 72-hour monitoring was done by the nursing staff, after Resident 1's overdose episode on 6/9/23. The DON also stated that Resident 1 can be very sneaky and manipulative, and that Resident 1 was capable of hiding medications in his pocket or taking medications while in the bathroom. The surveyor inquired about implementing the one-on-one staff to Resident 1 due to his manipulative and sneaky behavior. The DON stated that providing one-on-one staff might help. The surveyor inquired if the reason the IDT recommended the one-on- one staff to monitor Resident 1 was to prevent the recurrence of the overdose incident from 6/9/23, the DON agreed. Review of Review of Resident 1's Care Plan, dated 6/12/2023, indicated that Resident 1 had Medication overdose. The interventions included health teaching on medication administration effect and benefits of medication including adverse effects, physiological referral .Resident is taking medication that is not prescribed to him. The interventions included, consulted with MD for alternatives to evaluate if current regimen is effective. Offered resident drug rehab. Review of Resident 1's Physician's Order, dated 6/14/2023, indicated, Monitor the resident for s/sx (signs and symptoms) of altered mentation due to overdose and or consumption of non-prescribed medication. Special instructions: For resident monitoring illicit drug use every shift .Routine room checks/sweeps for drugs and or medications not prescribed. Special instructions: For prevention of illicit drug use. Every shift . Review of Resident 1's Observation Detail List Report: Risk Meeting Notes Initial Week One, dated 6/12/23, indicated, .on 6/12/23 Staff contacted 911 for this resident due to overdose of medication labeled Diazepam (10 mg) .Plan of Action: 1) The resident admitted to the hospital for self administered non prescribed medication overdose. 2) One on one for this resident upon return to the facility for monitoring and prevention of another incident of illicit drug use. 3) Out on pass (temporary permission for resident to leave the facility) revoked. Resident requires a facility designed chaperone to accompany him to all necessary appointments outside of the facility . 6) Q-shift (every shift) monitoring for s/sx of being under the influence. 7) Q shift room sweep for narcotics. Q-shift monitoring for s/sx of emotional distress. 8) Q- shift monitoring for drug seeking behavior . Review of facility's policy and procedure, titled, Risk Meeting, dated 12/8/23, The Risk Meeting is designed to bring current resident/patient issues to the interdisciplinary team for discussion, potential alterations to the care plan, notification to all disciplines regarding current status of residents/patients, and to develop proactive approaches designed to prevent acute episodes from occurring. Review of facility's policy and procedure, titled, Safety Supervision of Residents, dated 9/24/23, indicated, Individualized, Resident -Centered Approach to Safety .2.The interdisciplinary care team shall analyze information obtained from assessmentsand observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adquate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. 5. Monitoring the effectiveness of intervetions shall include the following: a. Ensuring that interventions are implemented correctly and consistently .

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) and manufacturer's instructions for medication administration to ensure safe medication dosage administration for one of two residents (Resident 1) when it was discovered Resident 1 had an excess of buprenorphine patches (adhesive patch with opioid [opium-like; opium is a natural substance found in the poppy plant that works in the brain to relieve pain sensation, among a variety of other effects] medication on it for pain relief when applied to the skin) simultaneously applied to his skin. This failure in medication administration resulted in Resident 1 with multiple buprenorphine patches simultaneously applied to his skin that exceeded the physician's ordered dosage for a given time interval, which may have caused and/or contributed to his symptoms of feeling fuzzy, as documented in his emergency department (ED) medical record. Findings: Review of Resident 1's face sheet (a summary of a resident's important information) indicated the resident was admitted to the facility on [DATE] with diagnoses of malignant (tending to produce deterioration) neoplasm (cancerous growth of tissue) of bladder, malignant neoplasm of renal pelvis (enlarged upper end of the ureter, the tube through which urine flows from the kidney to the urinary bladder), and fusion of lumbar (five bones of the lower back) spine. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 9/14/23, indicated a BIMS score of 7 (Brief Interview for Mental Status, is a tool used to screen and identify the resident's cognitive condition. A score of 0-7 suggests severe impairment). Review of Resident 1's physician's orders, dated 7/7/23, indicated, buprenorphine patch weekly; 15mcg (microgram, a unit of measure)/hour; amt: 1 patch; transdermal (a route of administration of a medicine or drug through the skin, typically by using an adhesive patch) for chronic pain. Review of Resident 1's ED documentation, dated 9/20/23, indicated, Patient is a [AGE] year-old male brought to the emergency room for further evaluation of possible stroke from his PCP [primary care physician] office. The history is obtained from the patient as well as from the wife and they note that the wife brings the patient from their PCP office. The patient has been feeling fuzzy for the past day. He has a appointment already scheduled with his primary doctor and while at the appointment he became concerned that patient may have had a stroke and for that reason he was sent to the emergency room . [ .] While in the emergency room I have discussed the patient's pain medications with the wife and she states that he is supposed to be on one buprenorphine 10 mcg/h [microgram/hour, the patch delivers 10 mcg of buprenorphine per hour continuously] patch. On examination the patient he was found to have one 10 mcg patch on his back and he also had three 5 mcg patches on his chest for a total of 25 mcg. [ .] This in addition to the urine infection is likely what is causing the patient's fuzziness as he does not have signs of a stroke at this time. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) A on 9/29/23 at 9:44 a.m., Resident 1's Medication Administration Record (MAR), dated 9/2023, was reviewed with LVN A. LVN A stated when applying a transdermal patch, the nurse should make sure to remove the old patches, apply the new patches that the administering nurse labels with the date and her/his initials, and document the new patch's location in the clinical record. LVN A confirmed Resident 1's MAR lacked a designated area to document placement locations of transdermal patches. During an interview with LVN B on 9/29/23 at 10:25 a.m., she stated when discarding residents' used transdermal patches (after removing them from the resident), nurses usually cut them or fold them in half prior to disposing them in the medication disposal bin of the medication cart. She stated the disposal of transdermal patches required two nurses. She confirmed neither the Controlled Drug Record (CDR, an inventory and dispensing record for narcotics) or MAR had a place to document removal and disposal of residents' used transdermal patches. During a concurrent interview and record review with the Director of Nursing (DON) on 9/29/23 at 11:20 a.m., Resident 1's CDR and MAR, dated 9/2023, were reviewed with the DON. She confirmed both the CDR and MAR indicated he last received buprenorphine 15 mcg/hr patch on 9/15/23, but there was no documented evidence to indicate old patches were disposed of that day. She confirmed 9/15/23 was the last time Resident 1 received buprenorphine prior to his ED visit. She stated nurses would remove an old patch by cutting it up and disposing it in the medication disposal bin of the medication cart. She stated two nurses should sign off upon the removal and disposal of transdermal patches; however, there was no place for nurses to document the removal and disposal of the old patch. During an interview with Resident 1 and his wife on 9/29/23 at 1:00 p.m., Resident 1 stated he went to his appointment with his primary doctor in the community with his wife on 9/20/23. He stated, during the appointment, he felt weird; so, he was sent to the ED. The ED doctor at the hospital saw several patches on him of the same medication with different strengths. Resident 1 stated he could not remember whether the nurse removed any old patches on 9/15/23. Resident 1's wife confirmed her husband's statement was accurate. Review of the United States Drug Enforcement Administration (DEA) Drug Fact Sheet, dated 5/2022, indicated Buprenorphine . produces . sedation. However, acute, high doses of buprenorphine have been shown to have a blunting effect on both physiological (of the body) and psychological (of the mind) effects due to its partial opioid activity. Review of the facility's P&P, Transdermal Medication Disk (patch), dated 8/18/2021, indicated, Procedure 6. Remove any previously applied medication disk by gently lifting and peeling away from the skin [ .] Documentation 1. On the medication sheet, record: type of medication, date, time, and site of application, and dose. [ .] 3. Document in the electronic health records system. If the electronic health records system is not available, the documentation can be accomplished in paper form. Review of the facility's Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for buprenorphine transdermal patch, dated 6/2022, indicated, Each BTS patch is intended to be worn for 7 days . The old patch should be removed before applying the new one . the maximum BTS dose is 20 mcg/hour . Do not exceed a dose of on 20 mcg/hour . Dose adjustments may be made in 5 mcg/hour, 7.5 mcg/hour, or 10 mcg/hour increments by using no more than two patches of the 5 mcg/hour . or 10 mcg/hour system(s). The total dose from both patches should not exceed 20 mcg/hour. Because extended-release products deliver the opioid over an extended period of time, there is a greater risk for overdose and death, due to the larger amount of buprenorphine present.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of 13 sampled residents (1), with the [DIAGNOSES REDACTED]. throughout the facility, and touches other residents' personal belongings. Resident 8 stated she feels violated when Resident 1 goes through her belongings and Resident 9 stated one day she awoke to see Resident 1 staring at her while he stood at the foot of her bed. She stated it scared the hell out of me. This failure has the potential for injury and psychological harm to the residents. Findings: Clinical record review for Resident 1 was initiated on 12/11/17. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's History and Physical date 9/17/17 indicated the resident was a wander risk. Review of Resident 1's Minimum Data Set (MDS: an assessment tool) dated 9/20/17 indicated he had severe cognitive impairment and wanders ambulated with supervision. In addition, Resident 1 exhibited a wandering behavior. Review of Resident 1's Progress Note dated 11/17/17 at 9:04 p.m., indicated the resident was up ambulating, requires frequent redirection and had not attempted to enter other residents' rooms. A Progress Note written by the Director of Nurses (DON) on 11/21/17 at 1:10 p.m., indicated Resident 1's physician was notified of the resident wandering and intruded to another resident, urinated any place and found not sleeping at night. He documented the resident was not sleeping at night and wanders, was difficult to give redirect. A third Progress Note dated 12/1/07 at 5:42 p.m., indicated the resident touched another resident and was encouraged to stay in his room. Review of Resident 1's Change of Condition note dated 12/4/17 at 12:05 a.m., Licensed Vocational Nurse (LVN) I documented Resident 1 needs constant redirection, behavior becoming more aggressive upon aggravation. He documented Resident 1 gets re-direction at least 50 times a day. During an interview on 12/11/17 at 8:35 a.m., LVN I confirmed Resident 2 notified him involving the incident between Resident 1. He stated he told Resident 2 I have so much work on my station, you do what you need to do and if I need to follow up, I will. LVN I stated he did not tell any other staff members about the altercation. In addition, LVN I stated Resident 1 was disoriented and had aggressive behavior by grabbing staff and residents. He stated Resident 1 did whatever he wanted. LVN I stated during the night Resident 1 would go in and out of other resident's room and he had witnessed Resident 1 piss in the toilet or sink of another resident's room. He stated we (staff) would have to grab him and redirect him out of their room. During an interview on 12/11/17 at 10:15 a.m., Resident 2 stated on 11/22/17 at around 10 a.m., Resident 1 came into his room and tried to attack him. He stated he told LVN I about the incident and he told me he was going to write it down; however when he checked two to three days later, he found out nothing was written about the incident. Resident 2 stated no one from the facility has yet to interview him regarding the incident between Resident 1 and himself. He stated Resident 1 is not being monitored and goes into everybody's room. During observations on 12/11/17 at 11 a.m., Resident 1 was ambulating independently in his room with the door shut and then exited his room and ambulated in the hallway. Later the same day at 1:35 p.m., the resident was ambulating in his room, a 1:1 sitter was also in the room at this time. During observations on 12/12/17 at 7:15 a.m., Resident 1 was ambulating independently in his room, at 11:15 a.m. and 2 p.m., he was ambulating in the hallways with a 1:1 sitter, at 2 p.m. During an interview on 12/12/17 at 7:25 a.m., Licensed Vocational Nurse (LVN) B stated Resident 1 is alert and disoriented. She stated he wanders around a lot and goes into other residents' rooms. During an interview on 12/12/17 at 7:27 a.m., LVN C stated he was aware Resident 1 wanders into other residents' rooms. During a telephone interview on 12/12/17 at 1:25 p.m., LVN E stated Resident 1 is very confused. She stated the resident would see a garbage can and try to urinate in it and staff would intervene. During an interview on 12/12/17 at 2:05 p.m., Registered Nurse (RN) F stated she was aware of Resident 1 urinating on Resident 2's bed at night on 11/22/17. She stated she notified the Administrator and the DON of the incident. On 12/13/17 at 9:45 a.m., the DON was interviewed. He stated Resident 1 was confused and disoriented. Clinical record review for Resident 2 was initiated on 12/11/17. Review of Resident 2's MDS dated [DATE], indicated he was alert and oriented and able to make his needs known. Review of Resident 2's Progress Note dated 11/22/17 at 3:12 p.m., Registered Nurse (RN) F documented the resident expressed feelings regarding (Resident 1) coming into his room without his permission and urinating into his room. Review of Resident 2's care plan problem dated 11/29/17 to address his behavioral symptoms related to of being impatient of not understanding of other resident illnesses (dementia) showed approach plans for an Interdisciplinary Team meeting (IDT) to discuss his concerns about a dementia resident, to education and provide resident understanding of dementia residents, and for a possible room change or putting a stop sign on Resident 2's door. During an interview on 12/11/17 at 8:35 a.m., LVN I confirmed Resident 2 notified him involving the incident between Resident 1. He stated he told Resident 2 I have so much work on my station, you do what you need to do and if I need to follow up, I will. LVN I stated he did not tell any other staff members about the altercation. During an interview on 12/11/17 at 10:15 a.m., Resident 2 stated on 11/22/17 at around 10 a.m., Resident 1 came into his room and tried to attack him. He stated he told LVN I about the incident and he told me he was going to write it down; however when he checked two to three days later, he found out nothing was written about the incident. Resident 2 stated no one from the facility has yet to interview him regarding the incident between Resident 1 and himself. He stated Resident 1 is not being monitored and goes into everybody's room. Resident 2 stated nothing is being done to protect the other residents, especially the residents who cannot defend themselves. During an interview on 12/11/17 at 11:05 a.m., Resident 8 stated Resident 1 has come into her room, uninvited about 20 times and plays around with her personal belongings. She stated one time he almost hit me when I asked him to leave her room. Resident 8 stated she feels violated. When asked if she had told any staff members about Resident 1's behaviors, she stated yes, a bunch of people know he does this. In addition, Resident 8 stated Resident 1 poops and pees in the hallways; he just drops his draws and exposes himself. Review of Resident 8's MDS dated [DATE], indicated she was alert and oriented and able to make her needs known. During an interview on 12/11/17 at 11:10 a.m., Resident 9 stated Resident 1 comes into her room, uninvited. She stated one day when she was lying in bed and woke up, she saw Resident 1 standing over her bed looking at her. Resident 9 stated it scared the hell out of me. In addition, Resident 9 stated Resident 1 just walks into her room and looks out the sliding glass door. She stated, I do not like him coming in (to my room). Review of Resident 9's MDS dated [DATE], indicated she had moderate cognitive impairment.

Based on interview and record review, the facility failed to ensure a physician was notified of a change in condition for one of three sampled residents (Resident 1) when he had decreased food and fluid intake, weight loss and hypoxemia (reduced amount of oxygen in the blood). These failures did not allow for the interventions needed to ensure Resident 1 received adequate nutrition, hydration, and treatment for [REDACTED]. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility from the acute hospital on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. These were discharge [DIAGNOSES REDACTED]. Review of the acute hospital record, Nutrition Services Assessment, dated [DATE], at 2:20 p.m. indicated Resident 1's weight was 119.9 pounds at the acute hospital. Review of the facility's November Monthly Weight Record indicated a weight of 98.8 pounds was recorded on [DATE], a 21 pound drop in weight or 17.5% weight loss over eight days (loss of five percent over one month is considered a significant weight loss). During an interview and record review with the director of nursing (DON) on [DATE], at 4 p.m., she stated Resident 1 should have been weighed on admission and the weight compared to the previous weight taken at the acute hospital. The DON stated nursing staff should have been aware of Resident 1's significant weight loss. The DON stated the nurse should have informed the primary care physician (PCP) and the registered dietician (RD) of Resident 1's lower body weight. The DON stated Resident 1 should then have been weighed on a weekly basis, but the DON was unable to find a record of other weights taken at the facility. Review of the facility's 2004 policy, Weight Change indicated residents with significant weight change should be assessed by the interdisciplinary team and interventions should be implemented to minimize further weight change. Interventions included: 1. Weigh and screen all residents upon admission for their risk for weight change. 2. Weigh all residents weekly for the first month after admission to the facility. 3. Residents with weight variance defined as five percent or greater weight loss in one month or three pound weight loss for residents under 100 pounds should be reweighed within 24 hours after the admission weight is completed. 4. Residents identified at risk for weight change will have interventions to minimize weight change included in their care plan. 5. Nursing staff should communicate the above weight changes to the attending physician and to the registered dietician. Review of the facility's Nutrition Care Assessment dated [DATE], signed by the RD indicated Resident 1 had a poor food intake of less than 25 percent of his meals and an average fluid intake of less than 1000 milliliters (ml, a unit of measure) per day. The RD assessment indicated Resident 1 required an average of 1500 to 1800 ml of fluid to meet his daily fluid needs. Review of Resident 1's Meal Intake Record (MIT) from date of admission until the date of death on [DATE], indicated Resident 1 took in meals and liquids as follows: [DATE]: Breakfast: 25%, Lunch: 50%, Dinner: 25%, Daily fluids: 720 ml. [DATE]: Breakfast: Less than 25%, Lunch: 50%, Dinner: 50%, Daily fluids: 600 ml. [DATE]: Breakfast: 75%, Lunch: Less than 25%, Dinner: 25%, Daily fluids: 600 ml. [DATE]: Breakfast: 75%, Lunch: less than 25%, Dinner: Less than 25%, Daily fluids: 600 ml. [DATE]: Breakfast: Liquids only, Lunch: Liquids only, Dinner: 25%, Daily fluids: 720 ml. [DATE]: Breakfast: Less than 25%, Lunch: Less than 25%, Dinner: 25%, Daily fluids: 720 ml [DATE]: Breakfast: Less than 25%, Lunch: 25%, Dinner: 100%, Daily fluids: 840 ml. [DATE]: Breakfast: Less than 25%, Lunch: 25%, Dinner: 100%, Daily fluids: 960 ml. [DATE]: Breakfast: Less than 25%, Lunch: 0, Dinner: 0, Daily fluids: 240 ml. [DATE]: Breakfast: Refused, Lunch: Refused, Dinner: 100%, Daily fluids: 360 ml. [DATE]: Breakfast: Refused, Lunch: Refused, Dinner: 25%, Daily fluids: 120 ml. [DATE]: Breakfast: Refused, Lunch: Refused, Dinner: Less than 25%, Daily fluids: 240 ml. [DATE]: Breakfast: Refused, Lunch: Refused, Daily fluids: 200 ml. During an interview with the RD on [DATE], at 10 a.m., she stated she saw Resident 1 on [DATE] when completing a routine dietary admission assessment eight days after Resident 1's admission to the facility. The RD stated no one informed her of Resident 1's weight prior to the assessment but she would have assessed Resident 1 at the time she was informed of his weight. The RD stated she was very concerned about Resident 1's underweight and reduced fluid intake and wrote the following dietary recommendations: 1. Fortified Diet (a diet with extra nutrients added to the food). 2. A liquid drink [MEDICATION NAME] with protein, fats, carbohydrates, vitamins, and minerals three times a day. 3. A liquid drink with a highly concentrated form of liquid protein one time per day. The RD stated she gave her recommendations to the nursing unit manager (NUM) who was supposed to follow-up the recommendations and pass them on to the physician. There was no evidence found the above dietary recommendations were communicated to the physician or followed by the nursing staff. During an interview with the NUM on [DATE], at 3:15 p.m., she stated Resident 1's dietary recommendations were placed in her inbox but she did not pass them on to the physician prior to Resident 1's death. During an interview and clinical record review with the DON on [DATE], at 4 p.m., she stated the dietary recommendations should have been acted upon immediately. The DON stated the RD should have notified nursing staff immediately of the dietary recommendations and of her concern for Resident 1's lowered body weight. The DON stated the nursing staff should have notified the physician immediately of the dietary recommendations to help Resident 1 increase his body weight and his fluid intake. The DON was unable to find a record the PCP was notified of Resident 1's significant weight loss or of his low food and fluid intake or of the RD's dietary recommendations. During an interview with Resident 1's PCP on [DATE] at 4:45 p.m., he stated he did not, but should have received a call from the nursing staff informing him Resident 1 was not eating and drinking well, had a significant weight loss, and of the dietary recommendations. Review of the facility's ,[DATE] policy, Fluid Intake and Output Measurement indicated intake and output measurements should be taken and monitored for all residents identified as high risk for dehydration, and should have documentation in the progress notes, and the plan of care is updated to reflect interventions. The policy indicated to notify the physician of significant variations of intake and output and to document the physician response and the interventions implemented. The Vital Signs and Weight Flow Sheet, dated [DATE], indicated Resident 1 was placed on Oxygen at 2 liters per minute via nasal cannulla on [DATE] for an oxygen reading of 89% (levels below 90% indicate a need for oxygen intervention). The Daily Medicare Notes dated [DATE] to [DATE] indicated the following record of oxygen levels taken without oxygen unless noted as with oxygen: [DATE], 7 a.m.: 93% [DATE], 3 p.m.: no entry [DATE], 11 p.m.: 98% [DATE], 7 a.m.: 96% [DATE]. 3 p.m.: 94% [DATE], 11 p.m.: 93% [DATE], 7 a.m.: no entry [DATE], 3 p.m.: 95% with oxygen [DATE], 11 p.m.: 95% [DATE], 7 a.m.: 92% [DATE], 3 p.m.: 95% [DATE], 11 p.m.: 92% [DATE], 7 a.m.: no entry [DATE], 3 p.m.: 94% with oxygen [DATE], 11 p.m.: no entry [DATE], 7 a.m.: 92% [DATE], 3 p.m.: 94% [DATE], 11 p.m.: 95% [DATE], 7 a.m.: 97% [DATE], 7 a.m.: 96% [DATE], 3 p.m.: 93% [DATE], 7 a.m.: 95% [DATE], 7 a.m., 93% The situation, background, assessment, recommendation (SBAR, a communication tool), dated [DATE], at 12:30 p.m., indicated Resident 1 had labored breathing, was lethargic, and had a blood oxygen saturation level of 81%. The SBAR indicated the nurse placed an oxygen mask on Resident 1 at 2 liters per minute. During an interview with licensed vocational nurse C (LVN C), on [DATE], at 10:10 a.m., she stated at around 12:30 p.m. the certified nursing assistant informed her Resident 1 had trouble breathing. LVN C stated she found Resident 1 cool and clammy with an oxygen level of 80%. LVN C stated she changed Resident 1's oxygen from nasal cannula to a face mask at 2 liters per minute, called the PCP's office and heard a message the office was closed for lunch. LVN C stated she did not wait for a receptionist to come on the line or for an answering service but completed the change of condition report and faxed it to the office. LVN C stated she did not wait for a confirmation report and planned to call the office when the lunch hour was over. LVN C stated she checked Resident 1 after 30 minutes, found his oxygen level was 86%, did not record the findings, did not inform her supervisor of Resident 1's condition change because she did not expect Resident 1 would expire. A nurses note dated [DATE] at 2 p.m. indicated at 1:55 p.m., Resident 1 was found unresponsive without a heart beat or breath sounds. The Certificate of Death dated [DATE], indicated Resident 1's time of death was 1:55 p.m. A facsimile dated [DATE] at 2:01 p.m. indicated the SBAR was faxed to the physician, one and one-half hours after the resident was found in respiratory distress and five minutes past the time of death. During an interview with the PCP on [DATE], at 4:45 p.m., he stated he did not receive any communication from the facility regarding Resident 1's low oxygen level. During an interview and record review with the DON on [DATE], at 1:40 p.m., she stated LVN A should have contacted the facility's medical director if unable to reach the PCP. LVN A should have informed a physician about Resident 1's change of condition to receive orders for medical treatment of [REDACTED]. Review of the facility's 2008 policy, Changes in Resident Condition, indicated the physician should be notified when there is a significant change in the resident's physical status and when there is a need to commence a new form of treatment.