Every finding on record at East Bay Post-Acute

Based on observation, interview and record review, the facility failed to ensure that the Minimum Data Set (MDS, a standardized resident assessment tool used to guide and develop individualized care plans for residents in long-term care facilities) assessments accurately reflected residents' current tobacco use when smoking status was not coded for three of 12 sample residents (Resident 2, Resident 3, and Resident 4).This inaccurate MDS coding of current tobacco uses for Resident 2, Resident 3, and Resident 4 had the potential to misrepresent the residents' status and needs, affect the development of appropriate care plans, and impact the identification of interventions related to tobacco use and smoking safety.A record review of Resident 2's admission Record (AR), printed on 8/19/26, indicated Resident 2 was originally admitted to the facility on [DATE] with diagnosis of acute respiratory failure (a sudden, life threatening condition in which the lungs cannot get enough oxygen into the blood, cannot remove enough carbon dioxide, or both). A review of Resident 2's MDS, dated [DATE], indicated that Resident 2 had a Brief Interview for Mental Status (BIMS, consisting of a series of questions that measure memory, orientation, and attention. Score range from 0 to 15: 13-15 indicates cognitively intact; 8-12 indicates moderate cognitive impairment; and 0-7 indicates severe cognitive impairment) score of 15 out of 15.A record review of Resident 3's AR, printed on 8/20/26, indicated Resident 3 was originally admitted to the facility on [DATE] with diagnosis of cerebral infarction (when a blood clot blocks blood flow to part of the brain, causing brain cells to die within minutes) affecting the left non-dominant side. A review of Resident 3's MDS, dated [DATE], indicated that Resident 3 had a BIMS score of 15 out of 15.A record review of Resident 3's Care Plan, revised on 12/13/22, the Care Plan indicated Assess resident's ability to smoke safely .A record review of Resident 4's AR, printed on 8/19/26, indicated Resident 4 was admitted to the facility on [DATE] with diagnosis of schizophrenia (a severe, chronic mental disorder characterized by disturbances in thinking, perception, emotional responsiveness, and behavior). A review of Resident 4's MDS, dated [DATE], indicated that Resident 4 had a BIMS score of 11 out of 15 indicating moderate cognitive impairment.A record review of Resident 4's Care Plan, initiated on 6/24/26, Care Plan indicated Resident is a smoker .Assess ability to smoke safely .During an observation and interview on 8/19/26 at 8:50 a.m. with Resident 2, Resident 2 was observed smoking in the facility's backyard, on the smoking patio under the gazebo, accompanied by two other residents. Licensed Vocational Nurse (LVN) 1 brought and administered Resident 2's medications during this time and confirmed that Resident 2 was a smoker.During an observation and interview on 8/19/26 at 3:30 p.m. with Resident 2, Resident 3, and two other residents, Resident 2 and Resident 3 were observed smoking in the facility's backyard, on the smoking patio under the gazebo. Resident 3 stated they typically have four to five smoking sessions each day.During a current interview and record review on 8/20/26 at 10:55 a.m. with the MDS coordinator, the MDS assessments for Resident 2, dated 6/25/26, for Resident 3, dated 9/12/25, and for Resident 4, dated 5/13/26 were reviewed. The J1300 section, Current Tobacco Use, was coded 0 (no tobacco use) for all three residents. MDS coordinator stated these were coding errors and should have been coded 1 (yes) to indicate that the residents currently use tobacco.During a follow-up interview on 8/20/26 at 10:59 a.m. with MDS coordinator, MDS coordinator stated the MDS assessment was used to develop, review, and revise the residents' comprehensive care plans. The MDS coordinator stated inaccurate assessments could impact care plan development, affect interventions, and place residents at risk for unsafe smoking.During a review of the facility's policy and procedures (P&P), titled Resident Assessment, revised in November 2019, indicated Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducted timely and appropriate resident assessments and reviews according to.During review of Centers for Medicare & Medicaid Services' (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1, dated October 2024, the record indicated J1300, Current Tobacco Use, Coding Instructions, indicates Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented for one of 12 sampled residents (Resident 1) when a urinal containing half full of light, yellow-colored liquid was placed next to Resident 1's food and personal items for approximately 30 minutes.This practice had the potential to result in cross-contamination of Resident 1's food and personal belongings, increasing the risk of infection.During a record review of Resident 1's admission Record (AR), printed on 8/20/26, the AR indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (a long-term condition in which the kidneys are damaged and can't filter blood as well as they should) and dependence on renal dialysis (a treatment that cleans the blood and removes extra fluid when kidneys can no longer do the job adequately).During an observation on 8/19/26 at 12:20 p.m. in Resident 1's room, there was a white urinal containing half-full of light, yellow-colored liquid on Resident 1's over-bed table. The urinal was positioned next to a blue denture container, a carton of Nepro (nutritional drink), and a piece of bread that was in a plastic wrapper. A cup of water was on the opposite side of the table.During a follow up observation on 8/19/26 at 12:46 p.m., a lunch tray containing one cup of almond milk, one cup of a pink-colored sugar free beverage, one Magic Cup (a frozen nutritional supplement), and a plate covered by a lid was placed on the over bed table. The tray was set down without removing the urinal containing light yellow liquid. The water cup, denture container, wrapped bread, and Nepro carton observed earlier remained on the table.During an observation on 8/19/26 at 12:50 p.m. with Director of Staff Development (DSD)/Licensed Vocational Nurse (LVN) 2. DSD/LVN 2 picked up the lunch tray from Resident 1's over-bed table and returned it to the tray cart (a mobile cart used in healthcare food service to transport meal trays to and from residents). DSD/LVN 2 then assisted other residents while the urinal containing light yellow liquid remained on the over bed table where the lunch tray had been placed.During an interview on 8/21/26 at 12:55 p.m. with DSD/LVN 2 stated staff were expected to empty and rinse the urinal immediately after use, or as soon as possible, to prevent spills, contamination of nearby items, and the potential risk of infection.During a review of facility's policies and procedure (P&P), titled Infection Control, revised in October 2018, the P&P indicated The objectives of the infection control policies and practices are to .b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and general public.

Based on observation, interview and record review, the facility failed to ensure, for Residents 1-10, the scheduled (controlled medication, narcotic) medication record system was complete (all documents available) and accurate (numbers match). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance (drug) Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility did not have complete records. The facility did not have accurate records. These failures resulted in the potential for undetected loss and diversion of scheduled medications. In addition, these failures resulted in the potential for avoidable medication errors. Findings: During an interview, on 9/8/25 at 10:15 a.m., the Medical Record Director (MRD) was asked to describe the medical records system. MRD's description included that scheduled medicine delivery receipts were kept for seven years. In addition, MRD stated that controlled drug administration sheets (MAR) were kept for seven years. During a concurrent observation and interview, on 9/8/25 at 11:05 a.m., Licensed Vocational Nurse (LVN 1), identified a medication cart. LVN 1 was asked to describe the scheduled medication accountability process. Her description included that scheduled medications were delivered with a CDR (documents the amount of scheduled medication remaining). She further stated that the nurse placed the scheduled medication in the cart and filed the CDR at the cart. During an interview, on 9/8/25 at 11:30 a.m., Director of Nursing (DON) was asked to describe the scheduled medication accountability process with the automated dispensing unit (ADU, machine that dispenses medication). Her description included that the ADU printed a daily ADU Controlled Dispenses log (scheduled medications delivered to the facility). She was requested to provide the daily ADU Controlled Dispenses log for 3/4/24, 3/14/24, 3/22/24, 3/27/24, 4/6/24, 4/9/24, 4/18/24, 4/21/24, 5/2/24, 5/7/24, 5/16/24, 5/20/24, and 5/30/24. During a concurrent interview and record review, on 9/8/25 at 2:35 p.m., DON identified and provided the requested daily ADU Controlled Dispenses logs. During a concurrent interview and record review, on 9/10/25 at 11:15 a.m., DON identified the ADU Controlled Dispenses log documentation for:3/14/24 12:31 am Resident 1 Hydroco (narcotic pain reliever) /APAP (acetaminophen, pain reliever) TAB (tablet) 5-325MG (milligram)3/14/24 2:23 am Resident 2 Hydroco/APAP TAB 5-325MG3/14/24 2:24 am Resident 3 Oxycodone (narcotic pain reliever) TAB 5 mg3/14/24 2:38 am Resident 4 Oxycodone TAB 5 mg3/14/24 7:43 am Resident 5 Hydroco/APAP TAB 5-325MG3/14/24 7:44 am Resident 6 Hydroco/APAP TAB 5-325MG3/22/24 8:20 am Resident 7 Hydroco/APAP 5/3253/22/24 8:20 am Resident 8 Oxycodone TAB 5 mg3/27/24 12:45 am Resident 9 Oxycod/APAP TAB 5-325MG3/27/24 12:19 am Resident 10 Hydroco/APAP TAB 5-325MGDON was requested to provide the corresponding CDR records for the above Residents. During a concurrent interview and record review, on 9/10/25 at 12:50 p.m., DON identified the list of requested CDRs from the ADU Controlled Dispenses log. The DON stated the facility was unable to find the corresponding CDRs. During a concurrent interview and record review, on 9/11/25 at 2:45 p.m., DON identified the ADU Controlled Dispenses logs and Medication Administration Records for:3/14/24 12:31 am Resident 1 Hydroco/APAP TAB 5-325MG3/14/24 2:23 am Resident 2 Hydroco/APAP TAB 5-325MG3/14/24 2:24 am Resident 3 Oxycodone TAB 5 mg3/14/24 2:38 am Resident 4 Oxycodone TAB 5 mg3/14/24 7:43 am Resident 5 Hydroco/APAP TAB 5-325MG3/14/24 7:44 am Resident 6 Hydroco/APAP TAB 5-325MG3/22/24 8:20 am Resident 7 Hydroco/APAP 5/3253/22/24 8:20 am Resident 8 Oxycodone TAB 5 mg3/27/24 12:45 am Resident 9 Oxycod/APAP TAB 5-325MG3/27/24 12:19 am Resident 10 Hydroco/APAP TAB 5-325MG The DON acknowledged, for the Residents listed, that the ADU Controlled Dispenses logs showed the scheduled medications listed were dispensed by the ADU. The DON further acknowledged, for the scheduled medication dispensed, the facility was unable to locate the corresponding CDRs. The DON acknowledged the Resident's corresponding MAR showed the doses were administered.The DON acknowledged the facility's Policy required Controlled Drug Accountability Sheets to have been completed for the above Residents and scheduled medications. During an administrative record review, of the Quality Assurance & Performance Improvement, Medication Management/Pharmacy Services reports, dated March 2024-August 2024, did not document issues with scheduled medication accountably. During an administrative record review, of the Facilities Policy for Controlled Substances (Revision Date: November 2024) showed, Policy Interpretation and Implementation, Handling Controlled Substances, 4. If the count is correct, an individual resident controlled substance record is made for each resident who will be receiving a controlled substance. Continued review showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following.a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records. CDR is a declining inventory record.

Based on observation, interview and record review, the facility failed to ensure the facility administrator was managed by a state licensed nursing home administrator (NHA) when the facility assigned the Operations Assistant (OA), who was not a state licensed nursing home administrator, as the administrator and posted Administrator 1's (ADM 1) license on the wall without assigning ADM 1 actual administrative duties.This failure resulting in the facility operations being managed by an unlicensed administrative staff for four months.A review of Resident 11's admission record indicated Resident 11 was originally admitted to the facility on [DATE] and discharged on 1/9/26.A review of Resident 12's medical record indicated Resident 12 was admitted for pressure ulcer care, diabetes and weakness.During a record review of Resident 12's minimum data set (MDS, an assessment tool to guide resident care), dated 10/13/25, the MDS indicated Resident 12 had Brief Interview for Mental Status score of 15 (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.)A review of Resident 12's weekly nursing assessment titled, Nursing Weekly Summary, dated 11/3/25, indicated Resident 12 was alert and oriented with no impairments to vision or hearing.During an interview on 11/8/25 at 5:43 a.m., with Registered Nurse 1 (RN 1), RN 1 stated OA was the administrator for the facility. RN 1 did not know who ADM 1 was.During an observation on 11/8/25 at 5:45 a.m., ADM 1's NHA license was posted on the facility bulletin board.During an interview on 11/8/25 at 7:32 a.m., with Resident 12, Resident 12 stated OA was the administrator who replaced ADM 2. Resident 12 stated they didn't know who ADM 1 was.During a review of state licensing database titled, Licensing and Certification Verification Detail Page, dated 7/6/26, the database indicated OA was licensed as a Nursing Home Administrator on 1/16/26.During a record review of State Agency records, titled ELMS Facility Entity Tab - [Facility], dated 7/6/26, the record indicated: Administrator 2 (ADM 2) was the facility administrator from 1/29/25 to 1/15/26. OA was listed as the administrator from 1/16/26 to 3/6/26. Administrator 1 (ADM 1) was not listed.During a concurrent interview and record review on 7/1/26, at 11:24 a.m., with Administrative Staff 1 (AS 1), Resident 10's progress notes titled [Facility] Progress Notes *NEW* dated 7/2/26, was reviewed. AS 1 stated their note indicated, on 1/5/26, Resident 11 had a negative interaction with a CNA, and AS 1 had informed Resident 11 that administrator and ombudsman had a plan to address Resident 10's concerns against CNAs. AS 1 stated OA was the administrator at the time of the note. AS 1 stated ADM 2 was no longer working at the facility on 9/2025. AS 1 could not recall the exact date of OA's arrival. AS 1 stated Resident 11 would get upset about certified nursing assistant (CNA) care and would go directly to the administrator to complain. AS 1's desk was in front of the administrator's office so AS 1 would know how often Resident 11 would complain to the administrator.During a concurrent interview and record review on 7/2/26 at 12:00 p.m., with Human Resources (HR) the facility list of the past 12 months of employee terminations titled, Termination Details: Termination Details, undated, HR stated the list included all employee hire dates and termination dates. The list indicated ADM 2's termination date was 9/18/25 and OA's hire date was 9/30/24 and termination date was 3/6/26.During a phone interview on 7/2/26 at 1:13 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 10's progress notes by LVN 1 titled [Facility] Progress Notes *NEW*, dated 7/1/25, was reviewed. LVN 1 stated Resident 11 had a behavioral plan which was monitored by the administrator and the ombudsman because Resident 11 often made complaints against the CNA staff. A Behavioral Plan progress note, dated 9/8/26, indicated Administrator and LN discussed with the resident the terms of agreement with the facility and the ombudsmen, refusing one cna is refusing both cna's. LVN 1 stated the past three administrators were ADM 2, OA and ADM 1. LVN 1 stated ADM 2 was the administrator in the note, and OA was the subsequent administrator continuing the plan. LVN stated Resident 11 had been discharged from the facility before ADM 1 had assumed responsibilities of the administrator.During a concurrent interview and record review on 7/1/26 at 4:00 p.m., with ADM 1, Resident 11's grievance report titled, Grievance/Complaint Report, dated 12/31/25, was reviewed. ADM 1 stated they were not familiar with Resident 11's grievance report because OA had completed this report. ADM 1 stated they had never spoken to Resident 11. ADM 1 stated OA was assigned as the operations assistant of the facility, but OA operated essentially as the administrator without a license. ADM 1 stated their license was posted on the wall so the facility would technically have a licensed nursing administrator. ADM 1 stated OA received their nursing home administrator license on 1/16/26 and was not licensed in the state prior. ADM 1 stated they did not hire OA to the position and OA's function as the facility administrator was outside of ADM 1's control. ADM 1 stated OA was at the facility daily, and ADM 1 received telephone updates from OA about the facility.During an interview on 7/2/26 at 11:14 a.m., with ADM 1, ADM 1 stated OA was assigned to the facility on 9/15/25 until 3/7/26.During a record review of OA's employment record, untitled and undated, the record indicated OA had started as Operations Assistant at the facility from 9/15/25 to 1/15/26.A review of facility job descriptions titled, Administrator, dated 2/18, and Operations Manager, dated 2/24, indicated both job descriptions had identical General Purpose.Essential Duties.Supervisory Requirements and Qualifications. Both job descriptions indicated the individual must maintain licensing credentials for an Administrator and Reports to: Regional Director of Operations.A review of facility policy and procedure (P&P) titled, Complaints and Greivances, dated 4/2017, the P&P indicated the Administrator is responsible to thoroughly investigate, assure resolution of the grievance/complaint and complete documentation of the facility's action.During a review of state health and safety code titled, California Code, Health and Safety Code 1416.6, the code indicated it shall be a misdemeanor for any person to act or serve in the capacity of a nursing home administrator, unless he or she is the holder of an active nursing home administrator's license.A person who is acting as an administrator shall notify the program in writing within five days of acting in this capacity and provide factual information and specific circumstances necessitating the use of an acting administrator.No person shall act as an administrator for more than 10 days unless arrangements have been made for part-time supervision of his or her activities by a nursing home administrator who holds a license or provisional license under this chapter. Supervision shall include at least 8 hours per week of direct onsite supervision by the licensed administrator. The program shall be notified in writing of the nature of this arrangement. No person shall act as an administrator for more than two months without the written approval of the program.During a review of state regulation titled, Title 22, Chapter 3. Skilled Nursing Facilities, 72007 Administrator, the regulation defined an administrator as a person licensed as a nursing home administrator by the California Board of Examiners of Nursing Home Administrators.

Based on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse when Resident 2 pushed Resident 1 on the ground, while Resident 1 was sitting in a wheelchair in facility's smoking area. Resident 1 fell on his back on the ground.This failure resulted in Resident 1 sustaining a skin tear on his right hand, and a transfer to Acute Care Hospital (ACH 1) requiring hospitalization for three consecutive days. It resulted in Resident 1 feeling scared of Resident 2.During a record review of Resident 1's admission Record dated 01/03/23, the record indicated Resident 1 had a diagnosis of major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (nervousness). During a record review of Resident 1's Annual Minimum Data Set (MDS, an assessment tool used to evaluate a resident's functional capabilities, health needs, and clinical status) assessment dated [DATE], the assessment showed Resident 1 was able to understand others and make self-understood. Resident 1 was assessed with Annual Brief Interview for Mental Status (BIMS, an assessment for mental status) score of 15 out of 15, indicating no impaired cognition (mental status). During a record review of Resident 2's admission Record dated 8/6/25, the record indicated Resident 2 had diagnosis of dementia (memory loss), and cognitive communication deficit (a condition where someone has trouble organizing thoughts). During a record review of Resident 2's MDS assessment dated [DATE], the assessment indicated Resident 2 had a BIMS score of six (6) out of 15, indicating severely impaired cognition. During observation and interview on 4/7/26 at 11:00 a.m. with Resident 2, Resident 2 was sitting down on the chair in the smoking patio. Resident 2 stated he did not recall any altercations with other residents in the facility. During an observation and interview on 4/7/26 at 11:02 a.m., Resident 1 was lying in bed. Resident 1 stated there had been an altercation between him and Resident 2 around Christmas time in 2025. He was in the facility's smoking area and Resident 2 was also sitting there at the table. Resident 1 stated he put his canned drink on top of the table and Resident 2 placed his drink next to his. He told Resident 2 not to do it almost four times, then Resident 2 got upset and pushed him to the ground. Resident 1 stated he fell backwards on his back, hit his head onto the ground, and after Resident 2 pushed him on the ground, Resident 2 jumped on top of him and kneeled him on the chest. Resident 1 stated he had to shout as he could not breathe and he had to grab Resident 2 to get him off of him. Resident 1 stated that incident made him feel scared of Resident 2. Resident 1 stated he was hospitalized for a few days after that incident. During a phone interview on 4/7/26 at 12:11 p.m. Licensed Vocational Nurse (LVN 1) stated she was the desk nurse on 12/27/25, on the day of altercation between Resident 1 and Resident 2. LVN 1 stated Resident 3 was coming back from the smoking area and alerted her that a fight had happened in the smoking area. LVN 1 stated then she saw Resident 2 walking in the hallway through the door that goes into facility's smoking area. LVN 1 stated she immediately went outside the smoking area to assess the situation. LVN 1 stated Resident 1 was on his back on the ground and Resident 1 told her he's gotten into a verbal argument with Resident 2 physically pushed him down, causing him to fall on his back. LVN1 stated, her and another nurse (LVN 2) assisted Resident 1 back to his wheelchair. LVN 1 stated Resident 1 had a laceration (open skin) on his right hand and he was transferred to Acute Care Hospital (ACH 1) for further evaluation. During an interview on 4/7/26 at 3:25 p.m., LVN 2 stated she recalled requesting assistance from LVN 1 to assist Resident 1 back in his wheelchair on 12/27/25, after Resident 2 had pushed him down on the floor in the smoking area. LVN 2 stated Resident 1 told her Resident 2 continued to move his cup next to Resident 1's drink cup which caused the altercation. LVN 2 stated Resident 1 was alert and oriented with time, place, person and situation; and she had no reason to not believe Resident 1. LVN 2 also stated Resident 2 was strong and had the strength to push someone down as Resident 1 had described and Resident 3 had witnessed on 12/27/25. During a record review of Resident 3's BIMS score assessment dated [DATE], the assessment indicated Resident 3's BIMS score was 15/15, indicating no impaired cognition. Resident 3 remained unavailable for an interview during the investigation. During a record review of Resident 1's progress notes dated 12/27/25, indicated, LVN 1 documented [Resident 3] entered the facility and notified staff that [Resident 1] was intentionally provoking [Resident 2] . a physical altercation started in the designated smoking area.[LVN 1] and another nurse approached [Resident 1], who was observed lying flat on his back on the ground yelling .requesting assistance to get up .assessments revealed a superficial open area on the right hand. During a record review of Resident 2's progress notes dated 12/27/25, the progress note indicated Resident 2 stated he went outside to smoke as usual and Resident 1 got mad at him, because he didn't want Resident 2 by him. Resident 2 kicked Resident 1, his chair fell and he went down with it. During a record review of Resident 1's Emergency Department Provider notes from ACH 1 dated 12/30/25, indicated Resident 1 was seen at the hospital for assault altercation with another SNF (Skilled nursing facility) patient while smoking cigarettes outside. Resident 1 was struck to the chest, and wrestling on the floor, sustained abrasion to right hand. During a review of facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, the P&P indicated, Resident has the right to be free from abuse. This includes but is not limited to freedom from verbal, mental, sexual or physical abuse .resident abuse prevention program consists of a facility-wide commitment and resources allocation to support the following objectives of protecting residents from abuse from other residents .

Based on interview and record review the facility did not report an alleged abuse incident involving Resident 1 and Resident 2, nor the investigation results, to the State Survey Agency for over three months. Furthermore, notification to the Long Term Care Ombudsman was also delayed nearly three weeks. Resident 2 pushed Resident 1 from a wheelchair, causing a fall, a skin tear on the right hand, and hospitalization at Acute Care Hospital (ACH 1).This failure resulted in facility not adhering to the abuse reporting timelines.During a record review of Resident 1's admission Record dated 01/03/23, the record indicated Resident 1 had a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (nervousness). During a record review of Resident 1's Annual Minimum Data Set (MDS, an assessment tool used to evaluate a resident's functional capabilities, health needs, and clinical status) assessment dated [DATE], the assessment showed Resident 1 was able to understand others and make self-understood. Resident 1 was assessed with Annual Brief Interview for Mental Status (BIMS, an assessment for mental status) score of 15 out of 15, indicating no impaired cognition (mental status). During a record review of Resident 2's admission Record dated 8/6/25, the record indicated Resident 2 had diagnosis of dementia (memory loss), and cognitive communication deficit (a condition where someone has trouble organizing thoughts). During a record review of Resident 2's MDS assessment dated [DATE], the assessment indicated Resident 2 had a BIMS score of six (6) out of 15, indicating severely impaired cognition. During an observation and interview on 4/7/26 at 11:02 a.m., Resident 1 was lying in bed. Resident 1 stated there had been an altercation between him and Resident 2 around Christmas time in 2025. He was in the facility's smoking area and Resident 2 was also sitting there at the table. Resident 2 got upset and pushed him to the ground. Resident 1 stated he fell backwards on his back, hit his head onto the ground, and after Resident 2 pushed him on the ground, Resident 2 jumped on top of him and kneeled him on the chest. Resident 1 stated he was hospitalized for a few days after that incident. Resident 1 stated he had to tell the nurse to call the police as he wanted the incident to be documented. During an interview on 4/7/26 at 11:02a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 12/27/25, she saw Resident 1 lying on his back on the floor in the smoking area. LVN 1 stated Resident 1 told her he's gotten into a verbal argument with Resident 2 and Resident 2 physically pushed him down, causing him to fall on his back. LVN 1 stated Resident 1 wanted her to call the police for reporting. During a phone interview on 4/7/26 at 2:21 p.m. with the Ombudsman, Ombudsman stated he did not receive the report on physical altercation between Resident 1 and Resident 2 until 1/12/26 for the incident tht had occurred on 12/27/25. During an interview and record review on 4/7/26 at 3:40 p.m. with facility's Administrator (Admin) in presence of Director of Nursing (DON), an undated investigation report for abuse incident between Resident 1 and Resident 2 was reviewed. The Admin stated he was unable to find any documentation indicating that the facility notified the State Survey Agency or Ombudsman about the abuse incident or its investigation involving Resident 1 and Resident 2. The DON stated facility Administrator was responsible for notifying the Ombudsman and State Survey Agency. The Admin stated he had also checked his emails from the Administrator at the time of the incident; however, he was unable to locate any records of timely notification to above agencies. During a review of facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, the P&P indicated the facility would investigate and report of all allegations within federally required timeframes. This includes immediately reporting all allegations within two hours of the incident, results of investigation must be reported within five working days, maintain documentation proof of time of allegation, time reported, who was notified, and investigation steps and findings. However, based on record review and interview, the facility failed to provide evidence demonstrating compliance with these requirements. Record review of facility's internal investigation report summary lacked documented date and time when it was submitted to CDPH or ombudsman.

Based on observation, interview and record review, the facility failed to ensure doors to enter the building were locked for all 84 of 84 sampled residents when the facility failed to ensure two doors (main entrance and rear exit) had functioning locks and failed to ensure staff kept the rear exit closed and supervised according to facility expectations while the doors locks were broken.The failure had the potential for unauthorized people to enter the facility building which had to potential to affect all residents' safety.During an observation on 11/8/25, at 5:02 a.m., in the parking lot at the back of the facility, the rear exit door of the facility was inspected. From 5:02 a.m. to 5:40 a.m., the rear exit door was propped open by a wet floor sign. Facility staff were exiting and reentering the building without closing the door. A sign affixed to a nearby window indicated the facility Visiting Hours 8:00 a.m. to 8:00 p.m During an observation on 11/8/25, at 5:41 a.m., the surveyor entered the building and entered a resident hallway with resident rooms 16, 17, 18 and 19 without encountering any staff members. Residents were observed sleeping in bed. Surveyor walked down to the dining room near the nurses' station before encountering a certified nursing assistant exiting a resident's room outside of the dining room.During an interview on 11/8/25, at 5:43 a.m., with Registered Nurse 1 (RN 1), RN 1 stated the front door of the facility was expected to be closed and locked to prevent outside access when outside of visiting hours. RN 1 stated the visiting hours were 8:00 a.m. to 8:00 p.m.During an observation on 11/8/25, at 6:10 a.m., the front entrance door was inspected. The front entrance door was not locked and could be opened from the outside.During an observation on 11/8/25, at 6:19 a.m., the rear exit door was open and propped open by the same wet floor sign.During an observation 11/8/25, at 6:40 a.m., the Maintenance Director (MDir) removed the wet floor sign from the rear exit and closed the door.During an observation on 11/8/25, at 6:51 a.m., a staff member assisted Resident 1 through the rear exit door. The staff member left the door propped open.During a concurrent record review and interview on 11/8/25, at 7:25 a.m., with MDir, the facility maintenance logs titled, Maintenance Work Order, dated from 10/1/25 to 11/8/25, were reviewed. MDir stated the maintenance records did not include any reports about the broken rear exit door lock.During a concurrent observation and interview on 11/8/25, at 8:00 a.m., with MDir, the rear exit door was inspected. MDir stated the rear exit door's locking mechanism was broken and the rear exit door could not be locked.During a concurrent interview and record review on 11/8/25, at 8:10 a.m., with MDir, an online order for a door lock titled, Details for Order #114-1624816-4441814, dated 11/8/25, was reviewed. MDir stated they were informed of the broken lock a week ago and requested a locksmith to service the door. MDir stated the locksmith could not repair the door and had to order a new lock. The online order indicated MDir had E-procurement order placed: 11/8/25. MDir stated the lock would be installed on Monday.During an interview on 11/8/25, at 8:21 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the rear exit doors should remain closed but unlocked during visiting hours. LVN 1 stated all doors needed to be closed and locked from the outside after visiting hours. LVN 1 stated they were not aware of the rear exit door lock being broken.During a concurrent observation and interview on 11/8/25, at 8:37 a.m., with Operations Assistant (Operations Assistant), MDir and the Administrator present, the front door's locking mechanism was inspected. MDir stated they were not aware of any issues with the front door lock. Upon inspection, MDir could not engage the locking mechanism to lock the front doors. MDir stated the door was misaligned and prevented the front entrance door from being locked. OA stated the front entrance and rear exit doors were expected to be closed and locked to prevent unauthorized outside access outside of the visiting hours of 8:00 a.m. to 8:00 p.m OA stated all doors should remain closed but unlocked during visiting hours. OA stated the facility was aware of the inoperable lock and expected staff to supervise the hallway to prevent unauthorized entry and exit.During a concurrent interview and review on 11/8/25, at 9:05 a.m., with OA, the facility policy and procedure (P&P) titled, Exits or Means of Egress, dated 07/2024, was reviewed the P&P indicated exit doors remain unlocked at all times. OA clarified the expectation was the exit and entrance doors would be locked from the outside but were unlocked from the inside.During an observation on 11/25/25, at 8:10 a.m., the rear exit door was inspected. The rear exit door was propped open by an orange traffic pylon.

Based on observation, interview and record review, the facility failed to post the most recent Statement of Deficiencies (form CMS- 2567) results in a location where residents ( 14, 21, 36, 75, and 79), visitors, or other individuals had readily accessible access and did not have to ask to see the survey results.The resident council members felt their inability to access the survey results without asking fostered dependence on the staff and decreased their ability to act according to their own wishes. During an interview on 9/9/25 at 10:30 a.m. with the Resident Council members ( 14, 21, 36, 75, and 79) all members stated they did not know where the binder with the most recent survey results were located or if the results were available for their review without request.During a concurrent observation and interview on 09/09/2025 at 1:24 p.m. with the Activities Director ( AD), the AD stated the East Bay Post Acute Survey binder was located at the receptionist desk. The AD was unable to locate the survey binder at the receptionist desk.During an observation and interview on 9/09/25 at 1:26 p.m. with the Administrator (Admin), Admin stated the survey binder was in his office and not accessible to the residents. During a concurrent observation and interview on 09/09/25 at 2:30 p.m. with the Admin and Maintenance Director (Maint. D), Admin stated there was a holder on the wall outside the copy room that housed the East Bay Post Acute survey binder. The Maint. D stated the holder was removed during facility renovations and painting.During an interview on 9/11/25 at 8:30 a.m. with the Maint. D, Maint. D. stated the facility renovations started in 2022 and finished in 2024.During a review of the facility's policy and procedure titled, Resident Rights dated 2001, the Resident Rights policy indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' rights to . examine survey results.

Based on interview and record review, the facility failed to ensure qualified, full-time oversight of Dietary Services when the Registered Dietitian (RD) did not work full time and the dietary manager (DM) was not qualified to supervise the kitchen for 19 weeks. These failures had the potential to compromise the safety and nutritional status of residents through potential transmission of foodborne illness and decreased quality of food for 81 residents who received food from the kitchen out of 85 residents in the facility.During a concurrent interview and record review on 9/9/25, at 4:13 p.m., with Dietary Manager (DM), DM's Safe-serv Food Manager certificate was reviewed. DM stated the Safe-serv Food Manager certificate was the only certificate they had. DM stated they were not a certified dietary manager (CDM) and had not completed education requirements to qualify as a qualified dietetic service manager. DM stated they were hired in April 2025 as the dietary manager.During an interview on 9/10/25, at 11:30 a.m., with Registered Dietitian (RD), RD stated they were contracted to work 24-32 hours per week based on the facility needs. RD stated DM had oversight of the day-to-day kitchen supervision. RD stated CDM education included training in regulations, therapeutic diets, food texture and serving residents according to strict regulations to avoid harm.During a review of RD's facility visit invoices titled, [RD contractor] dated from May 2025 to August 2025, the invoices indicated on:May 2025, RD worked 42 hours in the first week of May, then worked 29-38 hours the rest of the month,June 2025, RD worked 32-33 hours per week,July 2025, RD worked 24-37 hours per week, andAugust 2025, RD worked 24-27 hours week.During an interview on 9/11/25, at 3:05 p.m, with Administrator (ADM), ADM stated the facility had not hired a qualified CDM to replace the previous CDM. ADM stated DM was responsible for kitchen supervision, and RD was responsible for clinical management of residents.During a record review of DM's job description titled, Job Description: Dietary Manager, dated 2/2024, the job description indicated Qualification Education and/or Experience.must be a graduate of an approved dietary manager's course that meet the state and federal care regulations. The job description indicated DM signed the document on 4/10/25.During a record review of DM's competency checklist titled, Dietary Manager Competency Checklist, dated 4/10/25, the checklist indicated RD had reviewed the checklist and RD indicated DM did not maintain CDM/[Certified Food Protection Professional] credential and [continuing education unit] requirements.During a record review of facility's contract with RD titled, [Contractor] Agreement to Provide Consultant Services, dated 5/31/24, the contract indicated RD had contracted hours .16-24 hours a week.

Based on observation, interview and record review, the facility failed to follow state regulations when:1. the facility did not have a qualified social worker to supervise, train and ensure the facility provided medically-related social services for nine months,2. the facility did not post the Centers for Medicare and Medic-aid Services (CMS) star rating in the facility.These failures resulted in1. Six residents did not have updated advanced directives (See Ftag 578), one resident did not have glasses because the facility failed to have trained staff conduct a vision test (See Ftag 685) and had the potential for all 85 residents to receive inadequate social services,2. and had the potential for residents and visitors to be uninformed about the overall quality of the facility.1. During an interview on 9/8/25, at 3:13 p.m., with social services assistant (SSA), SSA stated they were the only social service staff in the social services department and there was no social worker overseeing the department. SSA stated they were not a qualified social worker. SSA stated they had some training for a few months while assisting a former social services director in 2024.During a concurrent interview and record review on 9/9/25, at 9:40 a.m., with Director of Staff Development (DSD), SSA's employee file was inspected. DSD stated there was no training record for SSA's position.During a record review of SSA's employment history document titled, View Employee History [SSA], undated, the document indicated on 8/18/24, SSA had a Promotion.Social Services Assistant.During a record review of SSA's job description titled, Job Description: Social Services Assistant, dated 2/2024, the job description indicated the SSA reports to Social Service Director.assist in planning, developing, organizing and implementing.facility's social service programs in accordance with.state and local standards.During an interview on 9/8/25, at 3:26 p.m., with Activities Director (AD), AD stated they were the social services director from 10/2024 to 1/2024 when the social services director left. AD stated they were not a social worker and did not have previous training in social work. AD stated they had training for three days in social services at another facility before being designated the social services director. AD stated they were the social services director until a Social Services Director (QSSD) was hired in the beginning of 2025. AD stated SSA was the sole social services staff after QSSD left after a few weeks.A review of AD's employment history document titled, View Employee History [AD], undated, the document indicated AD was hired on 5/9/25 as the Activities Director, on 9/1/2024, AD had a Promotion.Social Services and on 2/19/25 AD had a Lateral Move.Activities Director.A review of FSSD's employment history document titled, Worker History, undated, the document indicated FSSD was hired on 1/6/25 and was terminated on 2/5/25.During an interview on 9/11/25, at 3:05 p.m., with Administrator (ADM), ADM stated there was no plan to have a social worker be a part of the social services department. ADM stated SSA was the only staff member working in the social services department. ADM stated they were unaware of any regulations which required the social services departmentDuring a review of facility's facility assessment titled, [Facility] Facility Assessment, dated 7/24/25, the facility assessment indicated a staffing plan which included Total Number Needed or Average or Range.Social Worker.FULL-TIME on AM and PM shift.During a review of facility's policy and procedure (P&P) titled, Social Services, dated September 2024, the P&P indicated the facility provided medically-related social services During a review of California state regulation titled, Title 22 S72437, the state regulation indicated Social Work Service Unit-Staff.the social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants.2. During an observation on 9/9/25, at 11:00 a.m., an inspection of the facility main posting board, two dining areas and facility entrance indicated there was no posting of the facility star rating.During a concurrent observation and interview, on 9/12/25, at 3:15 p.m. with ADM, the facility entrance, main posting board near the entrance and the reception desk area was inspected. ADM stated there was no posting of the facility's CMS star rating in the observed areas. ADM stated they did not know the CMS star rating posting was required.During a review of California state regulation titled, Health and Safety Code section 1418.21, dated 1/1/11, the state regulation indicated A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal CMS in accordance with the following requirement: the information shall be posted in at least the following locations.an area accessible and visible to members of the public.an area used by residents for communal functions such as dining, resident council meetings, or activities.

Based on interview and record review, facility failed to maintain accurate and complete medical records for four (Residents 6, 7, 75, and 76) out of twenty sampled residents. This deficient practice had the potential to cause inaccurate assessments of nutritional status, inappropriate care planning and unnecessary dietary restrictions, which could place residents at risk for unmet needs or avoidable decline. During a review of facility's document titled, admission Record, dated 9/12/25 for Resident 6, the admission Record indicated Resident 6 is a [AGE] year old woman initially admitted to the facility on [DATE] with multiple diagnoses, including unspecified protein-calorie malnutrition (a condition that occurs when an individual does not consume enough protein and calories to meet their nutritional needs), hypertension (high blood pressure), multiple sclerosis (a chronic disease of the brain and spinal cord characterized by changes in sensation, visual problems, weakness, depression, difficulties with coordination and speech, and impaired mobility and disability). During an interview and concurrent observation on 9/10/25 at 12:35 pm with Dietary Manager (DM), DM observed two Chobani Greek yogurts with peaches and a vanilla magic cup (sugar-free) on Resident 6's tray. DM observed a diet order slip on Resident 6's tray that indicated Resident 6 was allergic to milk and under notes stated do not give milk or dairy products. DM stated the yogurt and ice cream are dairy products, and they are given because of resident preference. During a concurrent interview and record review on 9/10/25 at 12:48 p.m. with the Registered Dietician (RD), the diet order for Resident 6 was reviewed. RD stated the document indicated that Resident 6 is allergic to milk and the document stated do not give milk or dairy products. RD stated that Resident 6 is not allergic to milk. RD stated this could create confusion and it should be removed. During a review of facility's document titled, admission Record, dated 9/11/25 for Resident 75, the admission Record indicated Resident 75 is a [AGE] year old woman initially admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure (when lungs cannot provide enough oxygen to the blood), unspecified protein calorie malnutrition, and muscle weakness. During a concurrent interview and record review on 9/11/25 at 12:55 p.m. with DON, facility's documents titled Nursing Weekly Summary dated 9/8/25, 9/1/25, and 8/26/25 for Resident 75 were reviewed. DON stated the weekly summaries state that Resident 75 ate 100% of her meals. During a concurrent interview and record review on 9/11/25 at 1:01 pm with DON, facility worksheets titled amount eaten dated September 2025 and August 2025 were reviewed. DON stated the worksheets show that the resident intake was not 100%. DON stated September 2025 amount eaten worksheet shows Resident 75 refused 10 meals in the past two weeks. DON stated in August 2025 the amount eaten worksheet indicated Resident 75 did not eat 100% of meals. (See F692) During a record review of facility's document titled, admission Record, dated 9/11/25, the admission Record indicated Resident 76 is a [AGE] year old man initially admitted to the facility on [DATE] with multiple diagnoses including unspecified protein calorie malnutrition and chronic kidney disease, stage 5 (also called end-stage renal disease, when kidneys have lost almost all ability to filter waste and fluids from the blood). During a concurrent interview and record review on 9/10/25 at 3:09 p.m. with RD, facility's documents titled Weights and Vitals Summary, dated 6/1/25 – 6/30/25, for Resident 76 was reviewed. RD stated the document indicated on 6/3/25 Resident 76 weighed 149 pounds and on 6/17/25, Resident 76 weighed 139 pounds. RD stated that she believed the 6/3/25 weight was incorrect and asked for it to be rechecked. RD stated she was not sure why the weight on 6/3/25 was not struck out and marked as incorrect. During an interview on 9/10/25 at 4:10 p.m. with Registered Nurse (RN 3), RN 3 stated that she entered a weight on 9/2/25 for Resident 76. RN 3 stated the weight from the dialysis center is in kilograms (a unit of measurement in the metric system, a decimal-based logical system) and they convert the weight to lbs (also called pounds, a unit of measurement in the US customary system, a historical system dating back from when the US was a British colony.) During a concurrent interview and record review on 9/11/25 at 1:19 p.m., with DON, facility's documents titled, Weights and Vitals Summary, dated 6/1/25 – 6/30/25 and document titled Dialysis Center Hemodialysis Communication Observation/Assessment dated 6/3/25 were reviewed. DON stated the Dialysis Center document indicated on 6/3/25, the resident weight was 57.5 kg, which is 126.7 lbs. DON stated the weight entered by the RN on 6/3/25 was 149 lbs and this weight was incorrect. DON stated inaccurate weights should be reevaluated and struck out because if the weight is inaccurate, we should re-weight to make sure the weight is accurate. DON stated the risk of the weight not being accurate could affect the plan of care. During a concurrent interview and record review on 9/11/25 at 1:19 p.m., with DON, facility's documents titled Nursing Weekly Summary dated 9/10/25 were reviewed. DON stated the weekly summary indicated that Resident 76 ate 100% of his meals in the time period of 9/3/25 – 9/10/25. During a concurrent interview and record review on 9/11/25 at 1:19 p.m., with DON, facility's documents titled amount eaten, dated September 2025 was reviewed. DON stated the documents indicate Resident 76 did not eat 100% of his meals. DON stated the amount eaten document between 9/3/25 – 9/10/25 shows that Resident 76 refused meals eight times. The document indicated between 9/3/25 – 9/10/25, Resident 76 ate 75-100% of his meals four times. DON stated the risk to not accurately recording resident intake is that if the facility does not know what the resident is eating, they will not know how to address the issue. During a review of the facility's policy and procedure titled, Charting Errors and/or Omissions, dated December 2023, indicated, .if an error is made while recording the data in the medical record, line through the error with a single line and correct the error. For electronic documentations, strike out the entry and state the reason for striking out. During a review of Resident 7's admission Record (AR), printed on 9/12/25, The AR indicated, Resident 7 was originally admitted on [DATE]. Resident readmitted on [DATE] with diagnoses that included hemiplegia (the total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a weakness on one side of the body) following cerebrovascular disease affecting left non-dominant side. During a review of Resident 7's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/28 /25, indicated Resident 7's BIMS ( an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 7/15. BIMS score of 7 indicated the resident had severe cognitive impairment. During a review of Resident '7's care plan Bowel & Bladder (B&B) care plan initiated on 10/18/23, the care plan indicated Resident 82 or Resident 83 requires check and change due to bowel and bladder incontinence. The care plan was revised on 01/10/2025. During a review of the facilities MDS Resident Matrix dated 9/8/2025, the MDS Resident Matrix indicated Resident 82 and Resident 83 had the same last name. During an interview on 9/11/25 at 2:41 a.m. with Medical Records Director (MRD), the MRD stated resident record reviews are performed in Point Click Care (PCC - electric health record). MRD stated the record reviews completed by the MDR assess for completion of the evaluation forms and updates to the care plan. The MRD stated she does not review the document themselves. She reviews the care plan and evaluation banner section in PCC. MRD stated when the evaluations have been completed, and the care plans are updated by the staff the banner section turns green. During a concurrent interview and record review on 9/11/25 at 3:00 p.m. with MRD, Resident 7's care plan B & B initiated on 10/18/23 was reviewed. The care plan for Resident 7 indicated Resident 82 /83 requires check and changes due to bowel and bladder incontinence. MRD stated she does not review nursing documentation for accuracy. MRD stated nursing services review their own documents. During a concurrent interview and record review on 9/12/25 at 8:19 a.m. with MRD, the facility's policy and procedure Charting and Documentation dated 2001 was reviewed. The Charting and Documentation section 5 indicated, Information documented in the resident's clinical record is confidential and may only be released in accordance with state law, the Health Insurance Portability and Accountability Act ( HIPPA) and facility policy. MRD stated the Medical Records Administrative Services Manual does not have a section that requires the facility to maintain medical records for each resident, . that are complete, and accurate.

Based on observation, interview and record review, the facility failed to prepare, distribute and serve food in a sanitary manner when:1. [NAME] 1 picked up Resident 11's meal ticket (printed tray ticket containing a resident's specific dietary needs, allergies, preferences, and even adaptive equipment requirements) from the floor and placed it on Resident 11's meal tray during meal tray food assembly.2. Two black oven mitts were dirty and in poor condition.These failures had the potential for cross contamination of food items and food borne illness for 81 residents who receive food in the kitchen.1. During an observation on 9/9/25 at 12:23 p.m., in the kitchen, [NAME] 1 took Resident 11's meal ticket from the second tray of station 2's meal cart to read the information. The meal ticket dropped on the floor, [NAME] 1 picked up the meal ticket with blue gloved left hand and placed it back on the second tray. [NAME] 1 did not remove the gloves nor performed hand hygiene and continued to scoop the food items from the steam table with the same gloved hand.During an interview on 9/10/25 at 8:35 a.m., the [NAME] recalled picking up meal ticket and placing it back on to the tray. The [NAME] stated the meal ticket was contaminated. The [NAME] stated a new meal ticket should have been printed.During an interview on 9/10/26 at 8:40 a.m., in the kitchen, the Dietary Director (DD) stated the meal ticket should have been discarded and replaced.2. During an observation on 9/9/25 at 11:43 a.m., in the kitchen, [NAME] 1 removed the pureed creamy polenta from the oven using two black mitts with dry brownish matter and two torn area.During an interview on 9/9/25 at 2:53 p.m. with [NAME] 2 and the DA, [NAME] 2 stated the black oven mitts were dirty. The DA stated the oven mitts should either be thrown away or washed.During an interview on 9/10/26 at 8:40 a.m., the Dietary Director (DD) stated the two dirty oven mitts were replaced with a new one.During a review of the undated facility's policy and procedure titled, Delivery of Food Carts and Tray Service, indicated, Meals will be delivered to residents/patients. free from the risk of cross contamination by those who are serving them.During a review of the facility's policy and procedure titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated 2001, indicated, 6. Employees must wash their hands:. h. after engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to ensure three of 20 sampled residents (Resident 75, 76, and 77) had physician orders followed promptly. This failure resulted in Resident 77 not being treated for promptly for pitting edema (swollen part of the body due to excess watery fluid that dimple or pit up to four millimeters when it's pressed for a few seconds) on both lower extremities. This failure resulted in Resident 77 feeling tightness and pain in both legs and frustration. It had the potential for Resident 77's both legs' edema to get worsened and to suffer from edema related complications such as fluid overload (a medical condition with excessive accumulation of fluids in the body's tissue and organs). This failure to follow physician orders resulted in Resident 75 and 76 not having their weight and/or nutritional intake monitored, which had the potential to result in inaccurate treatment and/or monitoring. During a review of Resident 77's record, admission Record printed on 9/9/25, the record showed Resident 77 was admitted to the facility on [DATE]. During a record review of Resident 77's Minimum Data Set (MDS, an assessment tool used to direct care) dated 7/5/25, indicated Resident 77 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact mental status. During a concurrent observation and interview on 09/08/25 at 9:00 a.m., Resident 77 was sitting on the edge of his bed. Resident 77 stated he had swelling in both legs, no one had been treating it, it's painful and made him feel frustrated and uncomfortable. Resident 77 had grey colored loose fitted nonskid socks on both feet. During an observation on 09/09/25 at 12:35 p.m., Resident 77 was sitting in a wheelchair in his room, with non-skid socks on. During a concurrent observation and interview on 9/9/25 at 10:51a.m., with MDS Coordinator (MDSC, a licensed nurse who completes residents' assessment), Resident 77's was lying in his bed with nonskid socks on. MDSC removed Resident 77's socks and stated Resident 77 had 3+ pitting edema (when pressed the dimple was about three millimeters deep) on right lower leg and 2+ pitting edema with a dimple of two millimeters) on left lower leg. MDSC stated she assisted Resident 77 to put the nonskid socks back on. During a concurrent interview and record review on 9/9/25 at 11:45 a.m., with MDSC, Resident 77's electronic health record including physician orders dated 9/2025 were reviewed. MDSC stated the orders indicated to monitor Resident 77's edema in both lower extremities and to apply compression stockings (are medical devices that apply graduated pressure to the legs to improve circulation and reduce swelling) on both lower extremities during the day, removed at bedtime. During an interview, 09/10/25 at 1:33 p.m. Director of Nursing(DON) stated having edema for long time puts the resident at risk for fluid overload and related complications such as heart failure. The DON stated nurses were responsible to put compression stockings on Resident 77's lower extremities. During the review of the facility Policy and Procedures (P&P) title, Edema Management dated July 2025, the P&P showed, it is our facility policy to ensure that residents with edema are assessed , monitored, and treated with California Code of Regulations, (Title 22) and Centers for Medicare & Medicaid Services (CMS) Federal Requirements for Long Term Care Facilities. Care will be delivered to maintain resident comfort, prevent complications, and promote optimal health. During a record review of facility's document titled, admission Record, dated 9/11/25, the admission Record indicates Resident 76 is a [AGE] year old man initially admitted to the facility on [DATE] with multiple diagnoses including unspecified protein calorie malnutrition and chronic kidney disease, stage 5 (also called end-stage renal disease, when kidneys have lost almost all ability to filter waste and fluids from the blood). During a concurrent interview and record review on 9/11/25 at 1:40 p.m. with the Director of Nursing (DON), physician orders for Resident 76, dated 6/5/25 and 2/27/25, and facility's document titled Weights and Vitals Summary, dated 6/1/25 – 6/30/25, were reviewed. DON stated the documents indicate on 2/27/25, Medical Doctor (MD1) ordered to weigh Resident 76 every week. DON stated on 6/5/25, MD1 ordered to re-weigh Resident 76 to confirm weight gain. (See F842). DON stated the Weights and Vitals Summary shows that Resident 76 was weighed on 6/3/25 and not weighed again until 6/17/25. DON stated the order to reweigh the patient on 6/5/25 was not followed until 6/17/25 and this is not a reasonable time frame for the order to be followed. DON stated the risk of not repeating a weight for 12 days after it was ordered is that there is a potential risk for inaccurate nutrition evaluation. During a concurrent record review and interview on 9/11/25 at 1:19 pm with DON, physician order for Nepro (a nutritional supplement) 8 oz one time a day, monitor % intake dated 1/23/25 and Medication Administration Record (MAR, a document where medication and supplement administration are recorded), dated January 2025, February 2025, and March 2025, for Resident 76 were reviewed. DON stated the order to monitor Resident 76's intake of Nepro was not followed between 1/23/25 to 3/6/25. DON stated the risk of not recording intake is that the facility would not know how much Nepro resident is consuming, and the lack of knowledge means they would not know how to address. During a review of facility's document titled, admission Record, dated 9/11/25 for Resident 75, the admission Record indicated Resident 75 is a [AGE] year old woman initially admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure (when lungs cannot provide enough oxygen to the blood), unspecified protein calorie malnutrition, and muscle weakness. During a concurrent interview and record review on 9/12/25 at 9:51 a.m. with DON, physician orders dated 1/29/25 and facility's document titled Weights and Vitals Summary dated 9/11/25 for Resident 75 were reviewed. DON stated the documents indicated that on 1/29/25, MD1 ordered that Resident 75 should be weighed weekly. DON stated weights were checked on 9/9/25, 9/3/25, and 8/18/25 and there was a 16-day gap in between the weights performed on 9/3/25 and 8/18/25. DON stated that the risk of not checking the residents weight weekly is not providing information to monitor the resident and to not be able to monitor for weight loss and status. (See F692)

Based on observation, interview and record review, the facility failed to ensure two of 25 sampled residents (Resident 29 and 87)'s Minimum Data Set (MDS, an assessment used to plan care) assessment reflected accurate information when the following was noted: 1.Resident 29's MDS assessment inaccurately indicated use of antianxiety medications (chemical agents used to treat anxiety disorder), when Resident 29 was not taking any.2. Resident 87's discharge MDS assessment inaccurately indicated Resident 87 was discharged to an acute care hospital, when Resident 87 went home. This failure resulted in inaccurate reflection of Resident 29's clinical status and discharge disposition for Resident 87. 1. During an observation on 9/8/25 at 10:15 a.m., Resident 29 was sitting up in her bed. Resident 29 stated she was paralyzed from her waist down and had adapted to do her self care with both arms. Resident 29 stated she enjoyed spending time with her plants, iPad and art activities such working with crystal beads. During a record review of Resident 29's MDS assessment dated [DATE] indicated, Resident 29 was able to understand others and make herself understood. Resident 29's Brief Interview for Mental Status (BIMS, an assessment for mental status) was 15 out of 15, indicating intact mental status. During an interview and record review on 9/9/25 at 2:58 p.m., with MDS Coordinator (MDSC 1), Resident 29's clinical record including MDS assessment dated [DATE], and Medication Administration Record dated 7/2025 were reviewed. MDSC 1 stated around 7/23/25, Resident 29 reported having anxiety, restlessness, lack of sleep to facility staff and stated that she was experiencing these symptoms for a month but did not tell anyone. MDSC 1 stated facility reported above to Resident 29's physician, who prescribed Hydroxyzine (antihistamine, a medication that is usually used to treat allergy symptoms). MDSC 1 stated Resident 29 was prescribed to take one tablet of Hydroxyzine 25 milligrams (mg) by mouth as needed for anxiety, restlessness for five days at bedtime and she received it from 7/23/25 through 7/27/25. MDSC 1 stated Resident 29's MDS assessment dated [DATE], hence indicated that she was taking Antianxiety medications within the seven (7) days look back period. MDSC 1 stated she checked drug classification for Hydroxyzine under Order Entry where it indicated Hydroxyzine HCl was an antianxiety agent. When asked if facility used an approved Drug book as a reference, MDSC 1 stated she would get back shortly. Resident 29's MDS assessment section N-Medications, under section N0415 indicated, check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. During an interview and record review on 9/9/25 at 3:30 p.m. with MDSC 1, facility's drug book titled Nursing Drug Handbook updated as of 2024 was reviewed. MDSC 1 stated on page 1238, the drug book indicated Hydroxyzine was used to relive symptoms of anxiety, pruritis and urticaria. MDSC 1 stated however, pharmacologic category for Hydroxyzine did not indicate if the medication belonged to Antianxiety classification. 2. During a record review, of Resident 87's admission Record printed on 9/9/25, the admission Record indicated Resident 87 was admitted to the facility on [DATE]. During a concurrent record review and interview on 09/10/25 at 1015am with Licensed Vocational Nurse (LVN2) , Resident 87's nursing progress notes from 7/18/25 through 7/30/25 were reviewed. The notes indicated Resident 87 left the faciity on 7/30/25, with a friend and stated they wanted to go home but never came back. During a concurrent interview and record review on 09/11/25, at 1037 am, MDSC (Minimum Data Set Coordinator) Resident 87's discharge MDS assessment dated [DATE] was reviewed. MDSC stated the MDS assessment inaccurately indicated that Resident 87 was discharged to hospital when they actually went home and never returned back to the facility.

Based on observation, interview and record review, the facility failed to ensure the residents' medical records were updated to indicate information pertaining if an advanced directive (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), was offered and if the resident or responsible representative (RR) accepted or declined to create an advance directive, whether or not the resident had executed an advance directive, or the resident wishes for six / six sample residents (Residents 1, 2, 4, 7, 8, and 10).This had the potential for the facility to provide treatment and services against the residents' wishes. During a review of Resident 1's admission Record (AR), printed 9/10/25 , indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia ( a condition where the body's lungs are unable to adequately provide oxygen to the tissues, leading to low oxygen levels in the blood).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 8/19/25 indicated Resident 1's BIMS ( an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 15/15. A BIMS score 15 indicated short and long-term memory was intact and the resident had decision-making capacity. During a review of Resident 1's baseline care plan person -centered care plan dated 8/13/2025, the baseline care plan indicated the advanced directive was discussed with the resident. The baseline care plan did not detail the advance directive discussion with the resident or the RP. The baseline care plan did not indicate if the advance directive was offered, if the resident accepted or declined to create an advance directive, whether or not the resident had executed an advance directive, or the resident wishes.During a review of Resident 2's AR, printed on 9/10/25, AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included hemiplegia ( total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis ( weakness on one side of the body) following nontraumatic intracerebral hemorrhage affecting right non-dominant side.During a review of Resident 2's MDS dated [DATE] under Section C, a brief interview for mental status (BIMS) was performed and resulted in a summary score of 8/15 . A BIMS score of 8 indicated moderate problems with thinking and memory (moderate cognitive impairment).During an interview and record review with the Social Services Assistant (SSA) on 9/10/25 at 10:00 a.m., the SSA stated Resident 2's baseline care plan was not available due to the resident's length of time in the facility. SSA would attempt to have the documents located.During a review of Resident 4's admission Record (AR), printed 9/10/25 , indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (where the kidneys have permanently lost most of their ability to function.During a review of Resident 4's MDS dated [DATE] under Section C, a brief interview for mental status (BIMS) as performed and resulted as a summary score of 15/15 A BIMS score of 15 indicated short and long-term memory was intact and the resident had decision-making capacity. During a review of Resident 4 's baseline care plan person -centered care plan dated 7/30/2025 indicated the advanced directive was discussed with the resident. The baseline care plan did not detail the advance directive discussion with the resident. The baseline care plan did not indicate if the advance directive was offered, if the resident accepted or declined to create an advance directive, whether or not the resident had executed an advance directive, or the resident wishes.During a review of Resident 7's admission Record (AR), printed 9/10/25 , indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses that included hemiplegia ( total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis ( weakness on one side of the body) following cerebrovascular disease affecting left non-dominant side.During a review of Resident 7's MDS dated [DATE] under Section C, a brief interview for mental status (BIMS) as performed and resulted as a summary score of 7/15 A BIMS score of 7 indicated severe problems with thinking and memory (severe cognitive impairment).During a review of Resident '7s baseline care plan person -centered care plan dated 7/20/2025 indicated the advanced directive was discussed with the RR. The baseline care plan did not detail the advance directive discussion with the resident or the RP. The baseline care plan did not indicate if the advance directive was offered, if the resident or RP accepted or declined to create an advance directive, whether or not the resident had executed an advance directive, or the resident wishes. During a review of Resident 8's admission Record (AR), printed 9/10/25 , indicated, Resident 8 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction CI (CI occurs when blood flow to the brain is interrupted, causing damage to brain tissue) due to embolism of left middle cerebral artery. During a review of Resident 8's MDS dated [DATE] under Section C, a brief interview for mental status (BIMS) as performed and resulted as a summary score of 6/15 A BIMS score of 6 indicated severe problems with thinking and memory (severe cognitive impairment).During a review of Resident 8's baseline care plan person -centered care planning dated 7/06/2025 indicated the advanced directive was discussed. The baseline care plan did not detail the advance directive discussion with the resident or the RP. The baseline care plan did not indicate if the advance directive was offered, if the resident or RP accepted or declined to create an advance directive, whether or not the resident had executed an advance directive, or the resident wishes.During a review of Residen10's admission Record (AR), printed 9/10/25 , indicated, Resident 10 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 10's MDS dated [DATE] under Section C, a brief interview for mental status (BIMS) as performed and resulted as a summary score of 10/15 A BIMS score of 10 indicated moderate problems with thinking and memory (moderate cognitive impairment).During an interview and record review with the Social Services Assistant (SSA) on 9/10/25 at 10:00 a.m., the SSA stated Resident 2's baseline care plan was not available due to the resident's length of time in the facility. SSA would attempt to have the documents located.During a concurrent interview and record review on 9 /10/2025 at 9: 37 a.m. with the admission Coordinator (AC) The AC stated the admission packet the resident or resident representative receives contain resident rights, grievance, consent to treat, financial arrangements, transfers and discharges, bed holds and readmission, personal property, photos, confidentiality documents, facility rules and grievance procedures and agreement and signature page. AC stated the documents listed on the admission Agreement for Skilled Nursing Facilities .are discussed and reviewed at admission. Review of the records for residents 1, 2, 4, 7, 8 and 10, the AC stated there was no documentation relating to the advance directive discussion details, if an option to create an advance directive was offered, whether or not the resident had executed an advance directive, nor the resident wishes. During an interview on 09/10/2025 at 10:18 a.m. with Director of Nursing (DON), DON stated the admitting nurse will query the resident or RR if they have an Advance Directive. If the residents have an advanced directive they are requested to provide the document to social service. Social Services is to follow up to ensure advance directive was offered or requested again. DON stated social services document the discussion about the advance directive in the medical record. DON stated if the resident becomes incapacitated the facility refers to the Physician Orders for Life Sustaining Treatment (POLST) for the resident. During a concurrent interview and record review on 9/10/25 at 3:15 p.m., with Social Services Assistant (SSA), the SSA stated each resident is assessed upon admission for an advance directive. She stated the resident, or resident representative (RR) is verbally informed an advance directive, do not resuscitate (DNR) and POLST is a document that will make their wishes know when they become incapacitated. SSA stated a baseline care plan is initiated within 48 hours after admission and discussed at the baseline care conference. Reviews of residents' 1, 4, 7, and 8 baseline care plans were reviewed. SSA stated baseline care plans did not indicate specific advance directive information discussed, or information given to the resident or RR. SSA stated resident 2 and 10's advanced directive documents from 2022 were not available but will attempt to get. SSA stated she tries to document the advance directive discussion in the progress notes but does not always. She stated she needs to improve her documentation. During an interview on 9/10/25 at 3:40 p.m. with residents 1, 4, and 10, all Resident's stated they were not asked if they had an advanced directive, informed what an advance directive was or given the option to create one. During a review of Social Services policy dated 2001, the policy and procedure indicated the facility must provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident.enhance resident dignity. The policy and procedure indicated assisting residents with advance care planning, including but not limited to completion of advance directives'During a review of Advance Directives policy dated 2001, the policy and procedure indicated advance directive -a written instructions , such as a living will or durable power of attorney for health care. relating to the provisions of health care when the individual is incapacitated. Physician Orders for Life Sustaining Treatment (POLST) paradigm form is designed to improve patient care by creating a portable medical order so that emergency personnel know what treatment the patient wants in the event of a medical emergency. A POLST paradigm form is not an advance directive.If the resident does not have an advanced directive nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. If the resident had an advanced directive, copies of the document are obtained and maintained in the medical record

Based on observation, interview, and record review, the facility failed to maintain procedures to ensure accurate accountability and replacement of drugs in the emergency intravenous (IV) kit for 1 of 1 kits reviewed. This deficient practice resulted in the lack of documentation, missing medications, and failure to follow required procedures for notifying the pharmacy, which placed residents at risk of not having necessary emergency medications available when needed.During an observation on 09/08/2025 at 11:15 AM of the emergency IV kit, it was noted that the kit was missing normal saline. When asked when the kit was last opened, LVN 4 stated that typically a form is left inside the kit and faxed to the pharmacy; however, no such documentation was present. LVN 4 stated she could not determine when the kit had last been opened. During an interview 09/08/2025 at 12:00 PM Minimum Data Set Coordinator stated that she found the Emergency Drug Kit usage slip. She acknowledged that the policy was to change the kits within 72 hours once they are opened. A review of the Emergency Drug Kit usage slip dated 08/27/25 at 10:00 AM showed that 0.9% normal saline was removed for a resident. As of the survey observation on 09/08/25, this indicated the kit had been opened 12 days earlier. Despite being opened on 08/27/25, the facility failed to replace or properly document the emergency kit contents in accordance with policy, leaving the kit incomplete and unavailable for emergency use. According to facility policy titled 3.4 Emergency Pharmacy Service and Emergency Kits (E-Kits), emergency pharmaceutical services must be available 24 hours a day through either the facility's approved emergency kit or by special order from the provider pharmacy. The policy requires that medications in the E-Kit are kept secure, checked regularly for integrity and expiration dating, and only removed with a valid prescriber order. Upon removal, staff must document the medication on the emergency kit log, fax or notify the pharmacy immediately, and reseal the kit until exchange. The policy further directs that opened or used kits be replaced promptly, with a new seal affixed as required, and that accountability for all items is maintained through pharmacy notification and proper recordkeeping

Based on observation, interview, and record review, the facility failed to ensure least restrictive alternatives were attempted for a reasonable amount of time, prior to installing bedrails (adjustable metal or rigid plastic bars attached to the bed) for one of one samples residents (Resident 70) upon admission to the facility. This failure placed the Resident 70 at risk for injury, entrapment, psychosocial harm, up to and including death.During a review of Resident 70's admission Record printed on 9/10/25, the record indicated Resident 70 was admitted to the facility on [DATE]. During a review of Resident 70's Minimum Data Set (MDS, an assessment used to plan care) assessment dated [DATE], the assessment indicated Resident 70's Brief Interview for Mental Status (BIMS) score was six out of 15, indicating severe cognitive impairment. The assessment indicated Resident 70 had impairment in range of motion on both sides of her extremities and was dependent upon staff for activities of daily living, indicating Resident 70 had minimal strength to use her arms. During an observation on 9/8/25 at 11:25 a.m., Resident 70 was lying in her bed, with bedrails up on both sides of her bed. Both bedrails were padded with blue colored fabric cushion. During an observation on 9/8/25 at 12:13 a.m., Resident 70 was sitting up in the bed with the back of the bed raised, eating her lunch. Both bedrails were raised at the time. During an interview with Certified Nursing Assistant (CNA) 3 on 9/11/25 at 1:17 p.m., CNA 3 stated that she has been working in the facility for one year. CNA 3 stated Resident 70's bedrails were used because she was at risk for falls. CNA 3 stated Resident 70 did not use bedrails to prop herself up in bed. During an interview with CNA 4 on 9/11/25 at 1:28 p.m., CAN 4 stated she had known Resident 70 since her admission to the facility, and bedrails on Resident 70's bed were being used to avoid her from falling out of bed. During an interview on 9/11/25 at 3:45 p.m. with CNA 2, CNA 2 stated she has been working with Resident 70 since she was admitted to the facility. CNA 2 stated that she did not know why Resident 70's bedrails are raised at all times. CNA 2 stated Resident 70 could pull on the rail for positioning during incontinence care, but it required staff's assistance to place her hands on the rail. During a phone interview with Registered Nurse (RN) 1 on 9/11/25 at 2:44 p.m., RN 1 stated Resident 70 was usually restless and was often found leaning on the bedrails. RN 1stated bedrails were always kept in the upright position. During an interview on 9/11/25 at 3:50 p.m. with RN 2, RN 2 stated the bedrails were kept up on Resident 70's bed as a safety precaution. RN 2 stated that she had not seen Resident 70 use the bedrails for support. During a concurrent interview and record review on 9/11/25 at 2:48 p.m. with the Assistant Director of Nursing (ADON), Resident 70's Physician Orders, dated 8/20/24, were reviewed. The physician orders indicated Resident 70 may have both 1/4 side rails (bedrails) while in bed as an enabler for bed mobility and not a restraint. The order was updated on 8/20/25, indicating May have bilateral 1/4 side rails as enabler for bed motility and position. May have side rail pads to prevent injury. ADON stated that Resident 70's bedrails were being used to prevent falls. ADON stated that she had not observed Resident 70 using them for support. ADON stated the risks of installing bedrails placed Resident 70 at risk for entrapment, injury, or even death. During a Record Review of Resident 70's care plan for siderail/bedrail use, dated 8/25/25, indicated Resident 70 is at risk for injury related to use of siderail/bedrail. Resident noted with possible injury to right side of face [manifested by] discoloration [related to] bedrail use. During an interview with the Director of Nursing (DON) on 9/11/25 at 11:47 a.m., DON stated Resident 70 had anxiety, restlessness, and frequently laid her head near the rails. DON stated since Resident 70 recently sustained a bluish discoloration from an unknown origin, the care team decided to pad the bedrails. During an interview on 9/11/25 at 4:06 p.m. with DON, DON stated that Resident 70 needed bedrails up at all times for mobility purposes. DON stated she thought removing the bedrails would hinder Resident 70's chances of improved mobility. DON then also stated with the padding on the bedrails, Resident 70 was no longer able to hold onto the bedrails (at least since 8/20/25). During a concurrent interview and Record Review on 9/12/25 at 11:06 a.m. with the DON, Resident 70's Electronic Health Record (HER), including Bed Rail and Entrapment Risk Observation/assessment dated [DATE], and 8/25/25 were reviewed. The assessment dated [DATE], indicated facility used adjustable bed as an alternative for bedrail on that same day. The assessment dated [DATE], indicated facility used anticipation of needs, bedside floor mat, and items within reach as alternatives to bedrails. The DON stated however, she was unable to find any documentation on when and for how long the alternatives were used and if the alternatives were successful for Resident 70. The HER did not have any information indicating if facility attempted to remove bedrails for re-evaluation. During a Record Review of facility's Policy and Procedure (P&P) titled Bed Safety and Bed Rails, dated 8/2022, the P&P indicated staff are required to attempt and document alternative interventions before using bedrails. Additional safety measures are implemented for residents who have been identified as having higher than usual risk for injury including bed entrapment (e.g. altered mental status, restlessness, etc.)

Based on observation, interview, and record review, the facility failed to ensure that residents maintained adequate nutrition status in accordance with professional standards of practice and resident preferences for 2 out of 20 sampled residents (Resident 75 and 6).This deficient practice had the potential to result in unrecognized weight loss, inaccurate assessment of nutritional status, and failure to meet resident's dietary needs and preferences, placing residents at risk for avoidable weight loss and decline.During a review of facility's document titled, admission Record, dated 9/11/25 for Resident 75, the admission Record indicated Resident 75 is a [AGE] year old woman initially admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure (when lungs cannot provide enough oxygen to the blood), unspecified protein calorie malnutrition, and muscle weakness. During a review of Resident 75's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/12/25, the document indicated Resident 75's BIMS ( an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 15/15. A BIMS score of 15 indicated short and long-term memory was intact and the resident had decision-making capacity.During an interview on 9/10/25 at 12:40 p.m. with Resident 75, Resident 75 stated she is given a supplement called Nepro (a nutritional shake), but she doesn't like it. Resident 75 stated it is hard to drink things she doesn't enjoy. Resident 75 stated she requested Glucerna (a different type of nutritional shake) instead. Resident 75 also stated she has been asking for chocolate pudding instead of yogurt. Resident 75 stated she is frustrated by her weight loss and states she is trying to gain weight so that she can have surgery to reverse her colostomy. During a concurrent interview and record review on 9/10/25 at 12:48 with Dietary Manager (DM), facility's documents titled progress notes dated 9/3/25 and 9/9/25 were reviewed. DM stated the documents indicate that on 9/3/25 and 9/9/25, Resident 75 requested chocolate pudding instead of yogurt. DM stated on 9/3/25 when Resident 75 requested chocolate pudding, the nurse should have sent a diet order communication slip to the kitchen. DM stated that the request for chocolate pudding was not received by the kitchen until 9/9/25. During an interview on 9/10/25 at 13:00 with Registered Dietician (RD), RD stated that dietary preferences should be honored, as they are trying to encourage Resident 75 to eat. During an interview and concurrent record review on 9/10/25 at 12:48 p.m. with RD, facility's document's titled progress notes dated 8/6/25 for Resident 75 was reviewed. RD stated she wrote the progress note on 8/6/25 and she recommended switching Resident 75 from Glucerna to Nepro. RD stated there is no note after 8/6/25 on if Resident 75 liked Nepro and she will see Resident 75 today. During a record review of facility's documents titled progress notes, dated 9/10/25, for Resident 75, RD wrote a progress note on 9/10/25 at 2:45 p.m. The progress note indicated Resident 75 lost 8.4 pounds in 7 weeks due to not eating and drinking enough. The note indicated that Resident 75 prefers Glucerna instead of Nepro. In the progress note, RD recommended changing Resident 75's supplement to Glucerna.During a concurrent interview and record review on 9/12/25 at 9:51 a.m. with DON, physician orders dated 1/29/25 and facility's document titled Weights and Vitals Summary dated 9/11/25 for Resident 75 were reviewed. DON stated the documents indicated that on 1/29/25, MD1 ordered that Resident 75 should be weighed weekly. DON stated there was a 16-day gap in between Resident 75's weights being checked between 8/18/25 and 9/3/25. During a review of facility's document titled Weights and Vitals Summary dated 9/11/25 for Resident 75, the document indicated that after MD1 entered the order for Resident 75 to be weighted weekly, Resident 75 was weighted 9/9/25, 9/3/25, 8/18/25, 8/11/25, 8/4/25, 7/30/25, 7/21/25, 7/15/25, 7/2/25, 6/18/25, 6/9/25, 6/3/25, 5/27/25, 5/20/25, 5/13/25, 5/9/25, 4/29/25, 4/22/25, 4/16/25, 4/11/25, 4/1/25, 3/6/25, 2/25/25, 2/18/25, 2/10/25, 2/4/25, 1/30/25. The document indicated 16 days in between the weights recorded on 8/18/25 to 9/3/25 and 26 days in between the weights recorded on 3/6/25 and 4/1/25.During an interview on 9/12/25 at 9:51 a.m., DON stated that the risk of not checking the residents' weight weekly is not having information to monitor the resident for weight loss and health status. (See F684)During a review of facility's document titled, admission Record, dated 9/12/25 for Resident 6, the admission Record indicated Resident 6 is a [AGE] year old woman initially admitted to the facility on [DATE] with multiple diagnoses, including unspecified protein-calorie malnutrition (a condition that occurs when an individual does not consume enough protein and calories to meet their nutritional needs), hypertension (high blood pressure), multiple sclerosis (a chronic disease of the brain and spinal cord characterized by changes in sensation, visual problems, weakness, depression, difficulties with coordination and speech, and impaired mobility and disability).During an interview and concurrent observation on 9/10/25 at 12:35 pm with Dietary Manager (DM) of Resident 6's lunch tray and diet order slip (a piece of paper indicating resident allergies, preferences, and items of food they receive), DM observed two Chobani Greek yogurts with peaches and a vanilla magic cup ice cream on Resident 6's lunch tray. DM stated the diet order slip indicated Resident 6 was allergic to milk and stated .Notes: do not give milk or dairy products. DM stated the yogurt and ice cream given to Resident 6 are dairy products and they were given because of resident preference. During a concurrent interview and record review on 9/10/25 at 12:48 p.m. with RD, the diet order for Resident 6 was reviewed. RD stated the diet order indicated that Resident 6 is allergic to milk and the document stated do not give milk or dairy products. RD stated that Resident 6 is not allergic to milk. RD stated this could create confusion and the diet order should be corrected. (See F842)

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents ( Resident 35) was provided reading glasses as prescribed by the doctor. This failure resulted in Resident 35 to be unable to see things clearly, participate in activities fully and feeling frustrated. During a review of Resident 35's admission Record printed on 09/10/25, the record indicated Resident 35 was admitted to the facility on [DATE]. During a review of Resident 35's Minimum Data Set (MDS, an assessment used to guide care) assessment dated [DATE], the assessment indicated Resident 35 did not wear glasses at the time of assessment. The assessment indicated the Resident 35 was able to understand others and make her self understood. During a review of Resident 35's care plan for vision dated 6/20/25, indicated Resident 35 had altered visual ability related to visual loss, and may impact ability to participate in ADL (activities of daily living). The care plan indicated to perform eye exam as ordered/if indicated. During an observation on 09/08/25 at 10:10 a.m., Resident 35 was sitting up in her bed. Resident 35 stated she was not able to read the time on the wall clock in her room. Resident 35 stated she needed eye glasses to see better, however she did not have any. Resident 35 stated her eyes usually burn and she felt frustrated as that was ongoing issue for a while. During an interview on 09/09/25 at 9:53 a.m., in Activity Room , Resident 35 was sitting in a chair, coloring a coloring book. Resident 35 stated she could not play bingo game very well because she could not see well. During an interview on 09/09/25 at 9:57 a.m., with Activity Assistant (AA), AA stated she had been working at the facility for last two years. AA stated playing bingo was Resident 35's favorite activity. AA stated however, she had to assist Resident 35 in activities many times because Resident 35's vision was blurry and she could not see very well. AA stated she had informed Resident 35's direct care nurses about this issue in the past. During an interview on 09/10/25 at 12:40 p.m. with Certified Nursing Assistant Certified Nursing Assistant (CNA) 5, CNA 5 stated he was direct care staff for Resident 35. CNA 5 stated he did not see Resident 35 wearing eyeglasses or having eye glasses in her possession since he had been taking care of her. During an interview on 09/10/25 at 12:50 p.m. Licensed Vocational Nurse (LVN) 2, stated she was not aware if Resident 35 had any issues with her vision. During a concurrent interview and record review with Social Services Assistant (SSA) on 09/09/25 at 3:13 p.m., Resident 35's Vision Examination Report dated 7/22/24 was reviewed. The report indicated a prescription for reading glasses for Resident 35. SSA stated she was unaware if facility ever followed up on the reading glasses prescription. SSA also stated she was responsible for scheduling eye exam appointments and following through on the recommendations. SSA stated 7/22/24 was the most recent eye exam conducted for Resident 35 and she was not seen by an eye doctor since then. During a review of facility's Policy and Procedure (P&P) titled_Ancillary Services, dated_January 2025, the P&P indicated, it is the policy of this Skilled Nursing Facility (SNF), to provide or arrange for medically necessary ancillary services to meet the individualized needs of residents in accordance with Caifornia Code of Regulations (Title22) and federal CMS requirements. Ancillary services include, but are not limited to, pharmacy, laboratory, radiology, rehab therapies, social services, and dietary services.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with manufacturer instructions and accepted standards of clinical practice observed during medication pass. These failures included the administration of an expired inhaler and improper inhaler technique and potentially contaminating a syringe of Lispro prior to administration. As a result, 2 medication errors were identified out of 25 opportunities, resulting in a medication error rate of 8%. This placed residents at risk of reduced potency, diminished therapeutic benefit, and compromised clinical outcomes.1. During an observation on 09/08/2025 at 10:07 AM of medication administration by LVN 4 to Resident 79, LVN 4 administered Breo Ellipta inhaler, but failed to instruct the resident to fully exhale prior to inhaling the dose. During an interview after the medication pass on 09/08/225 at 10:20 AM, LVN 4 acknowledged that she had not instructed the resident to exhale before using the inhaler. She further stated she was unaware that Breo Ellipta inhalers expire six weeks after opening and admitted she had administered the expired inhaler without realizing it. The nurse reported she would check the other inhalers and be more careful in the future. According to the Breo Ellipta manufacturer's instructions, patients must exhale completely before inhalation to ensure medication reaches the lungs effectively. Resident 79 was not provided this instruction, resulting in a medication error. 2. Review of the Breo Ellipta inhaler label revealed it was opened on 07/26/2025 and expired six weeks later on 09/06/2025 per manufacturer guidance. On 09/08/2025, LVN 4 administered the inhaler beyond its expiration date. Administration of expired medication constituted an additional medication error and placed Resident 79 at risk of reduced potency and therapeutic effect. 3. During a medication pass observation on 09/09/25 at 8:15 AM, RN 2 was observed drawing up Lispro insulin into a syringe at the medication cart. Prior to administering the injection to Resident 93, RN 2 placed the uncapped insulin syringe directly onto the resident's overbed table. This same surface was observed to hold personal food items and beverages during the survey. The syringe remained in direct contact with the table for approximately 20 seconds before the nurse picked it up and administered the dose. During an interview on 09/09/25 at 8:20 AM, RN 2 stated, she did leave the syringe on the table. She also stated that she had forgotten and should not have left it for a short period of time on the table. She acknowledged that it was inappropriate because of potential contamination of the syringe. According to the safe injection practices of the CDC guidelines, (https://www.cdc.gov/injection-safety/hcp/clinical-safety/index.html). This guidance establishes that medications must be prepared and handled in environments that protect them from contamination. Once a syringe is prepared, it should remain in a clean, controlled space and be administered promptly. Placing a prefilled syringe on a side table introduces a direct risk of contamination because such surfaces are frequently touched, not disinfected between uses, and cannot be considered sterile. Doing so compromises the sterility of the medication and places the resident at risk for infection, violating accepted standards of practice for safe injection and medication administration.

Based on observation, interview and record review, the facility failed to follow facility medication administration policy, provide pharmacy services and ensure controlled medication (those with high potential for abuse and addiction) were fully accounted for 11 of 57 sampled residents (Residents 1, 400, 69, 329, 42, 20, 70, 30, 41, 57 and 330) when: 1. Licensed Vocational Nurse 8 (LVN 8) gave Resident 400 and Resident 1 medications without verifying residents' identity and did not name the medications given to the residents. 2. Resident 69 did not take her medications for one hour after LVN 3 left medications on Resident 69's overbed table without watching administration. 3. Resident 329 did not receive scheduled medication for 44 hours because the medications had not been delivered. 4. An as-needed (PRN) controlled medication for Resident 42 was administered but not documented in the E-MAR (Electronic Medication Administration Record) during an inspection in one of two medication carts. 5. Three controlled medications were administered but not documented in the Controlled Substance Accountability Sheet (a.k.a. Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) upon administration for Residents 20 and 70. 6. Thirteen vials of lorazepam for Resident 30 were not counted during shift changes and was not removed from active stock for over a year. 7. Controlled Drugs-Count Record sign-in/sign-out record (records that account for controlled medications) was incomplete for two out of two medication carts (Stations 1 and 2). 8. Controlled medication use audit for Residents 41, 57, and 330 did not reconcile. The medications were signed out of the Count Sheet but was not documented on the E-MAR to indicate they were given to the residents. These failures resulted in: 1. Resident 400's hospitalization for excessive sedation and respiratory failure (inadequate breathing efforts) requiring mechanical ventilation (machine used to provide artificial breathing), a tracheostomy (a surgically created opening through the neck into the trachea, also known as the windpipe), a gastrostomy (a tube surgically inserted through the skin into the stomach for delivery of nutrients and/or medications), and encephalopathy (abnormal deterioration of brain function) from the opioid medications (a group of medications which are federally regulated substances used for pain control with a potential for physical or psychological dependence) overdose. 2. Resident 69 taking her medications one hour late. 3. Resident 329 had the potential to experience high blood pressure which could result in stroke or heart attack. 4. Inaccurate accountability of controlled medications which had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purpose not intended by the prescriber) of controlled medications. Findings: 1. During a review of Resident 400's Admission Record dated 12/22/23, the Admission Record indicated Resident 400 was admitted to the facility in 2008 for stroke (brain tissue death resulting in brain function impairment), hemiplegia (the loss of muscle function on one side of the body), hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), dysphagia (difficulty swallowing), heart failure and muscle weakness. During a review of Resident 400's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 11/10/23, the MDS indicated Resident 400 had a score of 13 on the Brief Interview for Mental Status. (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 400 was able to be understood and could understand others. The MDS indicated Resident 400 required setup assistance only for eating. The MDS indicated Resident 400 required supervision for oral and personal hygiene such as combing hair, washing hands and face. During a review of Resident 400's, Order Summary Report, Active Orders as of 12/18/23, dated 12/18/23, the Report indicated an order for a regular texture diet. The Report indicated Resident 400 had orders to take medications and food by mouth. The Report indicated Resident 400 had no active orders for baclofen (muscle relaxant medication which can cause drowsiness and shallow breathing), hydrocodone-acetaminophen (an opioid medication), methadone (an opioid medication) or Eliquis (medication to prevent blood clots which can cause stroke or heart attack). During a review of Resident 1's Admission Record dated 12/28/23, the Admission Record indicated Resident 1 was admitted to the facility in 2013 for atrial fibrillation (irregular heart rhythm which can lead to stroke) and chronic pain. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had a BIMS score of 14. The MDS indicated Resident 400 had adequate vision and was able to be understood and could understand others. During a review of Resident 1's Order Summary Report, Active Orders as of 12/28/23, dated 12/28/23, the Report indicated Resident 1 had medication orders for: baclofen 20 mg (milligram, a unit of measurement) oral tablet, three times a day; hydrocodone-acetaminophen 10-325 mg oral tablet, five times a day; Eliquis 5 mg oral tablet, twice a day; and methadone 10 mg oral tablet, four times a day. During a phone interview on 1/2/24, at 4:40 p.m., with LVN 8, LVN 8 stated on 12/16/23, at 9:00 a.m., she was performing a medication pass for Resident 400 and Resident 1, who shared a room. LVN 8 stated she checked the identity of both residents and prepared both of their medications in separate medication cups. LVN 8 stated she took a medication cup to Resident 400's bedside and watched Resident 400 take the medications, and then left the room. LVN 8 stated 30-40 minutes later, Resident 1 told LVN 8 the medications LVN 8 had left on Resident 1's overbed table did not belong to Resident 1. LVN 8 stated she realized she had accidentally switched the medications and had administered Resident 1's medications to Resident 400. LVN 8 stated Resident 400 had not received her morning medications of metformin (a medication to decrease blood sugar) and amlodipine (used to decrease blood pressure), and aspirin (to prevent blood clots), but had received Resident 1's medications which included methadone, hydrocodone-acetaminophen, Eliquis, and baclofen. LVN 8 stated she called the nurse practitioner (NP) and informed the NP that Resident 400 had received Resident 1's medications; the NP told LVN 8 to monitor Resident 400. During a concurrent phone interview and record review on 1/5/24, at 10:40 a.m., with LVN 8, Resident 1's Controlled Substance Accountability Sheet for methadone 10 mg tab and hydrocodone-acetaminophen 10-325 mg tablet, dated December 2023, was reviewed. LVN 8 stated on 12/16/23, Resident 400 had received two doses of methadone 10 mg at 9:00 a.m., and she recorded the two doses on 12/16/23, at 1:00 p.m. under Qty [quantity] destroyed/wasted of the sheet. LVN 8 stated Resident 400 had received two doses of hydrocodone-acetaminophen 10-325 mg at 9:00 a.m., and she recorded the two doses on 12/16/23, at 1:00 p.m. under Qty destroyed/wasted of the sheet. LVN 8 stated Resident 400 had also received the 9:00 a.m. and 1:00 p.m. dose of baclofen during the 9:00 a.m. medication pass. LVN 8 stated the doses were documented under destroyed/wasted because the doses had not been given to Resident 1. LVN 8 stated, at Resident 1's request, LVN 8 left both the 9 a.m. and 1 p.m. doses of hydrocodone-acetaminophen, methadone, and baclofen at Resident 1's bedside for the 1 p.m. doses to be self-administered later in the day. During a concurrent observation and interview on 12/28/23, at 12:06 p.m., with Resident 1, Resident 1 lay in bed with an overbed table across her lap. A palm-sized box with a hinged lid was on the overbed table. Resident 1 stated she had been Resident 400's roommate on the morning of 12/16/23, when LVN 8 came into the room with both Resident 400's and Resident 1's morning medications and placed the medications on the residents' overbed tables. Resident 1 stated LVN 8 left the room before either resident had taken the medications. Resident 1 stated she noticed while sorting the medications left at her bedside, that the medications were not the correct prescribed medications so Resident 1 called for the nurse. Resident 1 stated she told LVN 8 the medications left at her bedside were not her medications when LVN 8 answered the call bell about 30 minutes later. Resident 1 stated her morning medications included baclofen, hydrocodone-acetaminophen, methadone and Eliquis. Resident 1 stated LVN 8 would leave both the 9 a.m. and the 1 p.m. doses of methadone, hydrocodone-acetaminophen, and baclofen during the 9:00 a.m. medication pass at Resident 1's bedside, so Resident 1 would place the 1 p.m. doses in the hinged box on the overbed table for later self-administration. Resident 1 stated LVN 8 had not verified either Resident 400 or Resident 1's identities before leaving the medications at their bedsides or told either resident the names of their medications. During a concurrent interview and record review on 12/28/23, at 12:39 p.m., with Administrator (Admin) and OM, Resident 400's, Situation, Background, Assessment, Recommendation, Summary, (SBAR, a communication tool to summarize relevant medical information for changes in condition or unusual incidents) by LVN 8, dated 12/16/23, at 10:30 a.m., was reviewed. The SBAR indicated Resident 400 had a change in condition related to a medication error. OM stated the SBAR note indicated at 9:00 a.m., LVN 8 prepared Resident 400 and Resident 1's medications on the medication cart and took Resident 1's medications to Resident 400 and Resident 400 took Resident 1's medications. The SBAR indicated LVN 8 gave Resident 400's medications to Resident 1 but left the room before Resident 1 took the medications. The SBAR indicated after 30 minutes, Resident 1 informed LVN 8 the medications left with Resident 1 were not the correct prescribed medications. OM stated the SBAR indicated the NP was notified of the medication error and LVN 8 was given instructions to monitor Resident 400. During a phone interview on 12/28/23, at 12:23 p.m., with the NP, the NP stated in the morning of 12/16/23, NP received a text message from a facility staff member about Resident 400 receiving the wrong medications. NP stated she instructed the staff member to call the director of nursing (DON) and to monitor Resident 400. NP stated that was the extent of NP's involvement; NP had not done any follow-up or contacted anyone else after giving those instructions. During a concurrent interview and record review on 12/28/23, at 12:31 p.m., with Admin, the Admin presented a phone screenshot of LVN 8's text messages with NP. The text message indicated LVN 8 informed NP that Resident 400 had received baclofen, methadone, acetaminophen and Eliquis; NP responded with instructions to call the DON and monitor Resident 400. During a phone interview on 12/28/23, at 11:49 a.m., with Licensed Vocational Nurse 9 (LVN 9), LVN 9 stated she had worked the 3 p.m. to 11 p.m. shift on 12/16/23. LVN 9 stated that during the change of shift report on 12/16/23, at 3:00 p.m., LVN 8 reported Resident 400 had taken Resident 1's medications in the morning and needed to be monitored. LVN 9 stated Resident 400 was verbally responsive and had stable vital signs from the beginning of the shift until dinner time. LVN 9 stated at dinner time, a certified nursing assistant (CNA) came to LVN 9 and said Resident 400 was unresponsive, so they went to Resident 400's room. LVN 9 stated attempts to awaken Resident 400 were unsuccessful, and upon checking Resident 400's vital signs, Resident 400's oxygen saturation was 78-80%. (Oxygen saturation is a measurement of oxygen in the blood, expressed as a percentage, with 100 percent the maximum amount of oxygen possible, and normal values greater than 90%.) LVN 9 stated Resident 400 was given supplemental oxygen through a non-rebreather mask (an external mask worn over the nose and mouth to provide 100% oxygen), while 9-1-1 was called for emergency transport to the hospital. During a concurrent interview and record review on 12/28/23, at 12:39 p.m., with Admin and OM, Resident 400's nursing progress notes, for 12/16/23 to 12/17/23, were reviewed. A nursing SBAR progress note by LVN 9, dated 12/16/23, at 6:00 p.m., indicated at 5:28 p.m., Resident 400 had a situation of unresponsiveness different than usual with an oxygen saturation of 78-80% and a respiratory rate of seven (number of breaths per minute, normal respiratory rate is 12 to 18 breaths per minute). The SBAR indicated LVN 9 assessed Resident 400's breathing as labored or rapid breathing, with general weakness and altered level of consciousness. A nursing progress note by LVN 9, dated 12/17/23, at 12:45 a.m., indicated, at 5:28 p.m., Resident 400 was unresponsive to multiple attempts to rouse Resident 400. The note indicated Resident 400 had an oxygen saturation of 88% while using the non-rebreather mask. The progress note indicated at 5:46 p.m., the resident was taken to the emergency room . During a record review of Resident 400's hospitalization record, an emergency physician's Provider Note dated 12/16/23, at 7:29 p.m., indicated Resident 400 was transported by ambulance to the emergency room , at 6:02 p.m., and was diagnosed with altered mental status (term used to refer to a change in consciousness), opioid overdose and apnea (cessation of regular breathing). The Provider Note indicated Resident 400 had accidentally received methadone and hydrocodone-acetaminophen. The Provider Note indicated Resident 400 had a Glasgow Coma Scale score of three. (Glasgow Coma Scale is an assessment tool to determine purpose response to stimuli scored on a scale of one to 15 with a score of 15 indicating normal function, and 3-14 indicating abnormal function. A score of three indicates no eye opening, verbal or motor response to stimulus.) The provider note indicated Resident 400 was intubated (a tube is placed into the windpipe through the mouth or nose) and placed on mechanical ventilation (machine used to provide artificial breathing), and the decision was made to admit Resident 400 to the intensive care unit for further evaluation and management. During a record review of Resident 400's hospitalization record, a critical care physician's History and Physical (H&P), dated 12/16/23, at 8:38 p.m., indicated Resident 400 was diagnosed with accidental opiate overdose, acute respiratory failure, and encephalopathy from the opiate drug overdose. The H&P indicated admission to the critical care unit was necessary for further evaluation and management. During a record review of Resident 400's hospitalization record, a critical care Physician Progress Note, dated 1/1/24, indicated Resident 400 had a tracheostomy placed 12/28/23, and required a mechanical ventilator due to apnea. The Progress Note further indicated Resident 400 required a gastrostomy tube, placed 12/28/23, for delivery of medications and nutrition. During a review of facility policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, The individual administering medications verifies the resident's identity before giving the resident his/her medications .and checks the label three times to verify the right resident, right medication, right dosage and right time .before giving the medication medications are administered within one hour of their prescribed time .medication administration times are determined by resident need and benefit, not staff convenience. During a review of facility's P&P titled, Administering Oral Medications, dated 10/2010, the P&P indicated nursing staff were expected to, confirm identity of resident .remain with the resident until all medications have been taken. 2. A review of Resident 69's admission record indicated Resident 69 was admitted to the facility on ,d+[DATE] with a diagnosis of sacral pressure ulcer stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) and hypertensive heart failure (reduced heart output due to high blood pressure). During a review of Resident 69's MDS, dated [DATE], the MDS indicated Resident 69 had a score of 13 on the Brief Interview for Mental Status. (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 69 was able to be understood and could understand others. During a review of Resident 69's physician's orders titled, Order Summary Report, dated 1/10/24, indicated Resident 69 had medication orders for apixaban (medication to prevent blood clots) oral tablet 5mg (milligram, unit of measurement) twice a day, ascorbic acid(vitamin C, an anti-oxidant) tablet 500mg once a day, carvedilol (medication to treat high blood pressure) oral tablet 3.125mg twice a day, cholecalciferol (vitamin D, an essential vitamin) tablet once a day, docusate (medication to soften stool) tablet twice a day, and flaxseed oil (nutritional supplement) 1000mg capsule once a day. During a concurrent observation and interview on 1/8/24, at 10:37 a.m., with Resident 69, Resident 69 was asleep in her bed under her covers. A medication cup containing six medications were on the overbed table positioned over Resident 69's bed. Resident 69 woke up and stated LVN 3 brought her the medications, and she forgot to take them. Resident 69 did not recall when the medications were placed on the overbed table. Resident 69 picked up the medication cup and took some of the medications. Resident 69 placed the medication cup containing two medications back on the overbed table. During a concurrent observation and interview on 1/8/24, at 10:47 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 69 was asleep in her bed under her covers. The medication cup containing the remaining two medications were on the overbed table. LVN 3 woke Resident 69 up to instruct Resident 69 to take the two remaining medications. LVN 3 stated she had left Resident 69's medications on the overbed table without observing Resident 69 take the medications. LVN 3 stated she recorded the time she gave Resident 69's medication on Resident 69's medication administration record (MAR). LVN 3 stated she was expected to follow medication administration procedures and observe Resident 69 take her medications before leaving the room. During a record review of Resident 69's Administration History Report, dated 1/11/24, Resident 69's morning medications for 1/8/24 were reviewed. The Report indicated, at 9:22 a.m., LVN 3 gave Resident 69 the following medications: apixaban 5mg tablet, ascorbic acid 500 mg tablet, carvedilol 3.125mg tablet, cholecalciferol tablet, docusate oral tablet, and flaxseed oil 1000mg capsule. During a review of facility policy and procedure titled, Administration of Oral Medications, dated 8/2010, the P&P indicated the nurse who administers medication remain with the resident until all medications have been taken. 3. A review of Resident 329's admission record indicated Resident 329 was admitted to the facility on [DATE] for right knee effusion (fluid buildup in the knee) and hypertensive heart disease (heart disease from high blood pressure). A review of Resident 329's physician order titled, Order Details, dated 1/10/24, indicated, on 12/28/23, Resident 329 had an order for metoprolol 12.5mg tablet twice a day. During an interview on 1/8/23, at 11:37 a.m., with Resident Representative 1, RP 1 stated on 12/28/23 and 12/29/23, Resident 329 did not receive metoprolol 12.5 mg. RP 1 stated at home, Resident 329 had been taking the medication twice a day and the facility told her they did not have the medications for an entire day. During a concurrent interview and record review on 1/10/24, at 10:30 a.m., with Registered Nurse Supervisor (RNS), Resident 329's medication administration record (MAR), dated 12/2023, was reviewed. RNS stated the MAR indicated on 12/29/23 Resident 329 did not receive metoprolol 12.5 mg for the morning and evening doses. RNS stated nursing staff wrote a progress note about why the medication was not given. During a concurrent interview and record review on 1/10/24, at 10:35 a.m., with RNS, Resident 329's nursing progress note, dated 12/29/23, at 8:20 p.m. was reviewed. The progress note indicated Resident 329 was not given metoprolol 12.5mg because the medication had not been delivered. RNS stated medications were expected to be available when Resident 329 was admitted but did not know why this medication was not available. During a concurrent interview and record review on 1/11/24, at 1:20 p.m., with Operations Manager (OM), a pharmacy packing list titled Reorder Fill History, for Resident 329's metoprolol dated 1/11/24 was reviewed. OM stated the packing list indicated Resident 329's metoprolol 25 mg was received on 12/30/23. 49498 4. During a concurrent observation and interview on 01/08/24, at 03:01 p.m., with Licensed Vocational Nurse (LVN) 3, at Station 1 Medication Cart, two hydromorphone (a controlled medication used to treat moderate to severe pain) 2 milligrams (mg) tablets for Resident 42 were observed inside the locked compartment. LVN 3 stated the Registered Nurse Supervisor (RNS) gave her four tablets of hydromorphone for Resident 42 earlier that morning and she had given two tablets to the resident at 12:30 p.m. When asked to show documentation of the two hydromorphone tablets administered, LVN 3 looked up the E-MAR and stated she had not documented it yet. She acknowledged she should have documented right away after the medication was given. A review on 01/08/24, at 03:43 p.m. of Resident 42's E-MAR indicated the two hydromorphone 2 mg tablet was not documented. During a review of facility's policy and procedure (P&P) titled, Documentation of Medication Administration, revised on November 2022, P&P indicated, 1. A nurse . documents all medications administered to each resident on the resident's medication administration record (MAR) and 2. Administration of medication is documented immediately after it is given. 5. During an inspection of Station 1 Medication Cart on 01/08/24, at 03:01 p.m., with LVN 3, four capsules of pregabalin (a controlled medication to treat nerve and muscle pain) 50 mg and seven tablets of lacosamide (a controlled medication to treat partial seizures) 100 mg were documented in the Count Sheet for Resident 20; however, three capsules of pregabalin 50 mg and six tablets of lacosamide 100 mg were observed in the locked compartment of the medication cart. LVN 3 stated she administered one capsule of pregabalin and one tablet of lacosamide to Resident 20 in the morning but forgot to sign out of the Count Sheet. Similarly, during an inspection of Station 1 Medication Cart with LVN 3, on 01/08/24, at 03:03 p.m., four tablets of lacosamide 100 mg were documented in the Count Sheet for Resident 70; however, three tablets of lacosamide 100 mg were observed in the locked compartment. LVN 3 stated she administered one tablet of lacosamide to Resident 70 in the morning but forgot to sign out of the Count Sheet. She acknowledged she should have signed out as soon as she administered them to the residents. A review on 01/08/24, at 03:56 p.m., of Resident 20's E-MAR indicated one pregabalin 50 mg and one tablet of lacosamide 100 mg was administered during the morning medication pass. A review on 01/08/24, at 03:58 p.m., of Resident 70's E-MAR indicated one tablet of lacosamide 100 mg was administered on 1/8/24 during the morning medication pass . During an interview on 01/09/24, at 09:58 a.m., the RNS stated controlled medication should be documented in the Count Sheet right after giving it. During a review of facility's undated P&P titled, Narcotics, Controlled Substances, and Preventing Drug Diversion, P&P indicated, 2.b. Each time a resident receives assistance with administration of a narcotic, this is documented and the amount of medication on hand is updated on the Narcotic Count Sheet. 6. During a concurrent observation and interview on 01/08/24, at 11:42 a.m., in the Station 2 and 3 Medication Room, with the Director of Nursing (DON) and LVN 2, an inspection of the medication refrigerator identified thirteen 1-milliliter (ml) injectable vials of lorazepam (a controlled medication used to treat anxiety) 2 mg/ml for Resident 30. The DON and LVN 2 confirmed Resident 30 was already discharged . During an interview and record review on 01/10/24, at 09:39 a.m., the RNS stated the thirteen 1-ml vials of lorazepam was given to her this morning and the Count Sheet was created on 1/8/24 (the day it was identified by the surveyor). During an interview on 01/10/24, at 02:28 PM, the DON stated there was no order found in the EHR (Electronic Health Record) for Resident 30's lorazepam. The DON confirmed the order must have been discontinued over a year and cannot find the Count Sheet for the thirteen vials. The DON stated the RNS called the current and previous pharmacies, and both have no record of sending the lorazepam vials. The DON confirmed there was no Count Sheet for staff to count during shift change and was not able to tell how many the pharmacy sent and how many was used. During a review of facility's P&P titled, Controlled Substance Storage, Revised August 2014, P&P indicated, G. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented; K. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed. 7. On 1/10/24, review of the January 2024 Controlled Drugs-Count Record (a sign-in and sign-out document) for Station 1 Medication Cart indicated it was missing the nurses' signatures eleven times from 1/1 to 1/10/24. A review of Station 2's Medication Cart Controlled Drugs-Count Record indicated it was missing the nurses' signatures twenty-two times for December 2023, and fifteen times for January 2024. During a concurrent interview and record review on 01/10/24, at 09:41 a.m., the RNS stated the incoming and outgoing nurses were to sign the Controlled Drugs-Count after they counted the controlled medications together. She acknowledged the Controlled Drugs-Count Record for January 2024 for Station 1 and December 2023 & January 2024 for Station 2 had missing accounting documentation. During a review of facility's undated P&P titled, Narcotics, Controlled Substances, and Preventing Drug Diversion, P&P indicated, 2. A Narcotic Count Sheet will be maintained for all narcotic medications; 2.c. At the end of each shift, the staff member responsible for medication completing his/her shift, and the staff member responsible for medications who is starting his/her shift, count all narcotic medications and confirm that the amount on hand matches with what was listed on the Narcotic Count Sheet for each medication. 8. During an interview on 01/10/24, at 2:32 p.m., the RNS stated each time a controlled medication was removed for administration to a resident, the nurse administers the medication to the resident, signs it out of the Count Sheet, and documents the administration on the MAR. 8a. A review of Resident 41's clinical record indicated a physician's order, dated 12/27/23, for oxycodone (a controlled medication to treat moderate to severe pain) 15 mg 1 tablet by mouth every 4 hours as needed for moderate to severe pain. During a concurrent interview and record review on 01/10/24, at 02:36 p.m., with the RNS, a review of the Count Sheet for oxycodone 15 mg and the January 2024 E-MAR for Resident 41 indicated the nursing staff removed one tablet on 1/8/24 at 5:02 a.m., and 1/9/24 at 10:45 a.m.; however, they were not documented on the E-MAR as given to the Resident. The RNS confirmed they were not documented and therefore two oxycodone tablets were unaccounted for. 8b. A review of Resident 330's clinical record indicated a physician's order, dated 1/3/24, for Norco (a controlled medication to treat moderate to severe pain) 10/325 mg 1 tablet by mouth every 6 hours as needed for moderate to severe pain. During a concurrent interview and record review on 01/10/24, at 02:46 p.m., with the RNS, a review of the Count Sheet for Norco and the January 2024 E-MAR for Resident 330 indicated the nursing staff signed out one tablet of Norco 10/325 mg on 1/2/24 at 8:20 p.m. and 1/9/24 at 9:21 a.m. but did not document the administration on the E-MAR. The RNS confirmed they were not documented and acknowledged two Norco tablets were unaccounted for. 8c. A review of Resident 57's clinical record indicated a physician's order, dated 9/10/23, for tramadol (a controlled medication to treat moderate to severe pain) 50 mg 1 tablet by mouth every 6 hours as needed for pain. During a concurrent interview and record review on 01/10/24, at 02:57 p.m., with the RNS, a review of Resident 57's Count Sheet for tramadol 50 mg and the January EMAR indicated one tablet of tramadol 50 mg was signed out for Resident 57 on 1/6/24 at 1:40 a.m. but not documented on the E-MAR. The RNS confirmed they were not documented and acknowledged one tramadol tablet was unaccounted for. During a review of facility's policy and procedure titled, Documentation of Medication Administration, revised on November 2022, P&P indicated, 1.A nurse . documents all medications administered to each resident on the resident's medication administration record (MAR) and 2. Administration of medication is documented immediately after it is given.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 400) was free from significant medication errors when Licensed Vocational Nurse 8 (LVN 8) administered multiple doses of unprescribed medications, including opioid medications (a group of medications which are federally regulated substances used for pain control with a potential for physical or psychological dependence) to Resident 400. This failure resulted in Resident 400's hospitalization for excessive sedation and respiratory failure (inadequate breathing efforts) requiring mechanical ventilation (machine used to provide artificial breathing), a tracheostomy (a surgically created opening through the neck into the trachea, also known as the windpipe), a gastrostomy (a tube surgically inserted through the skin into the stomach for delivery of nutrients and/or medications), and encephalopathy (abnormal deterioration of brain function) from the opioid medications overdose. Findings: During a review of Resident 400's Admission Record dated 12/22/23, the Admission Record indicated Resident 400 was admitted to the facility in 2008 for stroke (brain tissue death resulting in brain function impairment), hemiplegia (the loss of muscle function on one side of the body), hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), dysphagia (difficulty swallowing), heart failure and muscle weakness. During a review of Resident 400's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 11/10/23, the MDS indicated Resident 400 had a score of 13 on the Brief Interview for Mental Status. (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 400 was able to be understood and could understand others. The MDS indicated Resident 400 required setup assistance only for eating. The MDS indicated Resident 400 required supervision for oral and personal hygiene such as combing hair, washing hands and face. During a review of Resident 400's, Order Summary Report, Active Orders as of 12/18/23, dated 12/18/23, the Report indicated an order for a regular texture diet. The Report indicated Resident 400 had orders to take medications and food by mouth. The Report indicated Resident 400 had no active orders for baclofen (muscle relaxant medication which can cause drowsiness and shallow breathing), hydrocodone-acetaminophen (an opioid medication), methadone (an opioid medication) or Eliquis (medication to prevent blood clots which can occlude blood vessels leading to stroke or heart attack). During a review of Resident 1's Admission Record dated 12/28/23, the Admission Record indicated Resident 1 was admitted to the facility in 2013 for atrial fibrillation (irregular heart rhythm which can lead to stroke) and chronic pain. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had a BIMS score of 14. The MDS indicated Resident 400 had adequate vision and was able to be understood and could understand others. During a review of Resident 1's Order Summary Report, Active Orders as of 12/28/23, dated 12/28/23, the Report indicated Resident 1 had medication orders for: baclofen 20 mg (milligram, a unit of measurement) oral tablet, three times a day; hydrocodone-acetaminophen 10-325 mg oral tablet, five times a day; Eliquis 5 mg oral tablet, twice a day; and methadone 10 mg oral tablet, four times a day. During a phone interview on 1/2/24, at 4:40 p.m., with LVN 8, LVN 8 stated on 12/16/23, at 9:00 a.m., she was performing a medication pass for Resident 400 and Resident 1, who shared a room. LVN 8 stated she checked the identity of both residents and prepared both of their medications in separate medication cups. LVN 8 stated she took a medication cup to Resident 400's bedside and watched Resident 400 take the medications, and then left the room. LVN 8 stated 30-40 minutes later, Resident 1 told LVN 8 the medications LVN 8 had left on Resident 1's overbed table did not belong to Resident 1. LVN 8 stated she realized she had accidentally switched the medications and had administered Resident 1's medications to Resident 400. LVN 8 stated Resident 400 had not received her morning medications of metformin (a medication to decrease blood sugar) and amlodipine (used to decrease blood pressure), and aspirin (to prevent blood clots), but had received Resident 1's medications which included methadone, hydrocodone-acetaminophen, Eliquis, and baclofen. LVN 8 stated she called the nurse practitioner (NP) and informed the NP that Resident 400 had received Resident 1's medications; the NP told LVN 8 to monitor Resident 400. During a concurrent phone interview and record review on 1/5/24, at 10:40 a.m., with LVN 8, Resident 1's Controlled Substance Accountability Sheet for methadone 10 mg tab and hydrocodone-acetaminophen 10-325 mg tablet, dated December 2023, was reviewed. LVN 8 stated on 12/16/23, Resident 400 had received two doses of methadone 10 mg at 9:00 a.m., and she recorded the two doses on 12/16/23, at 1:00 p.m. under Qty [quantity] destroyed/wasted of the sheet. LVN 8 stated Resident 400 had received two doses of hydrocodone-acetaminophen 10-325 mg at 9:00 a.m., and she recorded the two doses on 12/16/23, at 1:00 p.m. under Qty destroyed/wasted of the sheet. LVN 8 stated Resident 400 had also received the 9:00 a.m. and 1:00 p.m. dose of baclofen during the 9:00 a.m. medication pass. LVN 8 stated the doses were documented under destroyed/wasted because the doses had not been given to Resident 1. LVN 8 stated, at Resident 1's request, LVN 8 left both the 9 a.m. and 1 p.m. doses of hydrocodone-acetaminophen, methadone, and baclofen at Resident 1's bedside for the 1 p.m. doses to be self-administered later in the day. During a concurrent observation and interview on 12/28/23, at 12:06 p.m., with Resident 1, Resident 1 lay in bed with an overbed table across her lap. A palm-sized box with a hinged lid was on the overbed table. Resident 1 stated she had been Resident 400's roommate on the morning of 12/16/23, when LVN 8 came into the room with both Resident 400's and Resident 1's morning medications and placed the medications on the residents' overbed tables. Resident 1 stated LVN 8 left the room before either resident had taken the medications. Resident 1 stated she noticed while sorting the medications left at her bedside, that the medications were not the correct prescribed medications so Resident 1 called for the nurse. Resident 1 stated she told LVN 8 the medications left at her bedside were not her medications when LVN 8 answered the call bell about 30 minutes later. Resident 1 stated her morning medications included baclofen, hydrocodone-acetaminophen, methadone and Eliquis. Resident 1 stated LVN 8 would leave both the 9 a.m. and the 1 p.m. doses of methadone, hydrocodone-acetaminophen, and baclofen during the 9:00 a.m. medication pass at Resident 1's bedside, so Resident 1 would place the 1 p.m. doses in the hinged box on the overbed table for later self-administration. Resident 1 stated LVN 8 had not verified either Resident 400 or Resident 1's identities before leaving the medications at their bedsides or told either resident the names of their medications. During a concurrent interview and record review on 12/28/23, at 12:39 p.m., with Administrator (Admin) and OM, Resident 400's, Situation, Background, Assessment, Recommendation, Summary, (SBAR, a communication tool to summarize relevant medical information for changes in condition or unusual incidents) by LVN 8, dated 12/16/23, at 10:30 a.m., was reviewed. The SBAR indicated Resident 400 had a change in condition related to a medication error. OM stated the SBAR note indicated at 9:00 a.m., LVN 8 prepared Resident 400 and Resident 1's medications on the medication cart and took Resident 1's medications to Resident 400 and Resident 400 took Resident 1's medications. The SBAR indicated LVN 8 gave Resident 400's medications to Resident 1 but left the room before Resident 1 took the medications. The SBAR indicated after 30 minutes, Resident 1 informed LVN 8 the medications left with Resident 1 were not the correct prescribed medications. OM stated the SBAR indicated the NP was notified of the medication error and LVN 8 was given instructions to monitor Resident 400. During a phone interview on 12/28/23, at 12:23 p.m., with the NP, the NP stated in the morning of 12/16/23, NP received a text message from a facility staff member about Resident 400 receiving the wrong medications. NP stated she instructed the staff member to call the director of nursing (DON) and to monitor Resident 400. NP stated that was the extent of NP's involvement; NP had not done any follow-up or contacted anyone else after giving those instructions. During a concurrent interview and record review on 12/28/23, at 12:31 p.m., with Admin, the Admin presented a phone screenshot of LVN 8's text messages with NP. The text message indicated LVN 8 informed NP that Resident 400 had received baclofen, methadone, acetaminophen and Eliquis; NP responded with instructions to call the DON and monitor Resident 400. During a phone interview on 12/28/23, at 11:49 a.m., with Licensed Vocational Nurse 9 (LVN 9), LVN 9 stated she had worked the 3 p.m. to 11 p.m. shift on 12/16/23. LVN 9 stated that during the change of shift report on 12/16/23, at 3:00 p.m., LVN 8 reported Resident 400 had taken Resident 1's medications in the morning and needed to be monitored. LVN 9 stated Resident 400 was verbally responsive and had stable vital signs from the beginning of the shift until dinner time. LVN 9 stated at dinner time, a certified nursing assistant (CNA) came to LVN 9 and said Resident 400 was unresponsive, so they went to Resident 400's room. LVN 9 stated attempts to awaken Resident 400 were unsuccessful, and upon checking Resident 400's vital signs, Resident 400's oxygen saturation was 78-80%. (Oxygen saturation is a measurement of oxygen in the blood, expressed as a percentage, with 100 percent the maximum amount of oxygen possible, and normal values greater than 90%.) LVN 9 stated Resident 400 was given supplemental oxygen through a non-rebreather mask (an external mask worn over the nose and mouth to provide 100% oxygen), while 9-1-1 was called for emergency transport to the hospital. During a concurrent interview and record review on 12/28/23, at 12:39 p.m., with Admin and OM, Resident 400's nursing progress notes, for 12/16/23 to 12/17/23, were reviewed. A nursing SBAR progress note by LVN 9, dated 12/16/23, at 6:00 p.m., indicated at 5:28 p.m., Resident 400 had a situation of unresponsiveness different than usual with an oxygen saturation of 78-80% and a respiratory rate of seven (number of breaths per minute, normal respiratory rate is 12 to 18 breaths per minute). The SBAR indicated LVN 9 assessed Resident 400's breathing as labored or rapid breathing, with general weakness and altered level of consciousness. A nursing progress note by LVN 9, dated 12/17/23, at 12:45 a.m., indicated, at 5:28 p.m., Resident 400 was unresponsive to multiple attempts to rouse Resident 400. The note indicated Resident 400 had an oxygen saturation of 88% while using the non-rebreather mask. The progress note indicated at 5:46 p.m., the resident was taken to the emergency room . During a record review of Resident 400's hospitalization record, an emergency physician's Provider Note dated 12/16/23, at 7:29 p.m., indicated Resident 400 was transported by ambulance to the emergency room , at 6:02 p.m., and was diagnosed with altered mental status (term used to refer to a change in consciousness), opioid overdose and apnea (cessation of regular breathing). The Provider Note indicated Resident 400 had accidentally received methadone and hydrocodone-acetaminophen. The Provider Note indicated Resident 400 had a Glasgow Coma Scale score of three. (Glasgow Coma Scale is an assessment tool to determine purposeful response to stimuli scored on a scale of one to 15 with a score of 15 indicating normal function, and 3-14 indicating abnormal function. A score of three indicates no eye opening, verbal or motor response to stimulus.) The provider note indicated Resident 400 was intubated (a tube is placed into the windpipe through the mouth or nose) and placed on mechanical ventilation (machine used to provide artificial breathing), and the decision was made to admit Resident 400 to the intensive care unit for further evaluation and management. During a record review of Resident 400's hospitalization record, a critical care physician's History and Physical (H&P), dated 12/16/23, at 8:38 p.m., indicated Resident 400 was diagnosed with accidental opiate overdose, acute respiratory failure, and encephalopathy from the opiate drug overdose. The H&P indicated admission to the critical care unit was necessary for further evaluation and management. During a record review of Resident 400's hospitalization record, a critical care Physician Progress Note, dated 1/1/24, indicated Resident 400 had a tracheostomy placed 12/28/23, and required a mechanical ventilator due to apnea. The Progress Note further indicated Resident 400 required a gastrostomy tube, placed 12/28/23, for delivery of medications and nutrition. During a review of facility policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, The individual administering medications verifies the resident's identity before giving the resident his/her medications .and checks the label three times to verify the right resident, right medication, right dosage and right time .before giving the medication medications are administered within one hour of their prescribed time .medication administration times are determined by resident need and benefit, not staff convenience. During a review of facility's P&P titled, Administering Oral Medications, dated 10/2010, the P&P indicated nursing staff were expected to, confirm identity of resident .remain with the resident until all medications have been taken.

Based on observation, interview, and record review, the facility failed to give [MEDICATION NAME] (MS) ([MEDICATION NAME] sulfate is a controlled substance to treat moderate to severe pain) as ordered for breakthrough pain for one of 15 sampled residents (Resident 12) resulting in Resident 12 having unrelieved pain. Resident 12 (a resident under Hospice care program, end of life care) pain received MS 5 mg(milligrams) every 6 hours around the clock which did not completely relieve his pain. His pain was not assessed and his prn ( give as necessary ) order for MS 20 mg was only given once in 10 days. Findings: On 7/9/15, review of the clinical record showed that Resident 12 was admitted with multiple [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a comprehensive assessment of cognitive, functional and psychosocial status), dated 6/03/15, showed that Resident 12 able to recall information, able to reason, and able to understand communication. Review of Physician Orders, dated 7/1/15, showed that Resident 12 had 2 orders for [MEDICATION NAME] sulfate(MS) to be given for pain: 1) MS liquid 20 mg(milligrams)/ml (milliliters), give 5 mg/0.25 sublingually (underneath the tongue) around the clock every 6 hours (12:00 midnight, 6:00 a.m., 12 noon and 6:00 p.m.) and 2) an older order dated 2/27/15, for MS 20 mg/ml every 3 hours prn (give as necessary) for shortness of breath/pain. During an observation and concurrent interview on 7/9/15 at 7:50 a.m., Resident 12 was lying on his right side with head of the bed elevated with a grimace on his face. Resident 12 stated, I am hurting on my buttocks. When asked if he told the staff about his pain, Resident 12 stated, I told the nurse. In an interview on 7/9/15 at 7:52 a.m., Licensed Vocational Nurse (LVN) 3 stated, He had his pain medication at 6:00 a.m. He was on routine [MEDICATION NAME] for pain. I will check if he has pain medication that I can give. In an observation and concurrent interview on 7/10/15 at 7:25 a.m., Resident 12 was lying on his back with the head of the bed elevated. Resident 12 stated, I am hurting so much, this people don't care. When Registered Nurse (RN) 1 was informed of Resident 12's complaint of pain, RN 1 stated, He got his routine pain medication 30 minutes ago. In a follow up observation, on 7/10/15 at 8:20 a.m., while staff were assisting Resident 12 with breakfast, Resident 12 complained about his pain on his buttock. When RN 1 was asked about Resident 12's complaint of pain on his buttock, RN 1 said Resident 12 had order for [MEDICATION NAME] 5mg; administer 20mg/ml every 3 hours as needed for pain. RN 1 stated, I did not give him pain medication because he just got his pain pill at 6:00 a.m. I want to check first if the pain medication given earlier was effective. I will call the Physician if he can give me stat order of pain medication. In an interview on 7/10/15 at 10:08 a.m., Certified Nursing Assistant (CNA) 2 stated, Resident 12 was complaining of pain on his buttocks lately and more often when we turn him from side to side. Of course we notify the nurse, but he continues to complain of pain. In a follow up observation and interview on 7/10/15 at 10:30 a.m., Resident 12 stated, I did not get my pain medication yet. I am hurting so much. When Resident 12 was asked about the severity of his pain, using a scale of 0-10 with ten being the worst, Resident 12 said his pain was 8. LVN 5 was again notified of Resident 12's pain and said You did not tell me that he is in pain. I will give him his pain medication now. In an interview on 7/10/15 at 12: 15 p.m., Hospice Nurse stated, I told them already, to give him (Resident 12) his PRN pain medication because he is hurting. How could I increase the dose of his pain medication if the staff is not assessing the pain? In a follow up interview on 7/10/15 at 1:15 p.m., Resident 12 was awake on his right side. Resident 12 stated, This sore in my buttocks is painful. I am tired hurting. Review of Resident 12's July Medication Administration Record [REDACTED]. was given every 6 hrs as ordered, but the MS 20mg/ml prn every 3 hrs was only given on 7/1/15. Review of Resident Care Plan Altered Comfort (Pain) and Pain Assessment dated 2/27/15, showed Resident 12 was in pain secondary to terminal illness. Care plan approaches included to monitor and report signs and symptoms of pain i.e. flinching, moaning, crying, facial expression, position for comfort, allow for rest period, assess effectiveness of PRN medication and notify MD if needed, encourage resident to report pain, routine pain medication as ordered. Evaluate effectiveness on MAR indicated [REDACTED]. Review of July Pain Assessment Flow Sheet on 7/10/15, showed there was no pain assessment between 7/1/17 and 7/10/15. There was no indication Resident 12 received the prn [MEDICATION NAME]. Review of facility' policy and procedure titled Hospice Care revised 10/14, showed that the licensed nurse will oversee that all medications, treatments, and other procedures are provided in accordance with standards of practice and as per order of the primary care physician, the licensed nurse in charge of the resident, in conjunction with the Director of Nurses is responsible for coordinating hospice and non-hospice care, and for integration and implementation of supportive hospice services into comprehensive care plans of the facility.

Based on observation, interview and record review, the facility failed to provide supervision and assistive device to prevent accidents for four of 15 sampled residents (5, 9, 10, and 11) 1. Resident 10 was not provided supervision and smoking apron while smoking in the smoking area on 6/26/15 and sustained a partial thickness burn (a second degree burn, it occurs when the first layer and some of the second layer of the skin are burned) to his left thigh. The facility failed to conduct an investigation regarding the incident and Resident 10's smoking care plan and assessment were not updated. 2. Resident 5 and Resident 9 were not provided proper safety equipment(smoking aprons and availablity of a fire blanket) and supervision. Staff and residents were not aware of safety equipment availability and location. 3. Resident 11, who had a history of [REDACTED]. These failed practices resulted in Resident 10 sustaining a burn, and an increased risk of smoking related injuries for all smoking residents and the potential for serious harm from a fall for Resident 10. Findings: 1. A review of Resident 10's clinical chart, a Change of Condition Assessment form dated 6/26/15 at 9 a.m., indicated that Resident 10 was found with a hole in his pants on the left thigh and a partial thickness burn wound to his left thigh measuring 2 cm (centimeters) (width) x 1.7 cm (length) x. 1 (depth). During an interview on 7/10/15 at 9:50 a.m., Licensed Vocational Nurse 4 (LVN 4) stated she was the charge nurse for Resident 10 on 6/26/15. LVN 4 said Resident 10 was brought into the facility from the smoking area and she saw a hole in Resident 10's pants stated looks like from cigarette and found the burn wound on the left thigh. Review of Resident 10's Safe Smoking Assessment re-assessment dated [DATE], indicated that there are concerns about resident's ability to smoke independently due to possible side effects of cardiac (heart) medictions which may cause dizziness. It indicated Resident 10 needed minimal supervision and smoking apron. Review of Resident 10's Smoking Care Plan dated 5/28/15 indicated that Resident 10 may smoke under supervision and included use of smoking apron as an intervention. A review of f Resident 10's Safe Smoking Assessment dated 5/30/15, indicated Resident 10 was not able to hold cigarette without endangering others and he was not able to safely extinguish the cigarette and place it in the proper receptacle. During an interview on 7/10/15 at 9:55 a.m., the Environmental Service Coordinator (ECS) stated the maintenance department is assigned to sit with Resident 10 in the smoking area at 9 a.m. ECS stated he documents on the log (Smoking Watch Log) when he supervises residents in the smoking area. Review of the log indicated there were no documentation on 6/26/15 indicating the residents were supervised on that day. ECS stated he missed that day and did not know why there was no documentation that he supervised the smoking area. He further stated he was not aware Resident 10 was involved in an incident on 6/26/15. During an interview on 7/10/15 at 10:15 a.m., the Director of Nursing services stated there was no investigation done by the Interdisciplinary team regarding Resident 10's incident on 6/26/15 because she was not aware there was an incident. She also stated there was no smoking assessment done after the 6/26/15 incident. During an interview on 7/10/15 at 4:30 p.m., Registered Nurse 3 (RN 3), also the Nurse Consultant, reviewed Resident 10's Smoking Care Plan dated 5/28/15, and stated it is Resident 10's current smoking care plan and it was not updated after the 6/26/15 incident. Review of the facility's undated policy Smoking, indicated that the interdisciplinary team will ensure assessment is completed upon admission, quarterly, annually and upon significant change and interventions related to safe smoking. It further stated that staff will make reasonable accommodation to assist residents identified as unsafe, to smoke with supervision. Review of the facility's 2013 policy Interdisciplinary Team Meeting Standard indicated that the meeting process allows the team to review residents' care risk areas, ensure compliance with policy and procedure and determine root cause and effective intervention. Review of the facility's 10/14 policy Care Plan Interdisciplinary indicated that the Interdisciplinary team will review care plan and update individual care plan as necessary. 2. During an initial tour observation and concurrent interview on 7/6/15 at 10:10 a.m., four residents were smoking on the facility's back porch/designated smoking area. All of the residents were smoking without smoking aprons and there was no fire blanket available in the smoking area. The Social Service Coordinator (SSC) confirmed and stated, They (residents)are non-compliant. A sign with smoking rules was observed posted in the smoking area and read: Smoking period is as follows: 9 am, 2 PM, 4 PM, and 7 PM. Housekeeping Designee 9 am, Activities Designee 2 pm, CNA Designee at 4 pm, and 7 pm. Facility will provide the fire extinguisher, fire blanket, apron, smoking sign, and ash tray in the designated smoking area. On 7/6/15 at 10:15 a.m., in an interview, the Environmental Services Coordinator (ESC) stated, The smoking aprons were in the box and kept in my office. On 7/6/15 at 10:16 a.m., in an interview, Licensed Vocational Nurse (LVN) 3 stated, Residents should be supervised while outside smoking. When asked where the smoking aprons were kept, LVN 3 stated, I don't know where we keep the smoking aprons. During observations on 7/6/15 at 3:30 p.m., 3:45 p.m., and 4:20 p.m., there were residents smoking on the facility's back porch/designated smoking area without staff supervision present and without smoking aprons. In an interview on 7/6/15 at 4:20 p.m., Certified Nursing Assistant (CNA) 6 said that residents should be supervised and wearing smoking aprons while outside smoking. When asked where to get a smoking aprons he said I do not know where to get one. During observations and concurrent interview on 7/7/15 at 9:45 a.m. and 10:00 a.m., Residents 5 and 9 were smoking on the facility's back porch/designated smoking area without staff supervision and no smoking apron. When asked if they are aware of the smoking apron, Residents 5 and 9 both stated, We were not offered a smoking apron. Resident 5 stated, We were not aware that we are supposed to wear an apron while smoking, I never saw one, and I was never offered a smoking apron. 3. A review of the clinical record of Resident 11 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a resident assessment tool used to guide care) indicated a wheelchair was used for ambulation, with a need for total assistance when she was transferred from one surface to another. A review of the Interdisciplinary Team (IDT) Progress Notes indicated Resident 11 had experienced multiple falls, including falls from her wheelchair. After a fall on 6/8/15, the IDT, Resident 11's physician, and responsible party (RP) agreed on interventions which included: a tilt back seat cushion for the wheelchair; seat alarm for the wheelchair; and the use of a self-release seat belt at all times when Resident 11 was in the wheelchair. During an observation in the main hallway, on 7/9/15, at 4:25 p.m., Resident 11 was sitting in a slightly tilted back wheelchair, seat alarm on, but the seat belt was not on. When questioned about the seat belt, the Certified Nursing Assistant (CNA 8) put the seat belt on Resident 11, and stated this was the first time she had seen Resident 11 since starting her shift at 3 p.m. CNA 8 did not know who had helped Resident 11 into her wheelchair, or how long the seat belt had been off. A review of the care plan titled, Falls, revised 6/15/15, indicated Resident 11 was to have the self-release seat belt in use when in the wheelchair, with the nurse to monitor its use every shift.

Based on interview, and record review the facility failed to protect one (Resident 18) of 15 additionally sampled residents, from physical and emotional harm. Resident 18 reported to staff that another resident (24) ran into him with her electric wheelchair and knocked him out of his chair. Resident 18 was assaulted the next day by the same resident (24). This failure resulted in Resident 18 feeling unsafe in the facility. Findings: Record review on 9/8/14 showed Resident 18 was admitted on [DATE] for wound care and rehabilitation following a [MEDICAL CONDITION]. In an interview on 9/9/14 at 1:00 p.m., Resident 18 was asked about his care at the facility and replied that he did not, " Feel safe here." Resident 18 described an incident when another resident, (Resident 24), came into his room in an electrically powered wheelchair and ran him, "Off of his wheelchair and onto the railing of the balcony," outside of his room. Resident 18 stated that he reported this to the staff but felt that the staff, "Swept the incident under the rug." Resident 18 stated that there was a second incident the next day with Resident 24. Resident 24 was involved in a verbal and physical argument with Resident 25 in the hallway directly next to Resident 18's room. Resident 18 had been outside having a cigarette. He was trying to get past Resident 24 and 25 so he could enter his room and as he passed Resident 24, "Hit me in the face." In an interview on 9/9/14 at 12:05 p.m., the Social Services Coordinator, (SSC) was asked to describe the sequence of events regarding Resident 18. The SSC stated that Resident 18 had been, "Run off of his chair by another resident in a powered wheelchair on August 27th, 2014. The Director of Nursing did not find out about it until August 28th. We told both residents to stay away from each other. They were told to stay on each other's side of the building since their rooms are on opposite sides." The SSC was then asked to describe the incident regarding Resident 18 getting hit in the face by Resident 24. The SSC stated that, at approximately 9:30 p.m. on August 28, 2014, there was a physical and verbal fight between Resident 24 and another resident in the hallway. Resident 24 was still in her electric wheelchair. At that same time, Resident 18 was coming down the hall trying to get into his room. As Resident 18 passed by, Resident 24 punched him in the face." The SSC was then asked why Resident 24 was at that end of the hall since she had been told not to enter that area. The SSC stated that she, "Did not know. She, (Resident 24), was still in the electric wheelchair." The SSC was then asked to describe the steps in place to prevent Resident 24 from moving to the opposite side of the building and potentially injuring other residents. The SSC stated that Resident 24 is currently unable to, "Use her wheelchair as a weapon. We gave her a manual wheelchair which she cannot use without assistance from staff. We took the electric wheelchair away on August 31, 2014." The SSC was asked why it took 3 days before staff removed the electric wheelchair. The SSC stated "I do not know." In an interview on 9/10/14 at 8;30 a.m., the Director of Nursing, (DON), was asked to describe the steps taken following the first incident when Resident 24 ran into Resident 18 with her wheelchair. The DON stated that, following the first incident, she met with Resident 24 and, " Discussed the policy regarding electric wheelchair use." The DON was then asked why it took 3 more days for staff to replace the electric wheelchair with a manual one. The DON stated that she believed the first incident happened on a Friday and she was, "Off on Saturday and Sunday. I think we took it away that Friday but I am not sure." Record review of Resident 24's nursing notes dated 8/28/14 at 9:10 p.m. showed that Resident 24 had a verbal and physical altercation with another resident, Resident 25. Resident 25 yelled to Resident 24, "Stop coming to my side!" (of the building) Record review of the facility's policy and procedure titled, "Electric Wheelchair", and dated May, 2008, showed that, if a resident is not able to safely operate and maneuver the electric wheelchair as evidenced by related accidents or incidents, then attempts will be made immediately by the facility administrator and Director of Nurses or designees to regulate the use of the electric wheelchair. Record review of the facility's policy and procedure titled, "Abuse and Neglect": Measures to Prevent, showed that, if the suspected abuser is another resident, staff would separate residents and ensure the safety of the affected resident; and monitor residents closely to prevent a reoccurrence.

Based on observation, interview and record review, the facility failed to follow physician's order and apply a seat belt to one (Resident 15) of 15 sampled resident while up in a wheelchair, resulting in Resident 15 falling out of her wheelchair and sustaining a facial abrasion and being sent to the hospital. Findings: On 9/10/14. at approximately 9:00 a.m., observation showed Resident 15 was lying on the corridor floor near her wheelchair in close proximity of Nursing Station 2. Resident 15 had a facial laceration. LVN 1 and others were in attendance to the resident. There was no seat belt observed on the chair or in close proximity to the resident. The resident was later transferred to the acute care hospital for subsequent care and evaluation. The review of the Nurse's Notes dated, 9/10/14 and entry time, 9:00 a.m. showed, "Resident alert and verbally responsive was up on w/c...near to Nurse's Station II outside across to her room and fell from her w/c. Resident hit her head with the floor and got laceration. Checked for any neck and back injuries. Kept on the floor with head on pillow and waited on EMT's to assist. Resident sent to hospital. Review of the facility's record showed the facility admitted Resident 15 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the "Evaluation" section dated, 6/4/14 of the "Occupational Therapy Discharge Summary" (services from 6/2/14 - 6/20/14) showed, "Patient demonstrates total assist for ongoing/frequent supervision and (reposition) in w/c (wheelchair) d/t (due to)...R/L (right/left) trunk leaning resulting in increased risk of fall..." The review of the current "Functional Status"section of the quarterly MDS (assessment tool) dated, 7/1/14 and Weekly Summary dates, 9/9/14 showed the resident was totally dependent on staff for ADL (activities of daily living) that included transfer and ambulation. The review of current monthly orders dated, September, 2014 showed orders that included, "Seat belt while in wheelchair for safety and prevention on unassisted transfers On 9/11/14 at 9:45 a.m., during an interview, LVN 1 was asked about the "seat belt" application order. LVN 1 indicated that the resident was supposed to have the "lap belt" on when up in the chair because "she (Resident 15) likes to lean forward to adjust her pants and fidgets around." LVN 1 further stated she did not see it applied to the resident on the date of the fall incident. On 9/11/14 at 9:55 am, Housekeeping Technician stated she witnessed the resident fall approximately 10 steps away from her while she (Housekeeping Technician) was vacuuming the corridor floor carpet near the nurse's station. Housekeeping Technician stated she saw Resident 15 lean forward without a belt and fell on to the floor.