Every finding on record at Encino Hospital Medical Center D/P SNF

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. A plastic scoop was left in a food bin, in the dry storage area, during the initial kitchen tour. b. The facility failed to ensure food was labeled with a date, stored correctly and disposed of upon expiration. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in three of three medically compromised residents who received food from the kitchen. Findings: a. During an initial kitchen tour observation on 12/1/2025 at 9:16 am in the dry storage area, a plastic scoop was left in a large bin labeled flour. The bin contained white powdery material, and the scoop was covered in that white powdery material. During a concurrent observation and interview on 12/1/2025 at 9:19 am with the Director of Food and Nutrition (DFN), the DFN looked at the food bin with the white powdery material and stated scoops should never be left in any dry good bin. The DFN stated this particular bin was flour and once her staff uses any dry good, the scoop must be removed and stored separately to prevent the growth of bacteria and cross contamination. During a review of the facility's policy and procedures (P&P), titled, Food Storage, last reviewed on 2/17/2025, the P&P indicated the purpose is to ensure safe storage of food in order to prevent occurrence of foodborne illness. The P&P further indicated that scoops are never to be stored inside containers in the dry storage area. b. During a concurrent observation and interview on 12/1/2025 at 9:20 am with the Dietary Aid (DA), in the facility kitchen, ten bags of frozen vegetables were observed to be opened and did not have a label with the open date and expiration date. The DA stated that all food items are to be labeled with the date they were opened and a new expiration date. The DA stated that without an open date label on the food items, the staff would have no way of knowing when they were opened, and therefore the items should not be given to the residents because their (food) safety and freshness could not be verified. The DA stated residents can get sick from eating expired food. During an interview on 12/1/2025 at 9:30 am with the Director of Food and Nutrition (DFN), the DFN stated all food items should be labeled with an open date and expiration date that is one month after the date of opening. During a review of the facility's policy and procedure (P&P) titled, Food Labeling and Dating, dated 2/17/2025, the P&P indicated, the purpose of food labeling and dating is To ensure that food is labeled and dated in accordance with accepted food safety standards to prevent foodborne illness. The P&P also indicated, All stored foods shall be labeled to indicated type of product and date prepared or date the product is to be discarded.

Based on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) by failing to ensure the urinary catheter (a thin flexible tube that is inserted into the bladder to help drain urine) collection bag tubing was not looped or coiled to allow the urine to flow freely into the collection bag for two of two residents (Resident 1 and Resident 12) reviewed under the urinary catheter care area.This failure had the potential to result in the backflow of urine into the residents' bladders, which can cause urinary tract infections (UTI- an infection in the bladder/urinary tract). Findings: a. During a review of Resident 12's admission Record, the admission Record indicated, the facility initially admitted Resident 12 to the facility on 6/1/2008 and readmitted the resident on 9/30/2025. The admission Record indicated Resident 12 has a history of respiratory failure (a life-threatening condition where the lungs cannot effectively exchange gases; often requiring oxygen or mechanical ventilation), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) disorder, dysphagia (difficulty swallowing), urethral stricture (a narrowing of the urethra, the tube that carries urine out of the body, caused by scar tissue), obesity, immobility with chronic (long term) contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) with hypercoagulable state (increased risk for developing blood clots). During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 12 was in a persistent vegetative state (is a condition where a person is alive or awake but not aware of themselves or their surroundings) with no discernible consciousness. The MDS indicated Resident 12 was utilizing an indwelling urinary catheter appliance. During a review of Resident 12's Plan of Care, dated 11/14/2025, the Plan of Care indicated Resident 12 has a potential for infection related to the presence of indwelling foley (a type of urinary catheter) catheter due to urinary retention. The goal was to prevent signs and symptoms of UTI. The interventions included to check and ensure the indwelling catheter tubing is not kinked and there is free flow of urine at all times. During a review of Resident 12's Physician Orders, the Physician Orders indicated an order dated 9/30/2025 for an indwelling urinary catheter #18 x 10 milliliter (ml- a unit of measurement for fluid volume) due to dependent drainage. During a concurrent observation and interview on 12/1/2025 at 10:17 am with Certified Nurse Assistant 1 (CNA 1), in Resident 12's room, Resident 12's urinary catheter tubing was looped preventing the free flow of urine through the tubing and into the collection bag. CNA 1 stated the urinary tubing should not be looped and proceeded to move Resident 12's collection bag further towards the foot of Resident 12's bed to allow the tubing to uncoil and for urine to flow freely into the collection bag. CNA 1 stated the backup of urine in the tubing can cause Resident 12 to have a UTI. During an interview on 12/1/2025 at 10:45 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated indwelling urinary catheter tubing should not be coiled or looped to allow for the free flow of urine to prevent UTI's from occurring. During an interview on 12/3/2025 at 8:45 am with the Nurse Manager (NM), the NM stated that it is important to ensure the indwelling urinary catheter tubing is not coiled or looped to allow for the free flow of urine into the collection bag. The NM stated, if the urine is not draining into the collection bag, it could back up into the resident's bladder and cause a UTI. b. During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 to the facility on 7/19/2018 and readmitted the resident on 1/1/2025. Resident 1 has a past medical history including chronic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), motor vehicle accident with traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and tracheostomy (a surgical procedure to create an opening (stoma) in the neck directly into the trachea (windpipe). During a review of Resident 1's MDS, the MDS indicated Resident 1 was in a persistent vegetative state with no discernible consciousness. The MDS indicated Resident 1 was utilizing an indwelling urinary catheter appliance. During a review of Resident 1's Plan of Care dated 1/1/2025, the Plan of Care indicated Resident 1 has a potential for infection related to the presence of indwelling foley catheter due to urinary retention. The goal was to prevent signs and symptoms of UTI. The interventions included to check and ensure the indwelling catheter tubing is not kinked and there is free flow of urine at all times. During a review of Resident 1's Physician Orders, the Physician Orders indicated an order dated 12/02/2019 for an indwelling urinary Foley (type of urinary catheter that is inserted through the urethra and held in place by a balloon) catheter #20 x 10 ml placed for urinary retention as needed when plugged or dislodged. During a concurrent observation and interview on 12/1/2025 at 11:20 am with Certified Nurse Assistant 2 (CNA 2), in Resident 1's room, Resident 1's urinary catheter tubing was looped preventing the free flow of urine through the tubing and into the collection bag. CNA 2 stated the urinary catheter's tubing should be free of loops or kinks and proceeded to uncoil the tubing causing the urine to flow freely into the collection bag. CNA 2 stated back up of urine in the tubing can cause Resident 1 to have an infection. During an interview on 12/1/2025 at 10:45 am with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated indwelling urinary catheter tubing should not be coiled or looped to allow for the free flow of urine to prevent UTI's from occurring. During an interview on 12/3/2025 at 8:45 AM with the Nurse Manager (NM), the NM stated that it is important to ensure the indwelling urinary catheter tubing is not coiled or looped to allow for the free flow of urine into the collection bag. The NM stated that if the urine is not draining into the collection bag, it could back up into the resident's bladder and cause a UTI. During a review of the facility's policy and procedure (P&P) titled, Prevention of Catheter-Associated Urinary Tract Infections (CAUTI), dated 3/2024, indicated, the purpose of the policy is To improve patient safety and outcomes by preventing catheter-associated urinary tract infections. The P&P also indicated, to Maintain unobstructed urine flow . Maintain the catheter and collecting tube free from kinking.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered through a tube in the stomach) by failing to indicate with a label, the date and time the enteral feeding tubing was started for one of one sampled resident (Resident 18) investigated under the tube feeding care area. This deficient practice had the potential for administering expired enteral feeding which could place Resident 18 at risk for complications such as diarrhea (loose, watery stool) or vomiting leading to dehydration (loss or removal of water). Findings: During a review of Resident 18's Admission/Registration Record printed on [DATE], the Admission/Registration Record indicated the facility admitted Resident 18 on [DATE]. During a review of Resident 18's History and Physical (H&P) dated [DATE], the H&P indicated Resident 18's diagnoses included hypoxic brain injury (damage to the brain from not getting enough oxygen), ventilator (a machine that breathes for you or helps you breathe) dependent respiratory failure (a serious condition that makes it difficult to breathe on your own), and gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 18's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 18 was ventilator dependent and did not have the ability to make himself understood and understand others. The MDS indicated Resident 18 was completely dependent on facility staff for all of his needs. During a review of Resident 18's Physician Orders, the Physician Order indicated an order dated [DATE] for Jevity 1.2 (a brand name of EF) 80ml/hr (milliliters/hour - measurement of volume) x 16 hours via G-tube. During an observation on [DATE] at 8:18 am in Resident 18's room, Resident 18 was lying in bed. Observed an EF hanging on a pump and connected to Resident 18's G-tube. The tubing that was attached the EF to the G-tube did not have a label to indicate what date and time it was hung. During a concurrent observation and interview on [DATE] at 8:21 am in Resident 18's room with Licensed Vocational Nurse (LVN 2), LVN 2 looked at the EF tubing and stated the prior nurse either forgot to put a label on or the label fell off. LVN 2 stated the tubing must be labeled so other staff would know when the EF was started and that the tubing and EF must be discarded and changed every day to prevent spoilage and stomach issues. During an interview on [DATE] at 10:42 am in with Registered Nurse (RN 1), RN 1 stated all tubing, and EF are changed daily and the appropriate practice is to label each EF and tubing with the date and time it was started to prevent gastrointestinal (relating to the stomach and intestines) issues and possibly infection. During a review of the facility's Policy and Procedure, (P&P) titled Eternal Feeding via G or J tube, Continuous (Pump) last reviewed 2/2025, the P&P indicated formula may hang for 24 hours and the bag (feed) and tubing must be labeled with the date and time it was hung.

Based on interview and record review, the facility failed to ensure the facility's kitchen ice machine Daily Scoop Sanitizer log was completed daily to indicate the ice scooper was sanitized daily. This failure had the potential to result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) of harmful bacteria that could contaminate the ice and cause foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins) in three of three medically compromised and vulnerable residents who received food from the kitchen. Findings: During a concurrent interview and record review on 12/3/2025 at 11:00 AM with the Director of Food and Nutrition (DFN), the facility kitchen ice machine Daily Scoop Sanitizer Log, dated 12/2025, was reviewed. The log indicated, the sanitization of the ice machine scoop was not documented on 12/2/2025 and on 9/7/2025. The DFN stated the log is to be completed daily at the end of the day by the night shift. The DFN stated the night shift sanitizes the scoop by first washing it, then placing it into the sanitizer. The DFN also stated without the log documentation, there is no other way of knowing if the ice scoop was sanitized. The DFN stated if the ice scoop was not sanitized, it could be dirty, which could lead to a food safety and sanitization issue for the residents. During a review of the facility's policy and procedure (P&P) titled, Dispensing of Ice, dated 2/17/2025, the P&P indicated, the purpose of this policy is To dispense ice without contamination. The P&P also indicated, Sanitation of ice dispensing equipment will be maintained per established cleaning schedule . Scoop and container will be sanitized daily.

Based on interview and record review, the facility failed to conduct a timely and thorough investigation for one of one sampled residents (Resident 1) when a Certified Nurse Assistant 1 (CNA) allegedly pulled Resident 1 ' s wheelchair from Resident 1 therefore causing Resident 1 ' s to suffer a fall from the wheelchair on 10/14/2024 at 9:00 p.m. On 10/15/2024, Resident 1 was noted to have a purple bruise on her left buttock and Resident 1 reported body pain 3/10. This deficient practice had the potential to result in unidentified abuse affecting Resident 1 and therefore, the facility failure to conduct a thoroughly investigation of the alleged violation. Findings: During a review of Resident 1 ' s Admission Record (Face Sheet), dated 01/01/2024, the face sheet indicated that Resident 1 was admitted to the facility on [DATE] with a diagnose of respiratory failure (a serious medical condition that makes it difficult to breath on your own). The admission records also indicated that Resident 1 is receiving services in the sub-acute unit in room [ROOM NUMBER]/A. During a review of Resident 1 ' s Minimum Data Set [(MDS), a standardized assessment and screening tool], dated 6/17/2024, the MDS indicated under the Brief Interview for Mental Status (BIMS, is a short cognitive screening tool used to assess a person ' s cognitive functioning), Resident 1 had BIMS of 4 (equal to a decline in cognitive performance). During a review of Resident 1 ' s clinical records Social Services Note , dated 10/17/2024 at 1:55 p.m., the social services note indicated that the Social Worker (SW) was informed that the Resident 1 experienced a fall on 10/14/2024 at night 9:00 p.m. Some bruising on Resident 1 ' s arms but no fractures or major injuries. This note indicated that SW was instructed there was no need to file an Ombudsman (a person who investigates, reports on, and helps settle complaint) report by the Manager of the Sub-Acute Unit (MSAU). During a review of the SW note dated 10/21/2024 at 3:00 p.m., the SW note indicated that on 10/21/2024 during the meeting between the family member and the Manager of the Sub-Acute Unit (MSAU), that Resident 1 ' s family member was upset because no one called her to inform her about her mother ' s fall, Resident 1 ' s family member said that whether or not the fall was critical she should have been informed in order for her to be able to arrange for transportation. The Resident 1 ' s family member stated that she believed her mother (Resident 1) because this has been the second incident with that CNA 1. During an interview on 12/19/2024 at 2:25 p.m., in room [ROOM NUMBER] with the MSAU, the MSAU stated she was notified of the incident that occurred with the Resident 1 in room [ROOM NUMBER]A. The MSAU stated the facility did not report nor investigate the incident because neither she nor the Administrator at the facility considered the incident related to abuse. The MSAU stated it is a facility policy to report any allegations of abuse. The MSAU stated the facility should have reported the incident due to the circumstances and especially because Resident 1 did not feel safe around CNA 1 and complained of pain after the incident. The MSAU stated failing to report the incident is a violation of resident ' s rights, facility policy and state and federal regulations. The MSAU stated failing to report allegations of abuse places Resident 1 and other residents potentially at risk for undetected incidents of abuse within the facility. Furthermore, the MSAU stated the individual (CNA 1) should ' ve been suspended pending the outcome of the investigation. During a review of the facility's policy and procedure (P&P) titled, Abuse, Elder & Dependent Adult, dated 04/2024, the P&P indicated that all staff members are responsible for the reporting of any reasonable suspicion or of any witnessed or alleged abuse. By law, a supervisor or administrator cannot prevent a staff member from reporting elder or dependent adult abuse. Furthermore, the P&P indicated that all health practitioners and all employees in a long-term health care facility are mandated reporters and fill out an incident report, Suspected Dependent Adult/Elder Abuse Form (SOC 341), and other designated forms by the facility. During a review of the facility's policy and procedure (P/P) titled, Abuse, Elder & Dependent Adult, dated 04/2024, the P&P indicated that for instance that involve abuse all results in serious bodily injury, call the local law enforcement agency, long term care ombudsman, end the Department of Health services license and certification immediately but not later than two hours after the alleged incidents and within 24 hours for all other cases. Furthermore the policy and procedure indicated that if a staff member had been alleged to be involved in the act of abuse, that person will be suspended pending the investigation. The results of all the investigation must be reported to officials in accordance with state law (including to the state survey and certification agency) within five (5) working days of the incident and if the alleged violation is verified appropriate corrective action must be taken.

Based on interview and record review, the facility failed to report an alleged incident of physical abuse involving one of one sampled resident (Resident 1) to the long-term care ombudsman (a person who investigates, reports on, and helps settle complaints) office, the local law enforcement agency, and the Department of Health Services in accordance with State law and the facility ' s policy and procedures, within but not later than two hours of the alleged involved incident. This deficient practice resulted in the California Department of Public Health (CDPH) being unaware of this alleged abuse incident and potential injury to Resident 1, which could then had the potential for a delay in CDPH ' s investigation and other abuse allegations to go unreported at the same facility. Findings: During a review of Resident 1 ' s Admission Record (known as Face Sheet) dated 01/01/2024, the face sheet indicated that Resident 1 was admitted to the facility on [DATE] with a diagnose of respiratory failure (a serious medical condition that makes it difficult to breath on your own). The admission records also indicated that Resident 1 is receiving services in the sub-acute unit in room [ROOM NUMBER]/A. During a review of Resident 1 ' s Minimum Data Set [(MDS), a standardized assessment and screening tool], dated 6/17/2024, the MDS indicated under the Brief Interview for Mental Status (BIMS, is a short cognitive screening tool used to assess a person ' s cognitive functioning), Resident 1 had BIMS of 4 (equal to a decline in cognitive performance). During a review of Resident 1 ' s clinical records Nursing Progress Notes, dated 10/14/2024 at 9:10 p.m., the nursing note indicated that Resident 1 stated that she was bending down while in the wheelchair reaching for a bag when the Certified Nurse Assistant 1 (CNA) pulled the wheelchair from behind causing her to slide off and fall on her buttocks. Resident 1 stated that she hit her back on the front of the wheelchair. During a review of Resident 1 ' s clinical records document titled wound assessment, dated 10/15/2024, the document indicated left buttock bluish discoloration skin color is purple. This wound assessment document has a picture of the area described in the document. During a review of the SW note dated 10/21/2024 at 3:00 p.m., the SW note indicated that on 10/21/2024 during the meeting between the family member and the Manager of the Sub-Acute Unit (MSAU), the MSAU directed the SW that there was no need to file for an ombudsman report as this situation was addressed and both parties understood. During an interview on 12/19/2024 at 2:00 p.m. with SW 1 , SW 1 stated that on 10/17/2024 when the SW learned about Resident 1 ' s fall; SW stated she was instructed not to report this incident by the MSAU; however, SW went ahead and documented this in the Resident 1 ' s records about the directives received. SW stated that it is important to document this type of events. SW also added that there are several forms of abuse and physical abuse being one of those as well as financial, or sexual, or verbal abuse. SW stated that she understands the importance of reporting in a timely manner and to the proper agencies. During an interview on 12/19/2024 at 2:25 p.m., in the SW ' s office (room [ROOM NUMBER]) the MSAU stated she was notified of the incident that occurred with the Resident 1 in room [ROOM NUMBER]A. The MSAU stated the facility did not report nor investigate the incident because neither she nor the Administrator at the facility considered the incident related to abuse. The MSAU stated it is a facility policy to report any allegations of abuse. The MSAU stated the facility should have reported the incident due to the circumstances and especially because Resident 1 did not feel safe around CNA 1 and that Resident 1, had a bruise, and complained of pain after the incident. The MSAU stated failing to report the incident is a violation of Resident 1 ' s rights, facility policy and state and federal regulations. The MSAU stated failing to report allegations of abuse places Resident 1 and other residents potentially at risk for undetected incidents of abuse. During a review of the facility's policy and procedure (P/P) titled, Abuse, Elder & Dependent Adult, dated 04/2024, the P&P indicated that all staff members are responsible for the reporting of any reasonable suspicion or of any witnessed or alleged abuse. By law, a supervisor or administrator cannot prevent a staff member from reporting elder or dependent adult abuse. Furthermore, the P&P indicated that all health practitioners and all employees in a long-term health care facility are mandated reporters.

Based on observation, interview, and record review, the facility failed to follow safe food handling practices by failing to ensure: 1. Food stored in the resident unit refrigerator was labeled with the resident`s name, room number, date of preparation and discarded after two days. 2. The refrigerator in the resident's unit has a thermometer. These deficient practices had placed two of two residents (Resident 9 and 21) at risk for foodborne illnesses (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) with common symptoms such as nausea, vomiting, stomach cramps, and diarrhea. Findings: 1. During a review of Resident 9's History and Physical (H&P), the H&P indicated the facility admitted the resident on 2/5/2016 with history of respiratory failure and cerebrovacular accident (CVA-medical conditon that occurs when blood flow to the brain is suddenly interrupted). During a review of Resident 9's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 11/05/2024, the MDS indicated that the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS also indicated the resident is dependent on staff for eating, oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on and taking off footwear and personal hygiene. b. During a review of Resident 21's Physician Orders, the Physician Orders indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including generalized weakness and heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs). During a review of Resident 21's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/17/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS indicated the resident required substantial/maximal assistance from staff for shower, lower body dressing, putting on and taking off footwear and partial moderate assistance from staff for toileting hygiene, upper body dressing and personal hygiene. During an observation of the patient unit refrigerator and concurrent interview on 12/04/2024 at 09:45 a.m., with the Activity Director (AD), observed inside the refrigerator an unknown food item wrapped in foil without a label. The AD also confirmed that there is no thermometer inside the refrigerator. The AD the food item should have been dated and labeled with the resident's name. The AD stated the unlabeled food item if ingested could cause foodborne illnesses. The AD stated that it should be discarded immediately as it is not safe to be consumed by the residents. The AD stated that the temperature of the refrigerator must be maintained according to the facility policy's to ensure food stored in the refrigerator remains safe and does not spoil. During an interview on 12/04/2024 with the Director of Nursing (DON), the DON stated that families or visitors can bring food for the residents. The DON stated that there is a designated refrigerator to store the resident's food and the food should be dated and labeled with the resident`s name. The DON stated that dating the food item, will ensure it is discarded after one to two days. The DON also stated that there should be a thermometer in the refrigerator to make sure the temperature is kept within the proper range to prevent food spoilage and protect the two residents who are on oral feeding, from food borne illnesses. During a review of the facility`s policy and procedure (P&P) titled Food and Nutrition Services, last revised on February 2023, the P&P indicated that If perishable food is brought in but not eaten right away it may be stored in the refrigerator .food is labeled with patient`s name, room number and date of preparation and food is discarded two days after food is dated . During a review of the facility`s policy and procedure titled Refrigerators, Food-Patient Units, last revised on June 2024, the P&P indicated that Food refrigerators and freezers are used only for patient food .temperature norms are as follows: refrigerators are less than or equal to 41 degrees Fahrenheit; freezers are less than or equal to zero (0) degrees Fahrenheit .

Based on observation, interview, and record review, the facility failed to: 1. Ensure Certified Nursing Assistant 2 (CNA 2) was not standing over a resident while feeding the resident for one (Resident 9) out of two sampled residents investigated for the care area of dignity. This deficient practice violated the resident`s rights to be treated with respect and dignity which had the potential to affect the resident`s sense of self-worth and self-esteem. 2. Based on interview and record review, the facility failed to ensure a facility staff knocked and asked permission prior to entering a resident`s room for one of one resident (Resident 19) investigated under Resident Rights. This deficient practice violated the resident`s rights to be treated with respect and dignity which had the potential to affect the resident`s sense of self-worth and self-esteem. Findings: 1. During a review of Resident 9's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/5/2016 with diagnoses including multiple cerebrovascular accidents (CVA - stroke, loss of blood flow to a part of the brain), bilateral (both sides) lower extremity paraplegia (loss of movement and/or sensation, to some degree, of the legs), and right upper extremity paralysis (loss of muscle function). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 11/5/2024, the MDS indicated the resident had intact cognition (thought processes) and was dependent on staff for most activities of living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). On 12/2/2024 at 12:15 p.m., during an observation, observed CNA 2 standing over Resident 9 while feeding him. Observed a chair in the room. Observed the resident's bed to be in a low position. On 12/2/2024 at 2:46 p.m., during an interview, CNA 2 verified the observation and stated she should have moved the resident's up to a higher position so that the resident was at eye level with her. On 12/4/2024 at 2:05 p.m., during an interview, when asked what could potentially result from not having the resident at eye level during feeding, the Director of Nursing (DON) stated the resident did not like to have his bed moved and did not like it when CNAs sat next to his bed while feeding him. During a review of Resident 9's care plans (a document that outlines a person's health needs, current medical conditions, and the specific treatments or support required to manage their care), no care plan was found indicating the resident's preference to not have his bed raised or not have CNAs sit beside his bed during feeding. On 12/4/2024 at 2:21 p.m., during an interview, when asked if he ever told staff that he did not like his bed raised or did not like for CNAs to sit beside him while feeding him, Resident 9 stated, I never said that. The resident stated he would not mind either way if his bed was raised or if the CNA sat next to his bed while feeding. During a review of the facility's policy and procedure titled, Patient Rights and Responsibilities, last reviewed and revised on 5/2024, the policy indicated that patients have the right to receive considerate and respectful care, and to be made comfortable. 38469 2. During a review of Resident 19's Admission Record, the Admission Record indicated the facility admitted the resident on 8/22/2024, with diagnoses including respiratory failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood, or when there is too much carbon dioxide in the blood) and status epilepticus (a seizure lasting more than five minutes, or multiple seizures within five minutes without regaining consciousness). During a review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/13/2024, the MDS indicated Resident 19's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired. The MDS further indicated that Resident 19 was totally dependent on staff for toileting, shower, dressing and personal hygiene. During an observation on 12/02/2024 at 11:00 a.m., observed Respiratory Therapist (RT1) enter Resident 19`s room without knocking and asking permission to go inside the room. During an interview on 12/02/2024 at 1:04 p.m., with RT1, RT 1 stated that he went to Resident 19`s room to administer breathing treatment and forgot to knock and ask permission prior to entering the resident`s room. RT1 stated that it is proper to knock to show respect and ensure privacy and dignity. RT1 stated that not knocking on the resident`s door is a violation of Resident 19`s rights as a patient. During an interview on 12/04/2024 at 9:16 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that staff should knock on the door, introduce themselves and ask permission to enter the resident`s room. RN 1 stated the resident may feel disrespected if staff enter the room without asking permission and knocking on the door. During a review of the facility`s policy and procedures titled Patient Rights and Responsibilities, last reviewed on May 2024, indicated that the patient has the right to personal privacy .

Based on interview and record review, the facility failed to implement its abuse prohibition policy by failing to report immediately, but no later than two hours after the allegation was made, an allegation of staff to resident abuse (the willful infliction of injury with resulting physical harm, pain, or mental anguish) to the State Survey Agency (California Department of Public Health), ombudsman, and local law enforcement for one of three sampled residents (Resident 8). This deficient practice had the potential to result in a delay of an onsite investigation of abuse. Findings: During a review of Resident 8's History and Physical (H&P), dated 1/1/2024, the H&P indicated Resident 8 was admitted to the facility in December 2008 with diagnoses including but not limited to encephalitis (inflammation of the brain), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), and ventilator (a medical device to help support or replace breathing) dependent respiratory failure. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool), the MDS indicated Resident 8 could not speak and can sometimes understand others and make herself understood. The MDS further indicated Resident 8 was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During an interview on 12/2/2024 at 1:12 p.m. with the family member (FM 1) of another resident, FM 1 stated while she (FM 1) was standing outside of Resident 8's room a couple of weeks ago, she (FM 1) saw Resident 8 with bruises on the arm. FM 1 further stated she thinks a night shift staff did something to Resident 8 to cause the bruising. During an interview on 12/2/2024 at 2:05 p.m. with the Manager of Subacute (MOS), the surveyor informed the MOS of the allegation of abuse to Resident 8, which caused bruising to the resident's arm. During an interview on 12/3/2024 at 8:35 a.m. with the MOS, the MOS stated the charge nurse assessed Resident 8 and found no signs of bruising. The MOS stated nothing was reported to any agencies as there is currently no bruising, nor has there been any recently, and there is no known incident that could have caused any bruising. During an interview on 12/3/2024 at 10:05 a.m. with MOS and the Chief Nursing Officer (CNO), surveyor informed the CNO and the MOS that there was an allegation of abuse by a night staff to Resident 8, which caused bruising to the resident's arm. During a concurrent interview and record review on 12/3/2024 at 2:52 p.m. with the SW, the SW provided a fax confirmation time stamped 12/3/2024 2:50 p.m. of a report of suspected dependent adult/elder abuse to the ombudsman's office notifying them of the allegation of abuse. During a concurrent interview and record review on 12/4/2024 at 8:12 a.m. with the SW, the facility's policy and procedure (P&P) titled, Abuse, Elder & Dependent Adult, revised April 2024, was reviewed. The P&P indicated, For incidents that involved abuse or results in serious bodily injury, call the local law enforcement agency, Long Term Care Ombudsman and the Department of public health Services Licensing and Certification immediately but not later than two hours after the alleged incident and within 24 hours for all other cases. The SW stated she is responsible for completing the report of suspected dependent adult/elder abuse form and reporting the alleged abuse. SW 1 stated she (SW 1) thought she could notify one entity within 24 hours and the rest later. After review of the P&P, SW 1 confirmed the allegation should have been reported to the ombudsman, the Department of Public Health, and law enforcement within two hours as indicated in the policy. During a concurrent interview and record review on 12/4/2024 at 1:42 p.m. with the MOS and CNO, reviewed the facility's P&P titled, Abuse, Elder & Dependent Adult, revised April 2024, that indicated For incidents that involved abuse or results in serious bodily injury, call the local law enforcement agency, Long Term Care Ombudsman and the Department of Health Services Licensing and Certification immediately but not later than two hours after the alleged incident and within 24 hours for all other cases. The MOS and ADM stated the allegation of abuse should be reported as indicated in this policy. During an interview on 12/4/2024 at 3:23 p.m. with the SW, SW stated if she received an allegation of abuse she would report to the ombudsman, law enforcement and the Department of Public Health within two hours so the allegation of abuse can be investigated quickly and to prevent any further distress to the resident. During a review of the facility's P&P titled Abuse, Elder & Dependent Adult revised April 2024, the P&P indicated For incidents that involved abuse or results in serious bodily injury, call the local law enforcement agency, Long Term Care Ombudsman and the Department of Health Services Licensing and Certification immediately but not later than two hours after the alleged incident and within 24 hours for all other cases. The P&P further indicated Reports of abuse or results in serious bodily injury are to be made immediately within two hours to the local law enforcement agency, Long Term Care Ombudsman and the Department of Health Services Licensing and Certification and within 24 hours for all other cases and follow-up written report (SOC 341) must be sent.

Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) did not transfer a resident from the wheelchair to the bed using a mechanical lift (a device used to assist with transfers and movement) without assistance from another staff for one of one sampled resident investigated under the accident care area (Resident 14). This deficient practice had the potential for the resident to sustain a serious injury in the event of a fall incident. Findings: During a review of Resident 14's Face Sheet, the Face Sheet indicated that the facility admitted the resident on 9/09/2024 with diagnoses that included encephalopathy (a general term for a brain disorder or disease that can be caused by a number of things, including injury, disease, drugs, or chemicals) and respiratory failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood, or when there is too much carbon dioxide in the blood). During a review of Resident 14's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/22/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired and required two staff for toileting, shower, dressing and for personal hygiene. During an observation and interview on 12/02/2024 at 1:41 p.m., observed Certified Nurse Assistant bringing in a mechanical lift inside Resident 14`s room. CNA 1 then closed the privacy curtain of Resident 14. CNA 1 stepped out of the room and was asked what she did inside the resident`s room. CNA 1 stated that she transferred Resident 14 from the wheelchair to his bed. CNA 1 stated she did the transfer by herself because the other CNAs were busy. CNA 1 stated that there should be two staff assisting the resident during transfers when using a mechanical lift. During an interview on 12/02/2024 at 2:14 p.m., CNA 2 stated that Resident 14 requires two person assistance with transfer using a mechanical lift for the safety of the resident and staff. CNA 2 stated that with mechanical lift transfer, one person will attach the hook on one side and the other person will attach the hook on the other side. CNA 2 stated that one person will hold and support the resident and the other person will move the mechanical lift. CNA 2 stated that the resident can fall resulting in injury, if only one person will operate the mechanical lift during a transfer. CNA 2 stated that Resident 14 could have suffered a fall because of the unsafe transfer. CNA 2 stated that they are trained in using the mechanical lift. During an interview with Registered Nurse 1 (RN 1) on 12/04/2024 at 9:16 a.m., RN 1 stated that transferring a patient using the mechanical lift requires two-person assistance. RN 1 stated that transferring Resident 14 using a mechanical lift by one person is not safe and can increase the resident's risk of accidents resulting in a fall or serious injuries. During a review of the facility`s policy and procedures (P&P), titled Mechanical Lift, last reviewed on 5/2024, the P&P indicated that It is the policy of this facility that the Mechanical Lift will be utilized for resident transfers only .Assistance of two personnel will be used with Mechanical Lift.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) performed hand hygiene (the practice of cleaning your hands to prevent the spread of disease and infection) after doffing (to take off) her gown, touching a soiled linen cart, and leaving a resident's room for one (Resident 9) out of six sampled residents investigated under the care area of infection control. This deficient practice had the potential to place residents at increased risk of contracting an infection. Findings: During a review of Resident 9's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 2/5/2016 with diagnoses including multiple cerebrovascular accidents (CVA - stroke, loss of blood flow to a part of the brain), bilateral (both sides) lower extremity paraplegia (loss of movement and/or sensation, to some degree, of the legs), and right upper extremity paralysis (loss of muscle function). During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 11/5/2024, the MDS indicated the resident had intact cognition (thought processes) and was dependent on staff for most activities of living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). The MDS also indicated that the resident received tracheostomy (a surgical procedure that creates an opening in the neck and inserts a tube into the windpipe to help with breathing) care while a resident. On 12/3/2024 at 10:26 a.m., during an observation, observed CNA 1 inside Resident 9's room doffing her gown, placing it inside the soiled linen cart, and exiting the resident's room without performing hand hygiene. Observed CNA 1 going into another room without first performing hand hygiene. On 10/3/2024 at 10:45 a.m., during an interview with CNA 1, CNA 1 confirmed that she did not perform hand hygiene after doffing her gown and exiting Resident 9's room. On 10/4/2024 at 1:48 p.m., during an interview with the Director of Nursing (DON), the DON stated it was important for staff to perform hand hygiene after doffing their gowns and exiting residents' rooms for infection control. During a review of the facility's policy and procedure titled, Hand Hygiene, last reviewed and revised on 3/2024, the policy indicated that hospital personnel shall wash their hands to prevent the spread of infections between handling of individual patients and on leaving an isolation area or after handling articles from an isolation area.

Based on interview and record review, the facility failed to ensure staff protect and maintain residents privacy and confidentiality for one of two sampled residents (Resident 2) when a Charge Nurse (CN) 2 released Resident 2's medical information to Resident 1's family member (FM 1). This deficient practice resulted in Resident 2's medical information released to other people who do not have the rights to know about. Findings: During a review of Resident 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/1/2024, the H&P indicated, Resident 2 was admitted to the facility with diagnoses including but not limited to chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), ventilator dependent (a medical device to help support or replace breathing), dysphagia (difficulty swallowing), and status post gastrotomy (an artificial external opening into the stomach for nutritional and medication administration) tube placement. During a review of Resident 2's Nutritional assessment dated [DATE], the nutritional assessment indicated, Resident 2 received Vital 1.2 (a type of feeding formula for patients who receive enteral feeding [tube feeding, a way to deliver nutrition and hydration through the feeding tube]) at 40 milliliters per hour (ml/hr, unit of measures) for 20 hours daily. During an interview on 10/28/2024 at 9:26 a.m. with Resident 1's family member (FM 1), FM 1 stated the Charge Nurse (CN 2) had told her (FM 1) that Resident 2's tube feeding was off for five hours on one occasion. During an interview on 10/28/2024 at 10:13 a.m. with CN 2, CN 2 stated the following: when she (CN 2) was providing education to FM 1 regarding the importance of receiving tube feeding per physician order, she (CN 2) informed FM 1 that Resident 2's tube feeding was off for five (5) hours. CN 2 stated FM 1 was not Resident 2's family member so she (CN 2) should not have discussed Resident 2's medical information with FM 1. CN 2 stated she (CN 2) did not state Resident 2's name but she used Resident 2's room number as the identifier. CN 2 stated, I would be more careful and should not say anything (about discussing Resident 2's medical information) to others. During an interview on 10/28/2024 at 2:54 p.m. with the Nurse Manager (NM 1), NM 1 stated the following: to maintain and protect patients privacy and confidentiality, the facility expected all staff not to discuss any resident information or matter with anyone who were not related to or not authorized to know about that resident. Nursing staff should not discuss any residents matter to other residents' family members. Using the room number as the identifier would be considered as violation of resident's privacy as others could identify that particular resident based on the room number. During a review of the facility's policy and procedure (P&P) titled, Patient Rights and Responsibilities, dated 2/2023, the P&P indicated, Patients Rights . 13. The right to the confidentiality of his or her clinical records. The right to confidential treatment of all communications and records pertaining to your care and stay in the hospital. During a review of the facility's the policy and procedure (P&P) titled, HIPAA (Health Insurance Portability and Accountability Act of 1996) Privacy Rule, dated 9/2022. The P&P indicated, Protected Health Information. The Privacy Rule protects all individually identifiable health information held for transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper or oral . 'individually identifiable health information' is information . that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.

Based on interview and record review, the facility failed to support one resident's (Resident 1) right to access personal and medical records (all records maintained for the purposes of patient treatment, including reports, notes, orders, diagnoses, treatments, test results, photographs, medical images, and more); failed to provide Resident 1's and/or Resident 1's representative (RR, an individual who is authorized either by a patient or a State law, to make health care treatment decisions for the patient when the patient is unable to do so) access to the personal and medical records within 24 hours of a written request; failed to follow up and mail to the requestor (Resident 1's representative) a written statement explaining the delay and setting forth the date by which the facility will provide records or a response. This deficient practice had the potential to violate Resident 1's rights to obtain copies of the protected health information as per federal regulation and the facility's policy and procedure. Findings: During a review of Resident 1's History and Physical ( H&P, a through medical examination conducted upon admission to the facility), dated 4/29/2023, the H&P indicated, Resident 1 was admitted on [DATE] with past medical history (PMH, a record of information about a person's health) of hypertension (HTN, when the pressure in the blood vessels is above defined normal parameters) and traumatic brain injury (TBI) with right (R) subdural hematoma (SDH, a type of bleeding near your brain that can happen after a head injury) after a ground level fall; two craniotomies (surgical opening into the skull) and worsening mental status (unable to make decisions for self or speak); tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck intended for breathing) and percutaneous endoscopic gastrostomy (PEG, feeding tube inserted in the placement of a feeding tube through the skin and the stomach wall). During an interview on 3/20/2024 at 12:01 p.m. with Medical Records personnel (MR), MR stated, RR requested Resident 1's medical records and filled out an authorization form for medical record release in October 2023. MR further stated, since Resident 1's medical records contained a lot of information due to length of stay, the request was forwarded to the corporate office for medical record release. MR stated, there was no further follow up done by the facility's MR regarding Resident 1's medical records. During an interview on 3/20/2024, at 12:15 p.m. with the facility's Medical Record Supervisor (MRS), MRS stated, on 1/30/2024, the MRS received an email from the facility's MR regarding Resident 1's medical records. MRS further stated, the facility usually provides all medical records the same day as requested, but since RR wanted all medical records to be burned (write) on a compact disk (CD, a digital storage medium that can hold large amounts of data (information), the records were not released to the RR until 2/24/2024 due to a large amount of information that needed to be written on the CD. MRS further stated, by State regulation, medical records shall take no more than thirty days to be released to the requesting party. During an interview on 3/20/2024 at 4:00 p.m. with Resident 1's representative (RR), the RR stated, the facility did not release Resident 1's medical records in a timely manner. RR further stated multiple requests for Resident 1's personal and medical information were attempted before the records were finally released to RR in February 2024. RR further stated, RR did not receive a written statement explaining the delay for the medical records requested. During a review of the facility's policy and procedure (P&P), titled, Medical Records, dated 2/24/2024, the P&P indicated, Patient are permitted in most circumstances to inspect and obtain copies of their protected health information. Copies and records will be provided, or a written denial made, in response to requests from patients or their representatives within 15 days of receipt of the request. If the facility is unable to produce records within the time limits, requestor shall be mailed a written statement explaining the delay and setting forth the date which the facility will provide records or a response.

Based on observation, interview, and record review, the facility failed to make information available on how to file a grievance (an official statement of a complaint over something believed to be wrong or unfair) for one resident (Resident 1) and/or resident's representative (s) (RR). This failure resulted in violation of Resident 1's and/or Resident 1's representative to receive information on how to file a complaint in accordance with the Patient Rights and Responsibilities and the facility's policy and procedure. Findings: During a review of Resident 1's History and Physical ( H&P, a through medical examination conducted upon admission to the facility), dated 4/29/2023, the H&P indicated, Resident 1 was admitted on [DATE] with past medical history (PMH, a record of information about a person's health) of hypertension (HTN, when the pressure in the blood vessels is above defined normal parameters) and traumatic brain injury (TBI) with right (R) subdural hematoma (SDH, a type of bleeding near your brain that can happen after a head injury) after a ground level fall; two craniotomies (surgical opening into the skull) and worsening mental status (unable to make decisions for self or speak); tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck intended for breathing) and percutaneous endoscopic gastrostomy (PEG, feeding tube inserted in the placement of a feeding tube through the skin and the stomach wall). During an interview on 3/20/2024, at 11:04 a.m. with charge nurse (CN), CN stated, during the admission stay, Resident 1 developed Stage 4 pressure injury (Full thickness tissue loss with exposed bone, tendon, or muscle) to sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) and suffered from chronic (persisting for a long time) diarrhea (loose, watery, and possibly more-frequent bowel movements) since April 2023. CN further stated, Resident 1's gastrointestinal (GI, pathway by which food enters the body and solid wastes are expelled) issues were a big concern for Resident 1's representative (RR) (Resident 1's medical decision maker) because of how diarrhea negatively affected Resident 1's health. CN stated, RR complained about Resident 1's diarrhea many times and the facility's medical director was aware of the complaint. During a review of Resident 1's medical record (MR), titled, Nursing Progress Note, dated 6/27/2023, the progress note indicated, Gastroenterologist (GI, a medical practitioner specializing in the diagnosis and treatment of disorders of the gastrointestinal tract) was called and made aware of consultation request for chronic diarrhea and stated GI will see Resident 1. During a concurrent interview and record review on 3/20/2024, with FM, the facilities and RR's email correspondence, dated 11/29/2023 was reviewed. The MR indicated, RR reached out to the facility's Chief Nursing Officer (CNO) stating that Resident 1 had chronic diarrhea and the attending physician ordered GI consultation, but the GI consulting physician did not come to see Resident 1. The MR further indicated, the CNO responded to RR stating the gastroenterologist was contacted and was going to see Resident 1 the following day. During a review of Resident 1's medical record (MR), titled, Gastrointestinal consultation, dated 12/1/2023, the MR indicated, first consultation by GI specialist was done on 12/1/2023. During an interview on 3/20/2024 at 12:01 p.m. with Medical Records personnel (MR), MR stated, RR requested Resident 1's medical records and filled out an authorization form for medical record release in October 2023. MR further stated, since Resident 1's medical records contained a lot of information due to length of stay, the request was forwarded to the corporate office for medical record release. MR stated, there was no further follow up done by the facility's MR regarding the Resident 1's medical records. During an interview on 3/20/2024, at 12:15 p.m. with the facility's Medical Record Supervisor (MRS), MRS stated, on 1/30/2024, the MRS received an email from the facility's MR regarding Resident 1's medical records. MRS further stated, the facility usually provides all medical records the same day as requested, but since RR wanted all medical records to be burned (write) on a compact disk (CD, a digital storage medium that can hold large amounts of data (information), the records were not released to the RR until 2/24/2024 due to a large amount of information that needed to be written on the CD. MRS further stated, by State regulation, medical records shall take no more than thirty days to be released to the requesting party. During an interview on 3/20/2024, at 2:15 p.m., with facility's manager (FM), the FM stated, the facility does not have a specific department that handles grievances, but the facility's staff and the manager shall attempt to resolve the complaint first. The FM further stated, the chain of commands shall be activated, and the complaint should be forwarded to the Director of Nursing (DON) and the Chief Nursing Officer (CNO) for a follow-up if a prompt resolution cannot be achieved. The FM stated the information on filing complaints is not posted anywhere in the facility. FM further stated, there are no complaints filed by the Resident 1's representative (RR) regarding Resident 1's care, medical records, or anything else. During an observation on 3/20/2024 at 2:45 p.m., in the facility's hallway, Patient Rights signage was observed. The signage indicated that the space allocated for the information on how to file an internal (to the facility) complaint (information regarding resident's right to confidentially complain about the quality of care, the safety of the environment and services received) was left blank. During a concurrent observation and interview on 3/20/2024 at 2:46 p.m., with the facility's manager (FM), in the facility's hallway, an enclosed Bulletin Board was observed. The Bulletin Board contained a one page printed public notice intended to inform the facility's residents and visitors of a right to confidentially complain to the facility. The FM stated, the information regarding complaints in the facility was outdated and incorrect because the facility has a new process for filing complaints and the posted notice shall be updated. During an interview on 3/20/2024 at 4:00 p.m. with Resident 1's representative (RR), the RR stated, the facility does not have a clear channel for filing complaints. RR stated, multiple times RR made complaints regarding medical and treatment issues involving Resident 1's care. RR stated, the primary care physician never communicates a plan of Resident 1's care with RR and Resident 1 had to wait for months to obtain a gastroenterology consultation regarding chronic diarrhea, even though RR complained about it many times during to the management. RR further stated, Resident 1 has been having diarrhea for over six months before she was seen by a gastroenterologist specialist and continues to have chronic diarrhea without a definitive diagnosis. RR further stated, many other complaints and concerns such as inability to obtain Resident 1's medical records for months were also disregarded by the facility and no resolution of many complaints was ever achieved at the management level. During a review of the facility's policy and procedure (P&P), titled, The complaint/grievance process, dated 2/024, the P&P indicated, In accordance with Patient Rights and Responsibilities and the organization's desire to continually improve patient care services, the Facility elicits patients' complaints, concerns, and compliments and responds to significant patient complaints and concerns in a timely, and consistent manner. The CNO/Risk Manager and or designee(s) has the authority to investigate and resolve all patient complaints/grievances. Patient/family significant other complaints may be received at any level throughout organization. Staff is empowered to seek a prompt resolution of the complaint at the point closest to the problem.

Based on interviews and record review, the facility failed to ensure residents' rights were honored when the facility limited Resident 1's legal representative's visitation to one hour a day. This failure had violated Resident 1's visitation rights by not honoring exercising the resident's rights to designate visitors of his/her choosing. Findings: During a review of Resident 1's History and Physical (H&P), dated 09/26/2019, the H&P indicated, Resident 1 was admitted to the facility for continued tracheostomy (a surgically created hole in the windpipe (trachea) that provides an alternative airway for breathing) care, anti-aspiration ( to avoid food or fluids getting into the airway) measures, and pulmonary toilet ( exercises and procedures that help to clear the airways of mucus and other secretions). During a review of Resident 1's physician's progress note (PPN), dated 1/29/2024, the PPN indicated, Resident 1 had past medical history including, but not limited to. respiratory failure (a condition when blood does not have enough oxygen or too much carbon dioxide), severe encephalopathy (disease that affects the whole brain and alters how it works causing changes in mental function), dysphagia (difficulty swallowing), percutaneous endoscopic gastrostomy ( PEG)( a procedure to place a feeding tube into the stomach) placement and tube feeding (a liquid form of nutrition provided through a flexible tube). During an interview, on 1/30/2023, at 9:24 a.m., with RR 1, the RR1 stated, the facility limited RR1's visitation hours to a one hour a day as of December 2023. The RR1 stated, the RR1 is Resident 1's conservator ((a court arrangement where a judge appoints a responsible person (a conservator) to care for another adult who cannot care for themselves [conservatee]) was not notified of the imposed restrictions and the facility only kept in contact with the Resident 1's second conservator (RR 2). The RR1 stated, the facility violated Resident 1's rights by attempting to implement unreasonable visitation hours disregarding that the RR1 is Resident 1's conservator for Resident 1. The RR 1 further stated, the RR1 is not always allowed to participate in Interdisciplinary Treatment (IDT) meetings (an essential part of collaborative care, where physicians, nurses, therapists, social workers, and other professionals work together to plan and coordinate patient care) and is not regularly updated about Resident 1's treatment plan. During an interview on 1/30/2023 at 2:15 p.m., with the director of nursing (DON), the DON stated, Resident 1 was admitted to the facility in 2019. The DON further stated, during Resident 1's stay at the facility, there were multiple disturbing events involving Resident 1's Representative 1(RR1). The DON further stated, the RR1 witnessed and documented disturbing behavior included, but no limited to, yelling and threatening staff, physical assault to a charge nurse, disturbing other residents by looking for staff in their rooms and playing loud music at night, verbal assaults and name calling, throwing objects at staff, interfering with patient care and medication administration and physician's orders, not following infection control rules, and closing the Resident 1's door when asked by nursing staff to keep the door open for visual observation. During a further interview on 1/30/2023, at 2:15 p.m., with the DON, the DON stated, the facility attempted to address RR 1's behavior many times. The DON stated, the facility's manager (FM) received numerous staff complaints about RR1's behavior and some staff resigned, as a result. The DON stated, management addressed the RR1 inappropriate behavior many times by attempted educational sessions with RR1 and there were instances when the security was called to the unit, but RR1's threats, outburst, and interruptions in provision of Resident 1's care nevertheless continued. During an interview on 1/30/2023, at 2:15 p.m., with Director of Nursing Services (DON), the DON stated, on 12/05/2023, the facility restricted RR 1's visitation hours to a one-hour visitation time a day. The DON stated, the facility determined that the presence of RR1 may present danger to the health and safety of Resident 1 and the facility's staff. The DON further stated, the RR1 is no longer included in email correspondence regarding Resident 1's health status and the facility only interacts with RR2 due to RR 1's challenging behavior that is causing emotional distress to staff and interference with Resident 1's care. During an interview on 1/30/2023, at 2:19 p.m., with the DON, the DON stated, on 9/20/2023, the facility held an arranged meeting with RR1, RR2, and the ombudsman, to address disruptive behavior of RR1. The DON stated, during the meeting, the resolution was achieved when RR1 agreed to improve the behavior toward staff and not to interfere with Resident 1's treatments and care. The DON further stated, the behavior of RR 1 did not improve as per conditions placed by the facility, to which RR1 and RR2 mutually agreed to during the meeting held on 9/20/2023. The DON stated, on 12/4/2023, the RR 1's visitation hours were reduced to one hour a day. The DON also stated, the email was sent to the RR2, and RR1 was not notified of restricted visitation time. During a further interview on 1/30/2023, at 2:21 p.m., with DON, the DON stated, during the meeting held on 9/20/2023, the facility and RR2 came to an agreement, that all communication and email correspondence regarding Resident 1's health status and treatment plan shall occur only between the facility and RR 2 and no longer involved any communication with RR 1. The DON further confirmed, RR 1 is a legal, appointed by the court, Resident 1's representative since 7/8/2023 and this status is current. During a record review, on 1/30/2023, at 2:30 p.m., a copy of a document, titled Petition for Appointment of Probate Conservator of the Person, (a court arrangement where a judge appoints a responsible person (a conservator) to care for another adult who cannot care for themselves (conservatee) (Resident 1) dated 7/8/2021 was reviewed. The document indicated; two (2) representatives were appointed as conservators for Resident 1 on 7/8/2021. The facility failed to provide legal evidence indicating RR 1 is no longer obligated to be communicated with regarding Resident 1's health status; the facility also failed to provide evidence report indicative RR 1 was informed of restricted visitation hours. During a review of the facility's policy and procedure (P&P) titled Visitation, dated 8/2023, the P&P indicated, Any clinically necessary or reasonable restrictions or limitations imposed by the facility on a patient's visitation rights will be necessary to provide safe care to the patient or other patients. A justified clinical restriction may include, but not limited to: Court order, behaviors presenting direct risk or threat to the patient, facility staff, or others in the immediate environment, behavior disruptive of the functioning of the patient care unit, patient risk of infection by the visitor . During a review of the facility's policies and procedures (P&P) titled, Resident's Rights, dated 4/21/2023, the P&P indicated, Patients' rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient.

Based on observation, interview, and record review, the facility failed to: 1. Ensure there were no expired medications and supplies inside one of one medication storage room. This deficient practice had the potential to result in the use of expired care items for resident's care. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) did not leave one of two medication carts unlocked while unattended during medication administration observation. This deficient practice placed residents or unauthorized personnel at risk of accessing the medications. 3. Ensure the phenytoin (a medication used to treat seizures [abnormal electrical activity in the brain]) bottle was labeled with the current dose ordered by the physician or had an indication that the ordered dose was changed for one of four sampled residents (Resident 1) investigated for Medication Administration. This deficient practice had the potential to result in phenytoin toxicity (a potentially serious side effect of high levels of phenytoin in the body resulting in difficulty breathing, tremors [uncontrollable movements], low blood pressure (the force of the blood pushing on the blood vessel walls is too low), nausea, and vomiting) for Resident 1. Findings: 1. During a concurrent observation and interview on 1/6/2024 at 5:20 p.m., with Registered Nurse 1 (RN 1), observed the medication storage room. Observed a plastic tray of wound debridement (when a doctor removes dead or unhealthy tissue from a wound) supplies inside a cabinet which included a package of sterile gloves. RN 1 stated the package of sterile gloves expired on 2/2023. Observed five expired vials of sterile water (water that is sterilized and packaged for use as an irrigant). RN 1 stated the five vials of sterile water expired on 12/2023. Observed an expired package of Glutose 15 oral glucose gel (used to treat low blood sugar levels). RN 1 stated it expired on 7/31/2023. RN 1 proceeded to discard the medications/supplies, stating they were expired and should not be used. During an interview on 1/7/2024 at 5:18 p.m., with the Sub-Acute Nurse Manager (NM), NM stated that the pharmacist usually comes to check the medication room to ensure there were no expired supplies or medications. The NM stated it was important to ensure medications or supplies kept in the medication storage room were not expired because they could potentially have negative side effects when used or given to a resident. The NM stated that expired medications can also potentially lose their effectiveness. A review of the facility's policy and procedure titled, Pharmacy, dated 2/2023, indicated that drugs and devices shall be stored to ensure their stability and integrity. The hospital removes all expired, damaged, and/or contaminated medications and stores them separately from medication available for administration. 2. During a concurrent observation and interview on 1/7/2024 at 8:20 a.m., with LVN 2, observed LVN 2 administering medications for Resident 25. Observed LVN 2 walk away from medication cart, into Resident 25's room, and closed the resident's privacy curtain, without locking the medication cart. After the medication administration observation, when asked if she had locked medication cart before walking away from it, LVN 2 stated she had forgotten to lock it. During an interview on 1/7/2024 at 5:18 p.m., with the NM, the NM stated that before nurses leave their medication cart unattended, they should make sure it is closed and locked, and that there are no medications left on top of it. The NM stated, if left unlocked and unattended, then anyone can open it and take medication, especially psychotropics (any drug that affects a person's behavior, mood, thoughts, or perception) and narcotics (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep). A review of the facility's policy and procedure titled, Medication Security: Medication Storage Areas, dated 2/2023, indicated that the purpose of the policy was to establish measures for the security of medication storage areas within the hospital in accordance with federal, state, and local laws. To assure medications are secure and only accessible to designated and authorized personnel. It is the responsibility of each licensed health care professional who dispensed, handles, or otherwise works with medications at the facility to assure security and integrity of all medication storage areas within the hospital. All medications must be secure regardless of location. Medication carts must be locked when not in immediate use or when not in the control of an individual authorized to have access. 44244 3. A review of Resident 1's Admission/Registration Record, dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 1's Minimum Data Set (MDS- as assessment and care screening tool) dated 12/8/2024, indicated the facility admitted the resident on 7/13/2000. The MDS indicated the resident was in a persistent vegetative state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain) with no discernible consciousness (no evidence of awareness of self or environment). The MDS indicated the resident was dependent on staff for dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Care Plan titled, At Risk for Injury Due to Seizure Disorder, initiated 12/29/2023, indicated interventions of medication as ordered and monitor drug levels as ordered. A review of Resident 1's Physician Orders indicated an order to decrease Dilantin (phenytoin) to 150 milligrams (mg, a unit of measurement) via g-tube (a tube placed directly into the stomach to give direct access for supplemental feeding, hydration or medicine) every 12 hours (Dilantin level 27.9 [a measurement of the level of phenytoin in the body, a normal therapeutic range is typically 10 to 20 micrograms per milliliter]) for seizures, dated 1/2/2024. During a concurrent medication pass observation and interview on 1/7/2024 at 8:35 a.m., with Registered Nurse 2 (RN 2), RN 2 removed Resident 1's phenytoin bottle from Medication Cart 1 and poured the medication into a measured medication cup. RN 2 stated he poured 150 mg/six (6) milliliters (mL, a unit of liquid measurement) of phenytoin. Observed 6 mL in the medication cup. RN 2 stated the phenytoin medication bottle's label indicated the following: - Phenytoin 125 mg/five (5) mL, give 175 mg /seven (7) mL via g-tube every 12 hours, date dispensed 12/22/2023. RN 2 stated the labeled dose on the phenytoin medication bottle did not match the physician's order. RN 2 stated the bottle was dispensed from the outside pharmacy prior to a lab draw that indicated Resident 1's phenytoin level was high and the physician lowered the dose from seven mL to six mL. RN 2 stated when the medication label does not match the order, staff should put a sticker on the bottle to indicate there was a change in direction and to refer to the order. RN 2 stated there was no direction change sticker on the medication bottle. RN 2 stated the importance of placing a sticker is to alert the medication nurse and to ensure the correct dose is given to the resident so there are no adverse effects of too much phenytoin being administered resulting in side effects to the resident. During an interview on 1/7/2024 at 2:14 p.m., with RN 1, RN 1 stated a medication label should always match the physician's order and if it does match, they call the pharmacy. RN 1 stated when a medication dose changes the outside pharmacy should be notified right away and they indicate if they will send a new labeled medication or if they should use the remaining medication and place a sticker or note on the bottle to indicate there was a change and to refer to the order during administration. During an interview on 1/7/2024 at 3:40 p.m., with the Chief Nursing Officer (CNO), the CNO stated the medication label should match the physician's order. The CNO stated it was the standard of practice to call the outside pharmacy regarding the dose change and to place a change of direction sticker on the medication bottle and if it was not done then the standard of practice was not followed and could potentially result in a medication error during administration. A review of the facility's policy and procedure titled, Labeling of Medication, dated 2/2023, indicated the purpose of the policy was to assure that all medications are appropriately labeled in a standardized manner to meet federal, state regulations and standard of practice; to promote safety in administering the right drug, in the right quantity, to the right patient. All drugs stocked in the pharmacy, supplied to floor stock, or dispensed to patients shall be clearly and accurately labeled. Any medication dispensed for use in the institution shall be properly labeled. Only a pharmacist, or authorized pharmacy personnel under the direction and supervision of a pharmacist, shall label containers from which drugs are to be distributed or dispensed and make labeling changes. Drugs that are mislabeled (i.e. labels are illegible, incomplete, incorrect, etc.) shall not be available for use.

Based on observation, interview, and record review, the facility failed to: 1. Ensure irrigation bottles (contains water intended to flush [infuse] a feeding tube [also known as a G-tube- a tube inserted through the belly that brings nutrition and medication directly to the stomach] or help in cleansing cavities and wounds) at the residents' bedside were labeled with the date and time of when it was last changed for three of five sampled residents (Residents 1, 21, and 18) investigated for infection control. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) performed hand hygiene before and after administering medications for one of four sampled residents (Resident 25) observed during the medication administration task. 3. Ensure Certified Nursing Assistant 3 (CNA 3) and Housekeeper 1 (HSK 1) did not doff (remove) isolation gowns (personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials]) used for contact isolation (used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) then exit the room and walk down the hallway with soiled isolation gowns for one of three sampled residents (Resident 18) investigated for Infection Control. 4. Implement infection control practices by using and placing canned products as a wedge to prop the door open in the dry storage. These deficient practices had the potential to spread communicable diseases between staff, visitors, and residents in the facility. Findings: 1.a. A review of Resident 1's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/8/2023, indicated the facility admitted the resident on 7/13/2000. The MDS indicated the resident was dependent on staff for eating, personal hygiene, and bed mobility. A review of Resident 1's physician's orders, dated 1/1/2001, indicated to flush feeding tube with 20 - 50 milliliters (ml - unit of measurement) of water before and after giving medications. During an observation on 1/6/2024 at 9:59 a.m., observed Resident 1 awake in bed. Observed an unlabeled irrigation bottle at Resident 1's bedside. During a concurrent observation and interview on 1/6/2024 at 10:50 a.m., with Registered Nurse 2 (RN 2), RN 2 confirmed by stating that Resident 1's irrigation bottle was unlabeled. RN 2 stated that it was used to irrigate Resident 1's gastrostomy tube (G-tube). RN 2 stated it should have been labeled with the date. RN 2 stated the bottle should be changed every day to ensure that it did not grow any bacteria. During an interview on 1/7/2024 at 5:18 p.m., with the Sub-Acute Nurse Manager (NM), the NM stated that the nurses were responsible for labeling the irrigation bottles with the date and time of when it was last changed. The NM stated it was important to label the bottle with date of when it was last changed so that staff knew that it was actually changed. The NM stated that, if not labeled with the date of when it was last changed, then the bottle may be old and can cause possible contamination or infection to the resident. A review of the facility's policy and procedure titled, Irrigation Solutions, dated 2/2023, indicated that the water/saline irrigation bottle must be dated, timed, and initialed by the Sub-Acute staff when the bottle is opened initially. Discard all water/saline bottles that are not dated, timed, or initialed. 1.b. A review of Resident 21's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure. A review of Resident 21's MDS, dated [DATE], indicated the facility admitted the resident on 4/28/2023. The MDS indicated the resident was dependent on staff for eating, personal hygiene, and bed mobility. A review of Resident 21's physician's order, dated 7/8/2023, indicated to flush feeding tube with 20 - 50 ml of water before and after giving medications. During an observation on 1/6/2024 at 10:03 a.m., observed Resident 21 asleep in bed. Observed an unlabeled irrigation bottle at Resident 21's bedside. During a concurrent observation and interview on 1/6/2024 at 10:50 a.m., with RN 2, RN 2 confirmed by stating that Resident 21's irrigation bottle was unlabeled. RN 2 stated that it was used to irrigate the resident's G-tube. RN 2 stated it should have been labeled with the date. RN 2 stated the bottle should be changed every day to ensure that it did not grow any bacteria. During an interview on 1/7/2024 at 5:18 p.m., with the NM, the NM stated that the nurses were responsible for labeling the irrigation bottles with the date and time of when it was last changed. The NM stated it was important to label the bottle with date of when it was last changed so that staff knew that it was actually changed. The NM stated that, if not labeled with the date of when it was last changed, then the bottle may be old and can cause possible contamination or infection to the resident. A review of the facility's policy and procedure titled, Irrigation Solutions, dated 2/2023, indicated that the water/saline irrigation bottle must be dated, timed, and initialed by the Sub-Acute staff when the bottle is opened initially. Discard all water/saline bottles that are not dated, timed, or initialed. 1.c. A review of Resident 18's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure. A review of Resident 18's MDS, dated [DATE], indicated the facility admitted the resident on 8/21/2018. The MDS indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent on staff for eating, personal hygiene, and bed mobility. A review of Resident 18's physician's order, dated 1/19/2019, indicated to flush feeding tube with 20 - 50 ml of water before and after giving medications. During an observation on 1/6/2024 at 9:47 a.m., observed Resident 18 asleep in bed. Observed an unlabeled irrigation bottle at Resident 18's bedside. During a concurrent observation and interview on 1/6/2024 at 10:50 a.m., with RN 2, RN 2 confirmed by stating that Resident 18's irrigation bottle was unlabeled. RN 2 stated that it was used to irrigate the resident's G-tube. RN 2 stated it should have been labeled with the date. RN 2 stated the bottle should be changed every day to ensure that it did not grow any bacteria. During an interview on 1/7/2024 at 5:18 p.m., with the NM, the NM stated that the nurses were responsible for labeling the irrigation bottles with the date and time of when it was last changed. The NM stated it was important to label the bottle with date of when it was last changed so that staff knew that it was actually changed. The NM stated that, if not labeled with the date of when it was last changed, then the bottle may be old and can cause possible contamination or infection to the resident. A review of the facility's policy and procedure titled, Irrigation Solutions, dated 2/2023, indicated that the water/saline irrigation bottle must be dated, timed, and initialed by the Sub-Acute staff when the bottle is opened initially. Discard all water/saline bottles that are not dated, timed, or initialed. 2. A review of Resident 25's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure. A review of Resident 25's MDS, dated [DATE], indicated the facility admitted the resident on 3/8/2022. The MDS indicated the resident was dependent on staff for eating and personal hygiene. During a concurrent observation and interview on 1/7/2024 at 8:20 a.m., observed LVN 2 administering medications to Resident 25. Observed LVN 2 not perform hand hygiene either before or after administering medications. When asked if she had performed hand hygiene either before or after administering medications, LVN 2 stated she did not perform hand hygiene and she should have. During an interview on 1/7/2024 at 5:18 p.m., with the NM, the NM stated that during medication administration, nurses should perform hand hygiene before, during, and after administering medications. The NM stated it was important to perform hand hygiene during medication administration in order to prevent the spread of infection from one resident to another. A review of the facility's policy and procedure titled, Handwashing, dated 2/2023, indicated that hospital personnel shall wash their hands to prevent the spread of infections: When coming on duty; Before applying and after removing gloves; When the hands are obviously soiled; Between handling of individual patients; Before contact about the face and mouth of patients; Before and after personal use of the toilet; After sneezing, coughing, blowing, or wiping the nose or mouth; On leaving isolation area (separates sick people with a contagious disease from people who are not sick) or after handling articles from an isolation area; After handling use sputum containers, soiled urinals, catheters, and bedpans; Before eating; On completion of duty. 44244 3. A review of Resident 18's Admission/Registration form, dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure. A review of Resident 18's MDS dated [DATE], indicated the facility admitted the resident on 8/21/2018. The MDS indicated the resident sometimes had the ability to understand others and was rarely/never understood. The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 18's Physician Orders, dated 9/25/2023, indicated an order for contact isolation for multidrug-resistant organisms (MDRO, bacteria that have become resistant to certain antibiotics) and carbapenem resistant pseudomonas aeruginosa (CRPA, a group of bacteria that have developed resistance to antibiotics and are a serious cause of healthcare associated infections) of sputum (type of thick mucus produced by the lungs). During an observation on 1/6/2024 at 10:15 a.m., observed Resident 18 lying in bed with a Contact Precautions sign posted at the room entrance. Observed CNA 3 in the doorway of Resident 18's room wearing a yellow cloth isolation gown, CNA 3 removed the gown, exited the room holding the used gown, walked down the hallway and discarded the gown in a bin that indicated soiled isolation gowns. During a concurrent interview and record review on 1/6/2024 at 10:17 a.m. with CNA 3, reviewed the Contact Precaution sign. CNA 3 stated she wore an isolation gown while providing care to Resident 18 because the resident was on contact isolation. CNA 3 stated she removed the gown and walked with the gown down the hallway because there was no bin at Resident 18's room for her to discard it. CNA 3 stated the Contact Precautions sign indicated to wear gown and gloves when entering the room and remove and discard gown and gloves when leaving the room. During an observation on 1/6/2024 at 10:20 a.m., observed HSK 1 cleaning Resident 18's room wearing a yellow cloth isolation gown. Observed HSK 1 remove the gown in Resident 18's room, exit the room holding the used gown, and walked down the hallway and discarded the gown in a bin that indicated soiled isolation gowns. During an interview on 1/6/2024 at 10:22 a.m. with HSK 1, HSK 1 stated she removed the used gown in Resident 18's room and walked down the hallway with the used gown. HSK 1 stated there was no soiled isolation gown bin in Resident 18's room. HSK 1 stated the yellow isolation gowns are re-usable and are placed in the dirty isolation bin after use. HSK 1 stated every room should have a soiled isolation gown bin. HSK 1 stated when the bin is full, it is taken to the dirty linen area and the trash/linen staff empty and disinfect the bins, then return them to the rooms for use. HSK 1 stated while waiting for the trash and linen staff to return the bins, sometimes there are extra bins to place in the room and sometimes there are not. HSK 1 stated if there is no extra bin to place at the room, then staff have to put the dirty isolation gown in a bin at a different room. During an interview on 1/6/2024 at 10:36 a.m. with RN 2, RN 2 stated there are less soiled isolation gown bins today than normal. RN 2 stated usually there is a bin in every room. RN 2 stated staff should never walk down the hallway with a soiled isolation gown because of infection control issues. RN 2 stated used isolation gowns are considered dirty and staff must try to isolate the bacteria to the resident's isolation room. RN 2 stated when dirty gowns are brought outside the isolation room there is a potential to contaminate from the dirty room to the clean hallway and from there to other staff and residents. During an interview on 1/6/2024 at 10:55 a.m. with the NM, the NM stated it was absolutely not okay to walk down the main hallway with a soiled isolation gown because of the possibility of contaminating other people and objects and the possibility of spreading infection. The NM stated every room should have a soiled isolation gown bin and they should not be shared between rooms. A review of the facility-provided policy and procedure titled, PPE, Donning (putting on) and Doffing, dated 2/2023, indicated the purpose of the policy and procedure was to provide guidelines and procedures for the doffing and donning of PPE in the facility. The facility will use the Centers for Disease Control and Prevention (CDC) guidelines on the procedure for the donning and doffing of PPE supplies. A review of the facility-provided CDC Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings, undated, indicated PPE is donned before contact with the patient, generally before entering the room. PPE is used carefully to not spread contamination. PPE is removed of and discarded carefully either at the doorway or immediately outside the patient room. 38469 4. During an observation of the facility's kitchen and concurrent interview on 1/6/2024 at 8:45 a.m., with the Dietary Clerk (DC), observed the door in the dry storage area opened with three canned products placed on the floor to prop the door open. The DC stated that staff should not have used canned food items as a wedge to prop the door open because it is not sanitary. The DC stated that floors are contaminated as staff in the kitchen step on the floor and anything from the floor is a potential source of infection which could make the residents sick. A review of the facility's policy and procedure titled, Food Storage, approved on 2/2023, indicated, To ensure the safe storage of food in order to prevent the occurrence of foodborne illness .food and supplies are stored on shelves or dunnage (durable padding material used to protect goods inside of a package) type racks at least 12 inches off the floor .

Based on observation, interview and record review, the facility failed to ensure residents' right to a dignified existence by failing to: 1. Ensure an indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) was covered with a privacy bag (dignity bag- a bag that conceals urine in the collection bag) for one of two sampled residents (Resident 3) investigated under the Dignity care area. This deficient practice had the potential to affect Resident 3's dignity and privacy. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) knocked on a resident's door before entering the room for one of two sampled residents (Resident 25) investigated for dignity. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: 1. A review of Resident 3's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 3's Minimum Data Set (MDS- as assessment and care screening tool) dated 8/15/2023, indicated the facility admitted the resident on 9/14/2004. The MDS indicated the resident was in a persistent vegetative state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain) with no discernible consciousness (no evidence of awareness of self or environment). The MDS indicated the resident was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS further indicated the resident had an indwelling catheter. A review of Resident 3's Physician Orders Summary indicated an order for an indwelling catheter to dependent drainage (drainage from the lowest part and into a receptacle at a lower level than the structure being drained) for a diagnosis of urinary retention (unable to empty urine from the body) and urethral stricture (narrowing of the tubes that carry urine out of the body), dated 11/29/2020. During an observation on 1/6/2024 at 12:05 p.m., observed Resident 3 in bed with an indwelling catheter urine collection bag hanging from the right side of bed containing clear yellow urine. During a concurrent observation and interview on 1/6/2024 at 12:05 p.m. with Certified Nursing Assistant 5 (CNA 5), CNA 5 stood in the main hallway outside Resident 3's room and stated Resident 3 had an indwelling catheter and the urine was visible from the main hallway. CNA 5 stated there was no privacy cover over the urine collection bag. During a concurrent observation and interview on 1/6/2024 at 12:15 p.m. with Licensed Vocational Nurse 1 (LVN 1), observed Resident 3's urine collection bag and stated the unit does not cover urine collection bags. LVN 1 stated urine collection bags are to be covered for privacy, so the urine is not visible to visitors or other residents. During an interview on 1/7/2024 at 9:36 a.m. with Registered Nurse 1 (RN 1), RN 1 stated she was aware of privacy covers for urine collection bags and they are used for dignity purposes. RN 1 stated they do not cover the urine collection bags. RN 1 stated the residents on the unit live in the facility and have the right to dignity. During an interview on 1/7/2024 at 9:46 a.m. with LVN 2, LVN 2 stated urine collection bags are to be covered for dignity purposes while the residents were in bed in their rooms, so the resident's urine was not visible. LVN 2 stated privacy bags were not used in this facility. During an interview on 1/7/2024 at 9:55 a.m. with the Chief Nursing Officer (CNO), the CNO stated privacy bags should be used for urine collection bags. The CNO stated he was surprised the privacy bags were not being used at the facility. The CNO stated the privacy bags are used for dignity and the resident's right to cover the urine collection bag, so urine was not visible to visitors and other resident's. The CNO stated the facility's policy for foley catheters did not include privacy bags, but the policy would be changed. A review of the facility-provided Resident [NAME] of Rights, dated 12/3/2015, indicated the facility shall ensure the patients' rights are not violated. Patients have the right to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. 38549 2. A review of Resident 25's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure A review of Resident 25's MDS, dated [DATE], indicated the facility admitted the resident on 3/8/2022. The MDS also indicated the resident was dependent on staff for eating and personal hygiene. During a concurrent observation and interview on 1/7/2024 at 8:20 a.m., with LVN 2, observed LVN 2 enter Resident 25's room without knocking on the door. When asked if she had knocked on the resident's door before entering the room, LVN 2 confirmed by stating that she did not. LVN 2 stated she should have knocked on the door before entering the room. During an interview on 1/7/2024 at 5:18 p.m., with the Sub-Acute Nurse Manager (NM), the NM stated that staff should knock on the door before entering a resident's room. The NM stated it was important for staff to knock first in order to inform the resident that someone is entering the room. The NM stated the facility was the resident's home, so staff should treat it like it's their home. The NM stated it was also a way for staff to make the resident aware of their presence. The NM stated residents can possibly be made to feel disrespected or that their privacy is being invaded. The NM stated not knocking before entering the room can affect the resident's dignity. A review of the facility-provided Resident [NAME] of Rights, dated 12/3/2015, indicated the facility shall ensure the patients' rights are not violated. Patients have the right to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.

Based on interview and record review, the facility failed to promote the resident's right to be informed of and participate in their treatment for one of two sampled residents (Resident 5) by failing to obtain consent and inform the resident or responsible party in advance of the risks and benefits of the psychoactive (affecting the mind or behavior) medication sertraline (used to treat certain mental/mood disorders such as depression [(mood disorder that causes a persistent feeling of sadness and loss of interest]). This deficient practice violated Resident 5's and/or their responsible party's right to make an informed decision regarding the use of a psychoactive medication. Findings: A review of Resident 5's Admission/Registration form, dated 1/1/2024, indicated the facility admitted with the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 5's Minimum Data Set (MDS- as assessment and care screening tool) dated 10/26/23, indicated the facility admitted the resident on 9/3/2004. The MDS indicated the resident was in a persistent vegetative state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain) with no discernible consciousness (no evidence of awareness of self or environment). A review of Resident 5's History and Physical (H&P- a term used to describe a physician's examination of a patient) dated 1/3/2023, indicated the resident's diagnoses included anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells) and depression. A review of Resident 5's Physician's Orders included an order for sertraline 50 milligrams (mg- a unit of measurement) tablet, give via gastrostomy tube (G-tube- a tube inserted through the belly that brings nutrition and medication directly to the stomach) every day for depression manifested by crying, dated 6/14/2022. During a concurrent interview and record review on 1/7/2024 at 4:16 p.m., with the Sub-Acute Nurse Manager (NM), reviewed Resident 5's Resident Information and Consent for Antidepressant, form dated 1/15/2017. The form indicated that the consent on file was for sertraline 25 mg every morning. The NM confirmed that the current active order is for sertraline 50 mg every day. The NM verified by stating that there was no consent for the increased dose of sertraline 50 mg from the previous order of sertraline 25 mg. The NM stated that they should have obtained a consent from the resident or the resident's responsible party since this medication can cause adverse reactions which can harm the patient. A review of the facility's policy and procedure titled, Antipsychotic Drug Therapy Monitoring, approved on 2/2023, indicated, Patients who have antipsychotic (medication used to treat mental disorder) drug therapy initiated shall receive a comprehensive assessment to assure antipsychotic drug therapy is necessary to treat specific condition rather than used as a chemical restraint .nursing staff will ensure that an informed consent has been signed by the patient and/or representative indicating consent to receive the antipsychotic medication .

Based on observation, interview, and record review the facility failed to provide professional standards of care to residents receiving care for deep vein thrombosis (DVT, a blood clot [gel-like clump of blood] that develops in one of the large veins in the body) prophylaxis (prevention) for one of six sampled residents (Resident 7) investigated for Position/Mobility by failing to clarify the physician's order for sequential compression device (SCDs, a machine that intermittently pumps air into sleeves wrapped around the lower legs in order to increase blood flow and prevent DVTs) and apply the SCDs. This deficient practice had the potential to result in a DVT for Resident 7. Findings: A review of Resident 7's Admission/Registration Record dated 1/1/2024, indicated the facility admitted the resident with a diagnosis of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen). A review of Resident 7's Minimum Data Set (MDS- as assessment and care screening tool) dated 11/15/2023, indicated the facility admitted the resident on 1/23/2007. The MDS indicated the resident was in a persistent vegetative state (a chronic condition with absence of responsiveness and awareness due to overwhelming dysfunction of the brain) with no discernible consciousness (no evidence of awareness of self or environment). The MDS indicated the resident had impairment on both sides of the upper and lower extremities. The MDS further indicated the resident was dependent on staff for mobility, dressing, eating, and personal hygiene. A review of Resident 7's Physician Orders, indicated an order for SCD (DVT pumps) PRN (as needed) for DVT prophylaxis, dated 12/26/2023. During an observation and interview on 1/6/2024 at 2:41 p.m. with Certified Nursing Assistant 3 (CNA 3), observed Resident 7 lying in bed and CNA 3 stated Resident 7 did not have SCDs, that there was no SCD device on the bed or in the room, and the resident had never had SCDs that she was aware of. During a concurrent observation, interview, and record review on 1/6/2024 at 2:50 p.m., with Licensed Vocational Nurse 3 (LVN 3), reviewed Resident 7's physician orders. LVN 3 observed Resident 7 and stated the resident did not have SCDs. LVN 3 stated Resident 7's physician order for SCDs PRN did not indicate when to apply them or a time frame. LVN 3 stated she had never seen an order for SCD's PRN and would need to clarify the order. During a concurrent interview and record review on 1/6/2024 at 2:55 p.m. with Registered Nurse 1 (RN 1), reviewed Resident 7's physician orders. RN 1 stated Resident 7 previously received Lovenox (a medication used for DVT prevention) but was not tolerating the medication and the Lovenox was put on hold (do not give) and SCDs were ordered. RN 1 stated the physician's order indicating PRN should have been previously clarified and was not because she was busy with a lot of things going on. RN 1 stated it was important to clarify the order and administer the SCDs in order to prevent a DVT. During a concurrent interview and record review on 1/6/2024 at 5 p.m. with the Sub-Acute Nurse Manager (NM), reviewed Resident 7's physician orders. The NM stated SCDs, also called DVT pumps, are a mechanical device that squeeze the lower legs to move the blood and prevent clots from forming in residents that don't move or walk. The NM stated the order did not make sense because it indicated to use SCDs PRN without indicating how to determine if they were needed. The NM stated the order should have been clarified when it was written and the SCD's should have been applied. The NM stated the importance of implementing the SCD intervention was to prevent blood clots which can result in death of a resident. A review of the facility's policy and procedure titled, DVT Prophylaxis, dated 2/2023, indicated the purpose of the policy and procedure was to provide a physician-approved process by which registered nurse may independently implement mechanical venous thromboembolism (VTE- a condition that occurs when blood clots form in a vein) prophylaxis interventions. Each patient will be assessed for VTE prophylaxis exclusion criteria . the patient is already on pharmacologic anticoagulation. If one or more exclusion criteria are present, the physician will be contacted for specific VTE prophylaxis orders. The physician's order will be entered into the electronic medical record and implemented within one hour (maximum time from order to implementation not to exceed four hours).

Based on observation, interview, and record review, the facility failed to: 1. Maintain comfortable and acceptable room temperature (ambient air temperature) ranging from 71 to 81 degrees Fahrenheit ( F, unit of temperature). 2. Maintain the compressor (the driving unit of a chiller system) for one of two chillers in working condition. A chiller is a cooling water circulation device that is connected to the air conditioning (A/C) system. 3. Monitor room temperatures and retain records of temperature checks. These deficiencies affected the entire 4th floor of the facility, where 27 of 27 Sub-Acute (a medical facility that provides medical care to chronically ill patients who are medically stable) residents were residing. As a result, Residents 3, 6 and facility staff complained the room temperatures were hot and uncomfortable. This deficient practice placed Residents 3, 6 and other severely ill residents (Residents 1, 2, 4,5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27) at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). On 7/25/2023, at 6:29 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was declared. The facility's Chief Nursing Officer (CNO), Director of Plant Operations (DPO), and Lead Maintenance of Engineering (LME) were notified of the facility's failure to maintain the compressor for one of two chillers in working condition, monitor and record room temperatures, and provide comfortable and acceptable room temperature for all residents. On 7/27/2023 at 4:23 p.m., the CNO provided an acceptable IJ removal plan that included the following summarized actions/items: A. Procurement of portable chiller to provide acceptable temperature in the facility. B. Obtain emergency authorization from the Department of Health Care Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development - OSHPD) for the installation of portable chiller. C. Temporary transfer of residents from 4th floor sub-acute unit to 1st floor acute rehabilitation unit (ARU, an institution that provides restorative treatment for instance physical, occupational or speech therapy, to patients with physical injury, dysfunction or disability over a short period of time) and intensive care unit (ICU, a unit in a hospital where severely ill patients are treated and kept under constant medical observation). D. Submit program flexibility request for the use of the ARU and the ICU beds. E. Notification to family members/residents for the temporary location. F. Hourly temperature monitoring of resident rooms. G. In-services performed to staff regarding utilization of temperature log, precautionary measure during heat, and proper use and maintenance of portable cooling devices. On 7/27/2023, at 6:18 p.m., after verifying satisfactory implementation of the facility's immediate corrective actions noted in the IJ Removal Plan (interventions to correct the deficient practice), the Immediate Jeopardy was removed in the presence of the CNO. Findings: A review of the facility's Certification Information indicated that the facility was recommended for certification on 2/3/2023. A review of the facility's census dated 7/25/2023 indicated that there were 27 sub-acute residents in the facility. A review of Resident 3's Face Sheet indicated the facility admitted the resident on January 1, 2023, with diagnoses including respiratory failure (a condition where the lungs fail to perform their normal gas exchange function resulting in too much carbon dioxide or too little oxygen in the blood). Other diagnoses include chronic hypoxemic respiratory failure (a condition where the lungs are not functioning adequately to keep oxygen exchange at acceptable levels), pneumonia (an infection in the lungs that causes them to fill up with fluid or pus) and hypothyroidism (A condition in which the thyroid gland doesn't produce enough thyroid hormone) and chronic cough (a persistent cough that last longer than 8 weeks). Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated June 18, 2023, indicated the resident has no cognition deficient (ability to think and process information). Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for toilet use, personal hygiene and dressing. Resident 1 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other weight -bearing assistance) for bed mobility and walking. A review of Resident 6's Face Sheet indicated the facility admitted the resident on January 1, 2023, with diagnoses including respiratory failure. Resident 6's MDS, dated [DATE], indicated the resident has intact cognition. Resident 6 requires extensive assistance for bed mobility, transfer, toilet use, personal hygiene and dressing. Resident 6 requires supervision for eating. A review of Resident 7's Face Sheet indicated the facility admitted the resident on January 1, 2023, with diagnoses including chronic hypoxemic respiratory failure. Other diagnoses include traumatic brain injury (a sudden injury that causes damage to the brain) and status-post motor vehicle accident. Resident 7's MDS dated [DATE], indicated the resident had severe impairment in cognition. Resident 7 has total dependence (full staff performance every time during the entire 7-day period) for all activities of daily living. According to https://www.nia.nih.gov/health/hot-weather-safety-older-adults National Institute on Aging, under Hot Weather Safety for Older Adults, dated September 2, 2022, indicated older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100 F to put the residents at risk for a heat-related illness. Headache, confusion, dizziness, or nausea could be a sign of a heat-related illness. High environmental temperatures can be dangerous to the body. In the range from 90 F to 105 F, residents can experience heat cramps (painful, involuntary muscle spasms that usually occur during heavy exercise in hot environments) and exhaustion (a state of extreme physical or mental fatigue). During an interview on 7/27/2023, at 2:15 p.m., with registered nurse (RN) 2, RN 2 stated that residents may suffer from dehydration, sweating and heat rash (an itchy skin condition presenting as red blisters caused by blocked sweat ducts and trapped sweat under the skin) due to extreme heat. 1. During an interview on 7/25/2023, at 11:53 a.m., with Resident 3, an oxygen-dependent tracheostomy (a curved hollow tube made of rubber or plastic placed into the trachea of a person to enable mechanical ventilation or to relieve airway obstruction) resident, Resident 3 stated that the room gets very hot, and the facility offered a portable box fan, but it blows hot air and that makes her cough more. Resident 3 also added that other residents on the other side of the unit must get even hotter as the sun rises from that side of the building. During an interview on 7/25/2023, at 12:31 p.m., with certified nursing assistant (CNA)1, CNA 1 stated it was very hot and uncomfortable to clean patients while wearing personal protective gear (PPE). The facility practices enhanced standard precautions (an infection prevention intervention adopted by some nursing home facilities to reduce transmission of multidrug-resistant organisms) and staff must wear PPE to enter each resident's room. During an interview on 7/25/2023, at 1:23 p.m., Resident 6 stated that it was too hot in her room. During an interview on 7/27/2023, at 2:15 p.m., with registered nurse (RN) 2, RN 2 stated it was completely miserable being inside the resident's room with PPE due to the extreme heat that made staff feel uncomfortable inside the resident's room. During an interview on 7/25/2023, at 1:59 p.m., the RN Sub-Acute Manager (SAM) stated that the whole building is warm because of the A/C problem. During an interview with the LME and DPO on 7/25/2023, at 3:17 p.m., the DPO stated that 74 F to 75 F was the maximum room temperature and 68 F is the lowest room temperature required according to the facility's policy. A review of The Weather Channel's forecast indicated the highest temperature for the day of 7/25/2023 was 99 F for the facility's zip code. During concurrent observations and interviews on 7/25/2023, the LME measured resident room temperatures using a temperature gun (a non-contact thermometer [temperature-sensing instrument], also called infrared thermometer). The following temperatures were obtained: A. At 4:20 p.m., in Resident 1 and Resident 9's room, the LME measured the room temperature, and it was measured at 84 F. B. At 4:21 p.m., in Resident 2's room, the LME measured the room temperature, and it was measured at 84 F. C. At 4:21 p.m., in Resident 3's room, the LME measured the room temperature, and it was measured at 83 to 84 F. D. At 4:25 p.m., in Resident 4's room, the LME measured the room temperature, and it was measured at 83 F. E. At 4:25 p.m., in Resident 5's room, the LME measured the room temperature, and it was measured at 82 to 83 F. During an interview on 7/26/2023, at 2:17 p.m., the CNO stated that the past few days had been unbearable, I think it was 100[ F] in the valley. A review of The Weather Channel's forecast indicated the highest temperature for the day of 7/26/2023 was 99 F for the facility's zip code. The forecast also indicated a Heat Advisory (a period of hot temperatures is expected) for the facility's zip code. During concurrent observations and interviews on 7/26/2023, the LME measured resident room temperatures using a temperature gun. The following temperatures were obtained: A. At 5:31 p.m., in Resident 1 and Resident 9's room, the LME measured the room temperature, and it was measured at 86 F. The LME stated that it's hot in the room. B. At 5:33 pm, in Resident 2's room, the LME measured the room temperature, and it was measured at 84 to 87 F. C. At 5:33 p.m., in Resident 3's room, the LME measured the room temperature, and it was measured at 85 to 86 F. The LME stated, it's hotter here because of the heat from the sun. D. At 5:36 p.m., in Resident 5's room, the LME measured the room temperature, and it was measured at 84 F. A review of The Weather Channel's forecast indicated the highest temperature for the day of 7/27/2023 was 99 F for the facility's zip code. The forecast also indicated that the highest temperature recorded for 7/25/2023 and 7/26/2023 was 101 F. A review of the facility's policy and procedure (P&P) titled, Air Conditioning (HVAC) System Failure, dated 12/2019, indicated, the comfortable and safe temperature levels range between 71 to 81 F. A review of County of Los Angeles Public Health News Release, dated 7/26/2023, indicated, heat advisory extended - high temperatures for parts of Los Angeles County from 7/25/2023 to 7/27/2023. Public Health reminds everyone to take precautions to avoid heat-related illness, especially older adults, young children, outdoor workers, athletes, and people with a chronic medical condition who are especially sensitive to negative health impacts from extreme heat. 2. During an interview on 7/25/2023, at 11:29 a.m., the LME stated that the compressor for one of two chillers in the penthouse (rooftop) started having problems about two weeks ago and that is affecting the tower. The tower included the resident rooms in the 4thfloor sub-acute. The LME added, four portable A/Cs were installed in the sub-acute unit and fans were provided to the residents. During an interview on 7/25/2023, at 4:47 p.m., the DPO stated that the facility was waiting for parts to be delivered to repair the chiller's compressor. The parts were ordered on Sunday (7/23/2023) and scheduled to be delivered on 7/26/2023. During a concurrent observation and interview on 7/25/2023 at 12:02 p.m., with LME on the rooftop (penthouse), the evaluator observed one of the chillers not working with equipment parts on the floor. The LME pointed to one of the chillers and stated, that is not working and that it's off. The parts on the floor were the chiller's water valve and exhaust. During an interview on 7/25/2023, at 1:12 p.m., the LME stated, the facility has one chiller that is working but not enough to provide cool air because the other chiller is down. During an interview with the LME and DPO on 7/25/2023, at 3:17 p.m., the LME stated that the vendor started working on the non-functioning chiller on Thursday (7/20/2023). The DPO also stated, we know that we are having issues. During a concurrent interview and record review on 7/27/2023 at 2:28 p.m. with Engineering Staff 1 (ES 1), the Penthouse Chiller Room engineering log dated 6/26/2023 was reviewed. The log indicated, OFF, OOC, and called vendor for service. ES 1 explained, that means off, equipment is off, and we let the vendor know. OOC means out of service, because the unit starts to trip and the vendor [was] supposed to look at it. During a concurrent interview and record review on 7/27/2023 at 2:59 p.m. with ES 1, the Penthouse Chiller Room engineering log dated 5/22/2023 was reviewed. The log indicated, 5/23 - chiller #2 - reset oil pressure switch. - still tripping called vendor and #2 chiller not working notify vendor. ES 1 explained, that means the chiller had been shut off and the unit started having issues on 5/23/2023. It was not normal. During a review of the facility's policy and procedure (P&P) titled, Air Conditioning (HVAC) System Failure, dated 12/2019, the P&P indicated, The Engineering Department is responsible for the operation of the HVAC System throughout the hospital. The heating, ventilation, and air-conditioning (HVAC) system is designed, installed, operated and maintained in a manner that is designed to provide a comfortable and safe environment for patients, personnel and visitors. Procedures in the event of HVAC failure included the following procedures: check to ascertain if chillers are operating, if the engineering tech is unable to identify the problem, contact the approved vendor, and notify House Supervisor and Administrator on call. During a review of the facility's policy and procedure (P&P) titled, Utility systems Management Plan, dated 1/2022, the P&P indicated, The Director of Facilities Management has the responsibility of the Utility Equipment Management Plan and will ensure the hospital designs, installs and maintains utility systems that meet patient care and operational needs. The Director of Facilities Management has overall responsibility for the proper maintenance and operation of the utility and mechanical systems in the hospital. These systems include HVAC (heating, ventilation, and air conditioning) systems. 3. During an interview on 7/25/2023, at 12:21 p.m., the LME stated that the engineering staff either checks the thermostat (temperature regulating device) or uses a temperature gun to measure room temperatures. The temperature in resident rooms including the 4thfloor sub-acute should range between 68 F to 72 F according to facility's policy. The LME explained, the engineering staff conducts daily room temperature check in the surgical suite but we don't do sub-acute, on and off I do take temperatures, but I don't do it on a daily basis. The LME also stated that the facility does not keep record of the room temperatures taken in sub-acute. During an interview on 7/26/2023, at 3:18 p.m., the DPO stated that the facility was supposed to have a daily [room temperature] log that is monitored every shift by engineering department. The facility was unable to provide records of room temperature monitoring for the sub-acute. A review of the facility's policy and procedure (P&P) titled, Air Conditioning (HVAC) System Failure, dated 12/2019, indicated, the Engineering Department is responsible for the operation of the HVAC System throughout the hospital. The procedure included maintaining records of inspections and services performed in the Facilities Department.

Based on observation, interview, and record review, the facility failed to properly screen visitors and employees to prevent and control the spread of COVID-19 (coronavirus disease 2019, a serious disease resulting from a new virus that spreads easily from person to person) in accordance with the local Public Health guidelines and facility policy & procedure. This deficient practice had the potential to result in the spread of COVID-19, placing all 24 of 24 residents in the facility and all staff at risk for COVID-19 infection that could lead to severe respiratory illness, hospitalization , and/or death. On 3/11/2021, at 1:51 p.m., an Immediate Jeopardy (IJ, a situation in which a facility's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a resident) was called in the presence of the facility's Director of Nursing (DON) and Infection Control Preventionist (ICP) regarding the facility's failure to properly screen visitors and employees for COVID-19. On 3/11/2021, at 6:20 p.m., the IJ was lifted in the presence of the ICP and Director of Staff Development/Clinical Coordinator (DSD/CC) after they submitted an acceptable Plan of Action (POA, interventions to immediately correct the deficient practices). The surveyors verified and confirmed the implementation of the POA while on-site through observation, interview, and record review. The acceptable POA is as follows: 1. The Individual Risk Assessment for COVID-19 was updated to include travel history, new onset of symptoms, and potential exposure as part of daily screening to all employees and visitors. 2. The ICP provided an in-service regarding proper screening of all employees and visitors with verbal return demonstration to the current screener on duty. The ICP provided a schedule in which he and the House Supervisor would continue to in-service all screeners through 3/14/2021. 3. The ICP and Nursing Supervisor will monitor weekly compliance on updated Individual Risk Assessment for COVID-19 forms. Findings: During an observation on 3/11/2021, at 9:02 a.m., three surveyors (Surveyor 1, Surveyor 2, Surveyor 3) entered the main entrance of the hospital that was designated as the only screening area on the first floor of the hospital. The screener (Screener 1) instructed each surveyor to stand in a designated location to have their temperature read by the infrared thermometer machine (a digital thermometer capable of measuring the temperature of something based on heat and energy). After each surveyor's temperature was taken, Screener 1 instructed them to go to the security desk without asking any questions about signs and symptoms of COVID-19, recent exposure to someone with COVID-19, recent travel, or testing positive for COVID-19, or asking them to fill out any forms. During an observation on 3/11/2021, at 10:12 a.m., Surveyors 1, 2, and 3 entered the distinct part skilled nursing facility (D/P SNF) unit of the hospital by taking the elevator to the 4th floor. The elevator was located past the only screening area on the first floor on the hospital and the unit was not locked. During an interview on 3/11/2021, at 10:41 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she was screened at the main entrance of the hospital when she came to work that day. She stated her temperature was taken and she was asked about her symptoms only. During an interview on 3/11/2021, at 11:00 a.m., with EVS (Environmental Services) Technician 1, EVS Technician 1 stated that she was screened at the main entrance of the hospital when she came to work that day. She stated the screener took her temperature but was not asked questions about her symptoms or travel history as required. During an interview with a visitor on 3/11/2021, at 11:13 a.m., the visitor informed Screener 1 that he was previously at the main entrance of the hospital for screening on Monday but did not get logged on the screening form. The visitor did not fill out the proper screening form. During an observation of a screening process at the main entrance of the hospital on [DATE], at 11:14 a.m., Screener 1 took the temperature of a hospital employee who was visiting for therapy, but not reporting to work, and was asked if she was experiencing any COVID-19 signs and symptoms but was not asked about her recent exposure to someone with COVID-19, recent travel, or if she tested positive for COVID-19. During an interview with Screener 1 and ICP on 3/11/2021, at 11:09 a.m., Screener 1 stated that when someone would enter the facility, she would greet them, would ask them to stand in the designated area to have their temperature taken. Screener 1 then asked the ICP what she should do when screening staff and visitors because she did not know what proper screening questions and process to ask the staff and visitors. Screener 1 then stated that staff and visitors do not fill out the screening forms, but that she fills it out for them. During an interview on 3/11/2021, at 12:12 p.m., with the ICP, the ICP stated, For anyone who came in the hospital, their temperature would be taken, and then they should be asked the questions, if you have any signs and symptoms of COVID. The temperature, date of visit, and symptoms would be recorded in the back of the screening form. After that, they should also be asked about travel history or being exposed to someone with COVID-19. The ICP further stated that the screening form would only be filled out if the person has never been to the facility before but the policy indicated that patients, visitors, and employees should be screened upon arrival to the building. During an interview on 3/11/2021, at 1:00 p.m., with the Staff Coordinator, the Staff Coordinator stated the screening process should include temperature checks, asking questions about travel, symptoms of COVID-19, and changes in health status. The Staff Coordinator further stated that all staff and visitors should fill out the screening form. This process has been in place since April 2020, and the completed forms were being audited every couple of weeks to ensure they were filled out correctly. During an interview on 3/11/2021, at 1:21 p.m., with the Nursing Supervisor, the Nursing Supervisor stated, When someone came in the facility, they would stand in a box (square shape marked by red tape on the floor), would look on to the camera, look at a list of COVID related questions on the wall. Do they have any symptoms? If they would say no or yes, we would have them fill out a form. The screener would fill out the front page of the Individual Risk Assessment for COVID-19. The Nursing Supervisor stated Nursing Supervisors were responsible for auditing the forms and ensuring they were filled out correctly, and that they audit the forms by highlighting areas that were not filled out correctly. The Nursing Supervisor further stated, Once in a while, I would go over the Individual Risk Assessment for COVID-19 maybe every 3-4 weeks or a month. During a review of the blank Individual Risk Assessment for COVID-19, revised 4/29/2020, the front page of the Individual Risk Assessment for COVID-19 indicated that both health care personnel and visitors were to answer the following questions: 1. In the past 14 days, have you traveled outside the U.S., been on a cruise ship, or traveled outside California to any state? 2. Since your last worked shift, have you had: Fevers (Temperature > 100 degrees)? Cough? Shortness of breath or Difficulty breathing? Sore throat? Body ache/Muscle Pain? Chills? Repeated shaking with chills? Nausea/vomiting? Diarrhea? 3. In the past 14 days, have you had close, prolonged contact with an ill person who has suspected or confirmed COVID-19 and not wearing appropriate PPE? The back page of the Individual Risk Assessment for COVID-19 indicated that the date, their temperature, and symptoms should be recorded. The back should be re-used for the person's subsequent visits for the documentation of temperature and symptoms. The bottom of the form indicated that Risk Assessment must be certified by the Nursing Supervisor. During a review of LVN 1's Individual Risk Assessment for COVID-19, dated 12/12/2020, the Risk Assessment indicated the following: 1. LVN 1 did not fill out the required sections on the front page regarding travel history, potential exposure, and new onset of symptoms. LVN 1 signed the front page on 12/12/2020 2. LVN 1's most recent temperature and symptoms were documented on the back-page on 3/11/2021. During a review of Housekeeper 1's Individual Risk Assessment for COVID-19, dated 3/9/2021, the Risk Assessment indicated the following: 1. Housekeeper 1 answered no to all questions on the front page regarding travel history, potential exposure, and new onset of symptoms on 3/9/2021. 2. Housekeeper 1's most recent temperature and symptoms were documented on the back page on 3/11/2021. During a review of ICP's Individual Risk Assessment for COVID-19, dated 2/10/2021, the Risk Assessment indicated the following: 1. ICP answered no to all questions on the front page regarding travel history, potential exposure, and new onset of symptoms on 2/10/2021. 2. ICP's most recent temperature and symptoms were documented on the back page on 3/11/2021. During a review of the facility's policy and procedure (P&P) titled, EH-COVID-19 Employee Screening, revised 8/2020, the P&P indicated, To ensure the safety of our workforce, patients, and visitors, employees are screened upon arrival to the building . Screeners will ask the following questions and document the responses: 1. Since your last worked shift, have you had fever or chills? Cough? Shortness of breath or difficulty breathing? Fatigue? Muscle or body aches? Headache? New loss of sense of taste or smell? Sore throat? Congestion or runny nose? Nausea or vomiting? Diarrhea? (to be asked and answered one symptom at a time) 2. In the past 14 days, have you travelled to a country or region with a travel restriction upon return, or been on a cruise ship? 3. In the past 14 days, have you had close, prolonged contact with a person who has symptoms of COVID-19 or who has tested positive for COVID-19? 4. Have you tested positive for COVID-19 in the past 10 days?