Every finding on record at Lakeport Post Acute

F760 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) The facility must ensure that its- S483.45(f)(2) Residents are free of any significant medication errors. Based on observation, interview and record review, the facility failed to follow facility policies & procedures that required triple-checking of medication before administration which resulted in failure to administer the correct medication prescribed for one of three sampled residents (Resident 1). As a direct result, Resident 1 experienced a life-threatening adverse reaction requiring emergency rescue medications, transfer to a General Acute Care Hospital (GACH), and hospitalization in the intensive care unit for life threatening symptoms. This failure resulted in actual harm and exposed the resident to a substantial likelihood of death.A review of Resident 1's admission Record (facility demographic), indicated she was admitted to the facility on [DATE] with a primary admitting diagnosis of Parkinson's Disease (a nervous system disorder that affects movement, often causing tremors, stiffness, slowness, and balance issues).A review of Resident 1's medication order summary indicated she was prescribed Heparin Sodium (a medication to thin the blood and prevent blood clots) at a concentration of 5000 units/mL (where unit denotes a standard unit of measure and mL refers to milliliters). The regimen required administration of 1 mL of heparin every 12 hours. This order was written by a facility physician on 4/16/26.During a review of a progress note in Resident 1's medical record created by Licensed Nurse 1 (LN 1), dated 5/11/26, at 9:02 p.m., LN 1 indicated he thought he made a serious medication error at 8:05 p.m., on 5/11/26. LN 1 wrote that he may have given Resident 1 insulin instead of the ordered medication, Heparin. LN 1 also documented that Resident 1 was not diabetic (referring to Diabetes Mellitus, a chronic condition that causes increased blood sugar levels). The documentation indicated LN 1 checked Resident 1's blood sugar at 9:07 p.m., which resulted in a reading of 55 mg/dL (mg/dL means milligrams per deciliter, a standard unit of measure; normal blood sugar levels are 70-99 mg/dL when fasting) and proceeded by giving Resident 1 a peanut butter and jelly sandwich and a glass of orange juice. The note indicated LN 1 then contacted the Facility Medical Director (FMD) for a consultation. The FMD ordered a Glucagon injection (an injectable emergency medication prescribed to treat severe, dangerous low blood sugar) to be administered to Resident 1. The FMD also instructed Resident 1's blood sugar be checked every 10 minutes and that she be moved to the nurses' station, placed in a chair, and given another glass of orange juice. LN 1 documented that he called 911, and that the FMD notified the ER physician of Resident 1's status. LN 1 documented he checked Resident 1's blood sugar again, at 9:22 p.m., which resulted in 53 mg/dL, and emergency medical services arrived and transported Resident 1 from the facility to a GACH at approximately 9:48 p.m.A review Resident 1's GACH records, including emergency room (ER) records, dated 5/11/26 - 5/12/26, indicated Resident 1 received Dextrose 10% (a solution administered into a vein via a small tube, commonly used to treat severe low blood sugar levels in patients), while on route to the ER for evaluation of, Insulin [a medication to lower blood sugar] overdose. Resident 1's blood potassium level resulted in a reading of 2.8 mmol/L (millimoles per liter, a standard unit of measure; normal blood potassium levels are 3.5-5.1 mmol/L; a blood potassium level of less than 3.0 mmol/L can be life-threatening and requires urgent medical attention to avoid dangerous complications, such as abnormal heart rhythms, muscle weakness, or paralysis). Resident 1's medical record indicated her low potassium level was due to an insulin overdose and required her to be treated with potassium replacement administration. The record further indicated Resident 1's blood pressure was lower than normal likely due to her, insulin overdose. Resident 1 was administered the medication Levophed (a potent, fast-acting medication used in GACHs to treat life-threateningly low blood pressure) to treat her low blood pressure in the ER and additional intravenous (medications or fluids given through a small tube placed in a vein) fluids to maintain her blood pressure. The records indicated Resident 1 was admitted for hospitalization into the intensive care unit.During an interview on 5/13/26 at 3:15 p.m., LN 1 stated that on 5/11/26 at approximately 8:05 p.m., he administered 1 mL of the medication Insulin Lispro (a rapid acting medication prescribed to reduce a person's blood sugar level) to Resident 1 instead of her ordered Heparin injection. LN 1 stated he obtained the medication vial from the front of the medication drawer, where insulin vials were stored, instead of from the back of the drawer where Heparin vials were kept and did not verify the medication label against the physician's order before administering it. LN 1 stated he realized the error at approximately 9 p.m. and checked Resident 1's blood sugar at 9:07 p.m., which resulted in a reading of 55 mg/dL. LN 1 stated he gave Resident 1 a peanut butter and jelly sandwich and orange juice, then notified the Director of Nursing (DON) and the Facility Medical Director (FMD). LN 1 stated the FMD ordered Glucagon injection to be administered immediately, and LN 1 administered it to Resident 1 at 9:10 p.m. According to LN 1, the FMD also ordered Resident 1 to have her blood sugar checked every ten minutes, that she be moved to the nurses' station for monitoring, and that she be given additional orange juice. LN 1 stated the FMD instructed him to call 911 for transfer of Resident 1 to the GACH emergency department for evaluation and treatment, which he did upon the arrival of emergency medical services.During an interview on 5/13/26 at 3:52 p.m., Licensed Nurse 2 (LN 2) stated she worked the night shift on 5/11/26, and during LN 1's evening shift report handoff to her, LN 1 reported to her that Resident 1 was taken to the emergency room after he made a significant medication error while administering her medications during his shift. LN 1 reported to LN 2 that he administered insulin instead of Resident 1's ordered Heparin injection. LN 2 stated she called the hospital to inquire how Resident 1 was doing and see if she would be coming back to the facility during the night shift, and the emergency room nurse relayed to LN 2 that Resident 1 had a low potassium level and was being admitted to the GACH's intensive care unit for close monitoring. LN 2 stated she reported Resident 1's need for hospitalization into the intensive care unit status and low potassium level to the DON and the FMD by group text at 1:27 a.m., on 5/12/26. According to LN 2, at 1:30 a.m., on 5/12/26, the FMD responded to the group text, acknowledged LN 2's report, agreed Resident 1's hospitalization into the Intensive Care Unit was needed, and confirmed to LN 2 that a low potassium level was expected with Resident 1 being administered insulin.During an interview on 5/13/26 at 1:48 p.m., the Director of Nursing (DON) confirmed that LN 1 reported to her on 5/11/26 that he had made a significant medication error in which LN 1 administered 100 Units/1ml of Insulin Lispro to Resident 1 instead of her ordered Heparin medication, which resulted in Resident 1's hospitalization for treatment and evaluation. The DON stated LN 1 was put on a leave pending the outcome of an investigation. The DON confirmed that she expected licensed nurses to follow facility policies when administering medications to residents in the facility.During an observation of a medication administration for Resident 2 in the doorway of his room, on 5/13/26 at 11:47 a.m., Licensed Nurse 3 (LN 3) stated the first critical step in medication administration was to check the medication label on the vial against the physician's order to verify the correct medication, concentration, and dosage before drawing it into the syringe. LN 3 stated this step could not be skipped because doing so placed the resident at risk of receiving an incorrect medication, concentration, or dosage, which had the potential to cause harm.A review of the facility policy titled, Administering Medications, revised in April of 2019, indicated, Medications are administered in accordance with prescriber orders. If. a medication has been identified as having potential adverse consequences for the resident or suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns The individual administering the medication checks the label THREE (3) times to verify the right resident, the right medication, right dosage. before giving the medication .A review of the facility policy titled, Adverse Consequences and Medication Errors, revised in June of 2025, indicated, A medication error is defined as the preparation or administration of drugs . which is not in accordance with provider's orders. or accepted professional standards and principles of the professional(s) providing services. A significant medication-related error is defined as. requiring hospitalization, or extending a hospitalization. requiring treatment with a prescription medication. life threatening.

Based on observations, interviews and record reviews, the facility failed to provide nursing staff based on the 3.5 direct hours per patient day (DHPPD) for 27 out of 39 days reviewed. This failure resulted in two sampled residents, Resident 17 and Resident 37, ability to receive timely nursing care. This failure also had the potential to impact all residents in the facility. Findings: During a review of Resident 17's admission Record dated 6/18/25, the Admissions Record indicated that Resident 17 was admitted to the facility on [DATE] with the diagnosis of Cerebral Palsy (congenital disorder of movement, muscle tone, or posture), stroke (damage to brain from lack of blood supply), dementia (impairment of at least two brain function such as memory loss and judgement), and hemiplegia (muscle weakness of one side of the body). During a concurrent observation and interview on 6/17/25 at 9:30 AM with Resident 17 in his room, Resident 17 was observed laying on his right side, unable to reach his call light, and needed help to get up. Resident 17 had right hemiplegia and multiple contractures (unable to extend joints) to his elbow and hand. Resident 17 stated, It takes forever to get help here. I try to do as much as I can, but I need help. During a review of Resident 37's Minimum Data Set, dated 4/10/25, the Minimum Data Set indicated that Resident 37 was admitted to the facility on [DATE] with the diagnoses of Diabetes and Retinopathy (vision impairment). During a concurrent observation and interview on 6/17/25 at 12:40 PM, with Resident 37, in his room, Resident 37 was observed sitting on the side of his bed with the room dark (blinds pulled and lights off). Resident 37 indicated he was completely blind. Resident 37 stated, When I use the call light it takes a half hour, to an hour to get assistance. It is worse at night and on the weekends. Resident 37 stated, When I really need something, I go out to the nursing station and get it myself but I'm blind. Sometimes I call out until someone comes. During an interview on 6/19/25 at 8:30 AM with Certified Nursing Assistant (CNA) 3, CNA 3 stated, Often there is not enough staff. Today I have 15, I cannot care for the residents like I would like. During an interview on 6/19/25 at 8:45 AM with CNA 4, CNA 4 stated, Often there is not enough CNAs, I'm unable to spend as much time as needed to care for them, I feel rushed and cannot do a good job. During a review of California Department of Public Health workforce shortage waiver (staffing waiver), dated 6/14/24, the staffing waiver indicated, 2. The facility shall provide no less than 3.5 direct care service hours per patient day. During a concurrent interview and record review on 6/19/25 at 9:00 AM with the Director of Nursing (DON), Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 5/31/25 through 6/8/25 was reviewed. DON verified the DHPPD indicated eight of the nine days had a DHPPD of less than 3.5. DON stated that it is her expectation that call lights are to be answered within 15 minutes. During a review of DHPPD on 6/19/25, dated from 5/1/25 through 6/8/25, 27 of the 39 days reviewed indicated insufficient staffing levels of less than 3.5. The actual DHPPD hours are: 5/3/25 - 3.27 5/4/25 - 2.92 5/5/25 - 2.94 5/10/25 - 2.90 5/11/25 - 2.97 5/16/25 - 3.23 5/17/25 - 2.73 5/18/25 - 2.89 5/19/25 - 3.28 5/20/25 - 3.26 5/21/25 - 3.40 5/23/25 - 3.37 5/24/25 - 3.04 5/25/25 - 2.45 5/26/25 - 2.55 5/27/25 -3.38 5/28/25 - 3.27 5/29/25 - 3.47 5/30/25 - 3.29 5/31/25 - 2.98 6/1/25- 2.57 6/2/25 - 3.23 6/3/25 - 3.33 6/5/25 - 3.47 6/6/25 - 3.26 6/7/25 - 2.78 6/8/25 - 1.96

Based on observation, interview and record review, the facility failed to provide pain management services consistent with professional standards of practice for two of 18 sampled residents (Resident 15 and 222) when: 1. Licensed Vocational Nurse (LVN) 1 administered pain medication one hour seven minutes after Resident 15 requested pain medication and did not conduct a pain reassessment within an hour after administration. 2. Licensed Nurses did not conduct pain reassessments within an hour after administering pain medication to Resident 222. This failure had the potential for Resident 15 and 222 to have unrelieved pain and diminished quality of life. Findings: 1.During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted Resident 15 on 5/22/2025, with multiple diagnoses including open wound to right foot, acute osteomyelitis (bone infection) right ankle and foot. During a review of Resident 15's Minimum Data Set, dated 5/27/25, indicated Resident 15's Brief Interview for Mental Status (BIMS) assessment score was 14. The BIMS assessment indicated Resident 15 was cognitively intact. During a concurrent observation and interview on 6/17/25 at 9:42 AM with Resident 15, Resident 15 pressed his call light. Certified Nursing Assistant (CNA) 2 responded to the call light, Resident 15 informed CNA 2 that he needed pain medication for his foot. Resident 15 stated he had pain in his right foot from exercising and this was his first time asking for pain medication since admission. During a review of Resident 15's Medication Orders (MO) dated 5/22/25, the MO indicated acetaminophen two tablets every 6 hours as needed for generalized discomfort. Monitor pain every shift 1-3 mild pain, 4-5 moderate pain, 6-9 severe pain and 10 excruciating pain. During an interview on 06/17/25 at 11:02 AM with CNA 2, CNA 2 stated she informed LVN 1 of Resident 15's request of pain medication soon after leaving his room. During a concurrent interview and record review on 6/17/25 at 11:26 AM with LVN 1, Resident 15's Medication Administration Record (MAR), dated 6/25 was reviewed. The MAR indicated, LVN 1 administered PRN (as needed) Acetaminophen 325 MG (milligram-unit of measure) for a pain level of 3 of 10 at 10:49 AM on 6/17/25 [one hour seven minutes later from Resident 15's request]. LVN 1 stated pain should be addressed within 15-20 minutes. During a concurrent interview and record review on 6/18/25 at 2:51 PM with Minimum Data Set Nurse (MDS), Resident 15's Medication Administration Note (MAN) dated 6/17/25 was reviewed. The MAN indicated LVN 1 reassessed Resident 15's pain level at 1:24 PM [two hours and 35 minutes later]. MDS stated Resident 15 had osteomyelitis (infection) to the right foot. 2. During a review of Resident 222's AR, the AR indicated the facility admitted Resident 222 on 5/28/25 with multiple diagnoses including fracture of femur (thigh bone). During a record review on 6/19/25 at 11:05 AM, Resident 222's Medication Administration Record (MAR) dated 6/25 was reviewed. The MAR indicated, Resident 222 received PRN oxycodone (pain medication) for a pain level of 7 of 10 at 6:50 AM and was reassessed 10:14 AM [3 hours and 24 minutes later]. Resident 222 also received oxycodone at 7:08 PM for a pain level of 7 of 10 and was reassessed at 10:09 PM [3 hours later]. During an interview on 6/19/25 at 9:35 AM with the Administrator (ADM), ADM stated the facility did not have a policy in place to specify the timeframe the Licensed Nurse needed to reassess PRN oral pain medication. During an interview on 6/19/25 at 11:21 AM with the Director of Nursing (DON), the DON stated Licensed Nurses should respond to pain requests quickly to assess the underlying cause and intervene. The DON stated 30 minutes to an hour was a reasonable timeframe to reassess pain to ensure pain medication was effective. During a review of the policy and procedure titled, Answering the Call Light dated 10/2010, indicated, .Answer the resident's call as soon as possible .ask the nurse supervisor for assistance .If assistance is needed when you enter the room, summon help by using the call signal . During a review of the policy and procedure titled, Pain Assessment and Management dated 3/2015, indicated, .The pain management program is based on a facility-wide commitment to resident comfort .Pain management .includes the following .Monitoring for the effectiveness of interventions .

2. During a concurrent observation and interview on 6/19/25 at 1:40 PM, with Licensed Vocational Nurse (LVN) 1 at the medication cart. One box containing hemorrhoid ointment was observed with an expiration date of 4/25. LVN 1 stated the ointment was expired and should have been removed from the medication cart. During an interview on 6/19/25 at 2:17 PM, with the Director of Nursing (DON), DON stated medications should not be available for use past their expiration date because the effectiveness of the medication could not be ensured. The DON stated, staff should inspect the medication carts weekly and remove any expired medication. During a review of the facility's Policy and Procedure (P&P) titled Medication Labeling and Storage, reviewed February 2023, the P&P indicated, The nursing staff is responsible for maintaining medication storage and preparations areas in a clean, safe, and sanitary manner. If the facility has . outdated or deteriorated medications . pharmacy is contacted for instructions regarding returning or destroying these items. 3. During a review of Resident 271's Face Sheet the Face Sheet indicated Resident 271 was admitted to the facility on [DATE] with diagnoses which included Diabetes (disease causing high blood sugar levels). During a concurrent observation and interview on 6/19/25 at 1:40 PM, with Licensed Vocational Nurse (LVN) 1 at the medication cart, one opened multi-dose vial of insulin (medication used to control blood sugar) for Resident 271 was observed. The insulin vial was not labeled with the date it was opened. LVN 1 confirmed the insulin vial had been opened and used. LVN 1 stated insulin should be labeled with the date it was opened so that staff knew when it would expire. LVN 1 further stated insulin expired three months after it was opened. During an interview on 6/19/25 at 2:17 PM. with the Director of Nursing (DON), DON stated insulin should be labeled with the date it was opened and discarded 28 days after it was opened. DON stated, after 28 days, the insulin could lose potency. DON further stated, staff should label the insulin vial with the opened date so that they knew when it was time to discard it. During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration revised March 2025, the P&P indicated, Check expiration date, if drawing from an opened muli-dose vial. If opening a new vial, record an expiration date and time on the vial (follow manufacturer's recommendations for expiration after opening . During a review of the insulin manufacturer's instruction for use titled, Lantus Prescribing Information revised June 2023, the instructions indicated, Do not use after the expiration date stamped on the label or 28 days after you first open it. Based on observation, interview, and record review, the facility failed to safely store, and label drugs and supplies in accordance with acceptable standards of practice when: 1. Resident 222 had Fluticasone Propionate (nasal spray) on his bedside table. 2. Expired hemorrhoid cream was found in one of two medication carts. 3. Resident 271 was administered insulin from a previously opened but undated insulin vial. 4. Resident 12 had multiple eye drops and 2 vials of insulin on their bedside table. 5. 1 tab of Oxycodone HCl (oral pain medication) 5 mg (miligram- unit of measurement) was discarded into a non-controlled medication waste bin by Licensed Vocational Nurse (LVN) 1 without a witness. This failure had the potential to result in unauthorized access to medications and residents receiving expired medications which could lead to adverse effects. Findings: 1. During a review of Resident 222's admission Record (AR), the AR indicated the facility admitted Resident 15 on 5/28/2025, with multiple diagnoses that included respiratory disorder and Chronic Obstructive Pulmonary Disease (COPD-lung disease). During a concurrent observation and interview on 6/17/25 at 9:36 AM, with Resident 222, in Resident 222's room there was one Fluticasone Propionate located on top of Resident 222's bedside table. Resident 222 was alert and oriented. Resident 222 stated a staff member from the facility gave him the nasal spray. During a review of Resident 222 Order Summary Report (OSR) dated 5/28/25. The OSR indicated, Fluticasone inhale two times a day for COPD. During a concurrent interview and record review on 6/18/25 at 10:07 AM, with Licensed Vocational Nurse (LVN) 1, Resident 222's Physician Orders, dated June 2025, was reviewed. LVN 1 stated there was no Physician Order for bedside storage of Fluticasone Propionate. LVN 1 stated the nasal spray should not have been stored on the bedside cabinet without a physician's order. During an interview on 6/19/25 at 11:20 AM, with the Director of Nursing (DON) the DON stated medication should not have been stored in the room unless there was an order and care plan. The DON stated for safety, medications should be inaccessible to other residents. During a review of the facility's policy and procedure (P&P) titled, Bedside Medication Storage, dated 2007, the P&P indicated, .Bedside medication storage is permitted or residents who are able to self-administer medications, upon the written order of the prescriber .A written order for the bedside storage of medication is present in the resident's medical record . 4. During a review of Resident 12's care plan, the care plan indicated Resident 12 was admitted on [DATE] with diagnoses that included Type 1 Diabetes Mellitus (disease that causes increased blood sugar) and left eye blindness. During a concurrent observation and interview on 6/17/25 at 10:36 AM in Resident 12's room, 5 bottles of eye drops and 2 vials of insulin (medication to treat high blood sugar) were observed on the resident's bedside table. Resident 12 stated that the nurse provided the medications at 6 AM for the resident to self-administer. Resident 12 confirmed the medication had been sitting on her bedside table while she was in physical therapy. During an interview on 6/17/25 at 11:27 AM with Director of Nursing (DON) in Resident 12's room, DON confirmed that medications are not to be kept at the resident's bedside. The eye drops on the resident's bedside table observed by the DON were as follows: a. Atropine Sulfate Ophthalmic Solution 1% (Atropine Sulfate (Ophthalmic)- eye drops used to dilate (open) the pupil, relax the eye, and relieve eye pain from inflammation or swelling) b. Latanoprost Solution 0.005% (eye drops that help drain extra fluid from the eye to lower pressure) c. Simbrinza Opthalmic Suspension 1-0.2% (Brinzolamide-Brimonidine Tartrate- eye drop that lowers elevated pressure inside the eye) d. Timolol Maleate Gel Forming Solution 0.5% (eye drop that lowers pressure inside the eye by reducing fluid production) e. Prednisolone Acetate Ophthalmic Suspension 1% (steroid used to reduce inflammation or swelling in the eye) The two vials of Insulin Lispro (fast-acting insulin used to lower blood sugar in people with diabetes) on Resident 12's bedside table observed by the DON were as follows: a. Insulin Lispro 100 units per mL (unit of measurement) 10 mL bottle- sealed and unused b. Insulin Lispro 100 units per mL 10 mL bottle- vial empty. DON stated that medications should not be kept at the resident's bedside unsecured for the safety of the residents. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated, Compartments (including, but not limited to, drawers, cabinets .and boxes) containing medications .are locked when not in use. During a follow-up interview on 6/19/25 at 2:10 PM with DON, DON stated the nurse should have observed Resident 12 self-administer their medications and taken the medications back from the resident. 5. During a concurrent observation and interview on 6/18/25 at 8:40 AM with LVN 1 outside Resident 321's room, LVN 1 accidentally dropped Resident 321's morning medications, including 1 tab of Oxycodone, a controlled medication (drug that is strictly regulated because it can be addictive or easily misused). LVN 1 discarded the 1 tab of Oxycodone into a locked medication waste bin without a witness. During a follow up interview on 6/18/25 at 8:45 AM, LVN 1 stated that she should have obtained another licensed nurse to witness the disposal of the Oxycodone in the medication waste bin. During an interview on 6/18/25 at 1:45 PM. with the DON, the DON stated that if a nurse drops a controlled medication, it would be appropriate for the nurse to waste the controlled medication in the locked non-controlled medication waste container with a witness. She stated LVN 1 should have wasted the 1 tab of Oxycodone with another licensed nurse as a witness per policy. During an interview on 6/19/25 at 10:01 AM with Pharmacy Consultant (PC) via phone, PC explained that if a controlled medication was dropped during medication pass and must be discarded, the policy is for the nurse to waste with another nurse to ensure the medication was properly disposed of, inaccessible and not diverted. During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, dated November 2022, the P&P indicated, Waste and/or disposal of controlled medications are done in the presence of the nurse and a witness who also signs the disposition sheet.

Based on observation, interview, and record review, the facility failed to assess one of 18 sampled residents (Resident 12) for the ability to self-administer medications according to facility policy. This failure resulted in the potential for errors in Resident 12's medication administration. Findings: 1. During a review of Resident 12's Care Plan Report, the Care Plan Report indicated Resident 12 was admitted on [DATE] with diagnoses that include Type 1 Diabetes Mellitus (disease that causes increased blood sugar) and left eye blindness. During a concurrent observation and interview on 6/17/25 at 10:36 AM in Resident 12's room, 5 bottles of eye drops and 2 vials of insulin (medication to treat high blood sugar) was observed on the bedside table. Resident 12 explained that the nurse provided the medications at 6 AM for the resident to self-administer. Resident 12 stated she refilled her insulin pump (medical device that measures blood sugar and administers insulin) and self-administered her eye drops around 6:00 AM that morning before going to physical therapy. Resident 12 confirmed she had been self-administering her eyedrops and insulin since she was admitted to the facility. During a concurrent record review and interview on 6/19/25 at 2:10 PM with the Director of Nursing (DON), the DON stated she was unaware Resident 12 had been self- administering medications. DON stated, the Interdisciplinary Team (IDT) should have met to evaluate Resident 12's ability to self-administer medications and developed a plan of care. The DON confirmed that the IDT had not assessed the resident per policy to determine that it is safe for Resident 12 to self-administer their medications prior to the survey. During a record review on 6/18/25 at 8:05 AM of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, dated February 2021, the P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. In addition, If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person centered care plan for one of 18 sampled residents (Residents 222) when Resident 222's care plan intervention to store cigarettes and lighter in a lock box was not implemented. This failure had the potential for unauthorized access by residents which could result in harm. Findings: During an observation on 6/17/25 at 9:00 AM, in Resident 222's room, the room door was open and Resident 222 was not in the room. One cigarette lighter was on the bed and another lighter was on the nightstand. A box of cigarettes was also placed on the nightstand. During a concurrent observation and interview on 6/19/25 at 8:47 AM, with Certified Nursing Assistant (CNA) 1, in Resident 222's room, the room door was open and Resident 222 was not in the room. Two packs of cigarettes were on the bed and box containing six cigarettes packs were on top of the nightstand. CNA 1 stated that the cigarettes should not have been left out unattended to prevent other residents from unauthorized access. CNA 1 stated the cigarettes should have been locked in the nightstand. During a concurrent interview and record review on 6/19/25 at 11:02 AM, with Licensed Vocational Nurse (LVN) 1, Resident 222' s Care Plan (CP) dated 5/29/25 was reviewed. The CP indicated, . [Resident 222] has potential for injury related to smoking . Will continue to demonstrate safe smoking . Cigarettes and lighter will be stored in [Resident 222] lock box in room . LVN 1 stated direct care staff should implement care plan. LVN 1 stated the cigarettes should have been locked in the nightstand so other residents cannot access it. During an interview on 6/19/25 at 11:18 AM, with the Director of Nursing (DON), the DON stated care planned interventions should have been implemented by all staff. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 03/2022, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

Based on observations, interviews and record reviews, the facility failed to ensure quality of care when physician orders to monitor fasting blood sugar levels of Resident 35, who is on insulin medication, were not followed and recorded. This deficient practice had the potential to adversely affect the resident's medical condition. Findings: During a review of the resident's record, the physician order dated 5/20/25 indicated, Check FSBG [Fasting Blood Glucose] QA.M [Every morning]. During an interview on 6/18/25 at 2:20 PM with Infection Preventionist (IP), IP stated there was an order for fasting blood glucose every day, but no fasting blood sugar values were recorded in the chart since 5/20/25. IP stated they are supposed to be monitoring the values per the Physician order. During an interview on 6/18/25 at 2:29 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 35's blood sugar should have been checked every morning. During an interview on 6/18/25 at 2:30 PM with Resident 35, Resident 35 stated that she was told by nurses she did not need her blood sugar monitored every day. During a review of the facility's policy and procedures (P&P) titled, Diabetes - Clinical Protocol Revised December 2015, the P&P indicated .monitor blood glucose levels twice a day if on insulin .

Based on observation, interview, and record review, the facility had a medication error rate of 10 percent when three identified medication errors out of 30 opportunities were observed: 1. Aspirin 81 mg (miligram- unit of measurement) enteric coated (lower strength of aspirin that is often used to help prevent heart attacks and strokes) was administered without a physician's order for two residents (Resident 34 and Resident 54). 2. Lactulose (medication used to lower ammonia, a toxin in the body) was omitted without a physician's order for one resident (Resident 321). Findings: 1. During a review of Resident 34's Face Sheet (demographics), the Face Sheet indicated Resident 34 was admitted on [DATE] with diagnoses that included hypertension (high blood pressure). During a concurrent observation and interview on 6/18/25 at 8:13 AM with Licensed Vocational Nurse (LVN) 1 in Resident 34's room, LVN 1 administered one enteric coated (coated to resist stomach acid to dissolve in the intestines) tablet of Aspirin 81 mg (lower strength of aspirin that is used to help prevent heart attacks and strokes) to Resident 34. During a review of Resident 34's record on 6/18/25 at 9:10 AM, the Physician's Order dated 6/16/21 indicated, Aspirin Tablet Chewable (intended to be chewed for faster absorption) 81 mg, give once daily. During a concurrent observation and interview with LVN 1 at 9:48 AM, the medication label on the Aspirin bottle was reviewed with LVN 1 and compared against the physician order. LVN 1 confirmed the medication order for Resident 34 was for Aspirin 81 mg chewable tab. LVN 1 stated the enteric coated Aspirin she administered did not match the physician's order for Aspirin 81 mg chewable tablet. LVN 1 stated, there was no chewable Aspirin available in the medication cart. During an interview on 6/19/25 at 10:01 AM with Pharmacy Consultant (PC), PC stated that chewable aspirin and enteric-coated aspirin were not the same medication and should not be used interchangeably. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated that medications are administered in accordance with prescriber orders, including any required time frame. The P&P also indicated, The individual administering the medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 2. During a review of Resident 54's Face Sheet (demographics), the Face Sheet indicated Resident 54 was admitted on [DATE] with diagnoses that included hypertension (high blood pressure) and heart failure (condition where the heart muscle is unable to pump enough blood to meet the body's needs). During a concurrent observation and interview on 6/18/25 at 8:19 AM with LVN 1 in Resident 54's room, LVN 1 administered one enteric coated (coated to resist stomach acid to dissolve in the intestines) tablet of Aspirin 81 mg (lower strength of aspirin that is used to help prevent heart attacks and strokes) to Resident 54. During a review of Resident 54's record on 6/18/25 at 9:15 AM, the Physician's Order dated 2/27/25 indicated, Aspirin Tablet Chewable (intended to be chewed for faster absorption) 81 mg, give once daily. During a concurrent observation and interview with LVN 1 at 9:48 AM, the medication label on the Aspirin bottle was reviewed with LVN 1 and compared against the physician order. LVN 1 confirmed the medication order for Resident 54 was for Aspirin 81 mg chewable tab. LVN 1 stated the enteric coated Aspirin she administered did not match the physician's order for Aspirin 81 mg chewable tablet. During an interview on 6/19/25 at 10:01 AM with Pharmacy Consultant (PC), PC stated that chewable aspirin and enteric-coated aspirin are not the same medication and should not be used interchangeably. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated that medications are administered in accordance with prescriber orders, including any required time frame. The P&P also indicated, The individual administering the medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 3. During a review of Resident 321's Face Sheet (demographics), the Face Sheet indicated Resident 321 was admitted on [DATE] with diagnoses that included hepatic encephalopathy (brain dysfunction that occurs when a damaged liver can't properly filter toxins from the blood). During a concurrent observation and interview on 6/18/25 at 8:30 AM with LVN 1 in Resident 321's room, LVN 1 prepared Resident 321's scheduled morning oral medications into a medication cup and administered the medications to Resident 321. LVN 1 did not administer Lactulose (a liquid medication) during the observation. During a review of Resident 321's record on 6/18/25 at 9:18 AM, the Physician's Order dated 5/31/25 indicated, Lactulose 45 ml (milliliters- unit of measurement), give four times daily. During an interview on 6/18/25 at 9:44 AM with LVN 1, LVN 1 confirmed she did not give the lactulose to Resident 321 during the medication pass. LVN 1 stated she forgot. During an interview on 6/19/25 at 10:01 AM with Pharmacy Consultant (PC), PC stated the significance of missing a dose of lactulose or not administering at the appropriate scheduled time was that the treatment would not work as intended. During an interview on 6/19/25 at 2:10 PM with the Director of Nursing (DON), the DON confirmed that nurses are expected to administer scheduled medications within an hour of the scheduled time of administration. DON further stated, if a dose was missed, the nurse is expected to contact the physician to determine if the medication should be given late or if the nurse should just wait until the next time of administration for the omitted medication. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications administration times are determined by resident need and benefit .Factors that are considered include: a) enhancing optimal therapeutic effect of the medication; b) preventing potential medication or food interactions . Moreover, the P&P indicates, Medications are administered within one (1) hour of their prescribed time.

Based on observation, interview, and record review, the facility failed to ensure the kitchen food preparation and storage areas were maintained in a safe and sanitary manner when two fans blowing air into the kitchen had fine white colored particles. This failure placed all residents who received food prepared in the kitchen, at risk for foodborne illness and food contamination. Findings: During a concurrent observation and interview on 6/18/25 at 11:35 AM, with the Registered Dietitian (RD), in the kitchen, a stand-up fan had fine white colored particles and was blowing air directed into the food delivery cart. A floor fan had fine white colored particles and was blowing air directed to the tray-line and food preparation area. RD stated it was dust on both fans and stated that the fans should be dust free because the dust particles can land on the food. During a review of FDA (Food and Drug Administration) Food Code 2022, 4-602.13 Nonfood-Contact Surfaces, the FDA Food Code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During a review of the facility's policy and procedure (P&P) titled, Sanitization dated 11/2022, the P&P indicated, .The food service area is maintained in a clean and sanitary manner .All kitchens, kitchen area and dining areas are kept clean, free from garbage and debris .All equipment .are clean and sanitized .

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when powder like substance was observed on the surface areas around two of two pill crushers. This failure had the potential to result in harm from cross contamination. Findings: a. During a concurrent observation and interview on 6/19/25 at 1:28 PM, with Licensed Vocational Nurse (LVN) 2 in the facility hallway, the pill crusher on the medication cart for side two of the facility was coated in white and black colored powder-like substance. LVN 2 stated the pill crusher was dirty and that it should have been cleaned to prevent cross contamination. b. During a concurrent observation and interview on 6/19/25 at 1:40 PM with LVN 1 in the facility hallway, the pill crusher on the medication cart for side one of the facility was coated in white, brown, and black colored powder-like substance. LVN 1 stated the pill crusher was dirty. During an interview on 6/19/25 at 1:47 PM with the Director of Nursing (DON), the DON stated the pill crusher should have been cleaned after each use. The DON stated any residual should be cleaned with bleach wipes before crushing another medication. During a review of the Instruction for Using (IFU) [Brand Name] pill crusher titled Cleaning and Maintenance Instructions undated was reviewed. The IFU indicated, .May be cleaned regularly with a damp cloth .Using a damp cloth, wipe clean the [Brand Name] Pill Crusher using a normal detergent and water. Wipe down with dry cloth .

Based on interview and record review, the facility nursing staff failed to give acetaminophen (generic for Tylenol, a medication for mild pain and fever reducer) as ordered to one of two sampled residents (Resident 1) when Resident 1 was given more than 3000 mg (milligrams) of acetaminophen on 29 days of 34 days at the facility. This failure to follow Resident 1 ' s physician ' s orders had the potential to cause liver damage in a vulnerable resident who had several serious medical problems. Finding: During a record review of Resident 1 ' s electronic medical record on 2/20/25 at 1:20 p.m., Resident 1 ' s face sheet (demographic information) revealed Resident 1 was admitted to the facility on [DATE] with multiple medical diagnoses including heart transplant, end-stage kidney disease, Type 2 diabetes mellitus (a chronic disease characterized by high blood sugar), broken right hip with surgical repair, and Covid-19. Further review of Resident 1 ' s face sheet revealed he was discharged on [DATE]. Review of Resident 1's care plan revealed a focus area, dated 12/4/24, At risk for pain or discomfort due to fracture of the right femur and recent surgical repair of the right hip, [right] side rib pain. Interventions included, Administer medication as ordered. Review of Resident 1 ' s physician ' s orders revealed a physician ' s order dated 12/3/24 for Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet [sic] by mouth three times a day for PAIN NTE (not to exceed) 3000mg of acetaminophen in 24h/day. Further review of Resident 1 ' s physician orders revealed a physician ' s order dated 12/3/24 for Tylenol Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for Generalized Discomfort Not to Exceed 3000 mg in 24 hours. Review of Resident 1 ' s medication administration record (MAR) for December 2024 and January 2025 indicated Resident 1 received 3650 mg of acetaminophen on 17 days during his stay, 4300 mg of acetaminophen on 10 days during his stay, and 4950 mg of acetaminophen on 2 days during his stay. During a record review and concurrent interview on 2/25/25 at 1:56 p.m., Director of Nursing (DON) reviewed Resident 1 ' s physician orders during his stay 12/3/24 to 1/6/25, and Resident 1's December 2024 MAR. DON verified Resident 1 had concurrent physician orders for acetaminophen 1000 mg three times a day, for a total of 3000 mg daily, and acetaminophen 650 mg every six hours as needed. DON stated the fact that both orders indicated the acetaminophen should not exceed 3000 mg in 24 hours could be confusing to the nurses. DON verified Resident 1 ' s December 2024 MAR indicated Resident 1 was administered more than 3000 mg of acetaminophen on most days in December 2024. DON stated it was her expectation that if Resident 1 wanted more than 3000 mg of acetaminophen in 24 hours, the nurse should have called the doctor and clarified he wanted Resident 1 to have both orders. When queried, DON stated the concern with having more than 3000 mg of acetaminophen in 24 hours was that acetaminophen could hurt the liver. Review of facility policy and procedure Administering Medications, revised 4/2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident . the person preparing or administering the medication will contact the prescriber . to discuss the concerns. Review of acetaminophen 500 mg tablet package insert on dailymed.nlm.nih.gov (accessed on 2/27/25) indicated, Liver warning: This product contains acetaminophen. Severe liver damage may occur if you take more than 4,000 mg of acetaminophen in 24 hours with other drugs containing acetaminophen .

Based on observation, interview and record review, the facility failed to ensure the Quality Assurance Committee (QAA) is composed of the required committee members, such as an active licensed Nursing Home Administrator (NHA) of California during the QAPI meeting dated 10/23 & 11/23. This failure had the potential to result in mismanagement of the practices required by the Administrator to keep the vulnerable resident safe and healthy. Findings: During a concurrent observation and interview on 12/14/23 at 2 p.m., inside the glass of the bulletin board in Hall 500 was an approximately a 3x5 inches white paper with posting indicated [the name of the licensee Administrator], which was not the AIT present. When asked the AIT, who was this licensee Administrator whose name was posted on the bulletin board, the AIT stated that he was the licensee Administrator but had not been there for over 6 weeks. When the AIT was asked where the licensee Administrator was, the AIT replied, he had not been there. The AIT was asked for a copy of his current Nursing Home Administrator (NHA) license and the phone number of the licensee Administrator. A record review titled Licensure as Nursing Home Administrator under the State of Montana active, expires at 12/31/2023. A concurrent interview and record review titled Master's or Reciprocity (in exchange) Application for Nursing Home Administrator Examination application. AIT stated that he applied for Licensure for NHA. A record review titled email from the NHA to confirm an approval for California Nursing Home Administrator State Examination for December 14, 2023, at 2 p.m. to 4 p.m. for AIT. During an interview on 12/14/23 at 2:30 p.m., AIT stated that he was scheduled to take the test for License for Nursing Home Administrator. When asked AIT if he had a Nursing Home Administrator Licensed for California, AIT stated, No but he said that he was licensed in the State of Montana. AIT stated that he was in telephone contact with the Licensee Administrator regarding the recertification Survey. During a concurrent interview and record review of the Quality Assurance Program Improvement (QAPI) on 12/15/23 at 4:3 p.m. in the large conference room, the attendance sheets dated 10/24/23 and 11/23 were signed by the AIT under Administrator. The current licensee Administrator did not sign the attendance sheet dated 10/24/23 and 11/23 for QAPI/QAA.When the licensee Administrator (who arrived in the facility on 12/15/23) was asked about his signature in the attendance sheet for QAPI meeting, Licensee Administator stated, he was not in the facility anymore during that time. Licensee Administrator stated that he left the facility in the middle of October 2023. A review of the Health and Safety Code S483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary

Based on observations, interviews and record reviews, the facility failed to 1. ensure staff were offering and performing hand hygiene (HH, a way of cleaning one's hands that substantially reduces potential pathogens (harmful microorganisms) on the hands) to the residents before or after meals for 12 out of 12 sampled residents (Residents 47, 22, 40 11, 48, 50, 24, 63, 52, 72, 2 and 28), when Cook 1 did not perform HH and continue to cook eggs after he wiped his gloved hand in front of his shirt, and ensure staff were following the facility's guideline for donning Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when staff did not wear gloves when she scooped ice in the ice machine located in the kitchen 2. ensure an oxygen tubing was dated when it was changed and ensure there was a humidifier (a medical device used to humidify supplemental oxygen that provides long-lasting moisture for utmost patient comfort during oxygen therapy) when a resident was using an oxygen concentrator (a medical device that you could use if you have a condition that affects your breathing) for one out of one sampled resident (Resident 380). 3. ensure there were no flies in the kitchen, dining room, hallways and residents' room which could land on uncovered commode and urinals then land on residents' food, uncovered kitchen food and items, 4. ensure there was no urinal at a resident overbed table while he was eating his meal for one out of one sampled resident (Resident 48) and there were no food items on top of the commode for one out of one sampled resident (Resident 65). These failures could lead to cross contamination, accidental ingestion of contaminated food, gastrointestinal disease (diseases that affects the gastrointestinal (GI) tract, the passage that runs from the mouth to the anus) and infection. Findings: 1. During an observation on 12/11/23 at 12:21 p.m., Resident 47 received his lunch tray. There was no HH offered prior to eating his meal. During an observation on 12/11/23 at 12:22 p.m., Resident 22 received his lunch tray. There was no HH offered prior to eating his meal. During an observation on 12/11/23 at 12:23 p.m., Resident 40 received her lunch meal tray. There was no HH offered prior to eating her meal. During an observation on 12/11/23 at 12:25 p.m., Resident 60 received her lunch meal tray. There was no HH offered prior to eating her meal. During an observation on 12/11/23 at 12:47 p.m., Resident 11 left the dining room. There was no HH offered after eating her meal. The moist towelette (wipes used for cleaning hands) on her meal tray was left unopened. During an observation on 12/11/23 at 12:51 p.m., Resident 48 left the dining room. There was no HH offered after eating his meal. The moist towelette on his meal tray was left unopened. During an observation on 12/12/23 at 12:22 p.m., Resident 50 was served his lunch meal tray. There was no HH offered by staff prior to eating his meal. During an observation on 12/12/23 at 12:26 p.m., Resident 63 ate his dessert with his hand. There was no HH offered prior to eating his meal. Residents' 24 and 63 had their moist towelette for HH opened but not used. During an observation on 12/12/23 at 12:27 p.m., Resident 52 had her moist towelette for HH opened but not used. During an observation on 12/12/23 at 12:30 p.m., Resident 72 had her moist towelette opened but not used. During an observation on 12/12/23 at 12:32 p.m., Resident 24 left the DR. There was no HH noted after her meal. During an interview on 12/12/23 at 12:34 p.m., Resident 22 stated staff did not consistently offer HH to residents. Resident 22 stated staff should offer HH to all residents especially those who were not able to perform HH by themselves, but the staff just doesn't. During an observation on 12/12/23 at 12:42 p.m., there was no HH offered to Resident 2 after eating his lunch. The moist towelette was not used. During an observation on 12/12/23 at 12:44 p.m., there was no HH offered to Resident 52 after eating her meal. During an observation on 12/12/23 at 12:53 p.m., there was no HH offered to Resident 28 after eating her lunch. During an observation on 12/12/23 at 12:55 p.m., Resident 28 wheelchair was pushed back to her room by Management Staff F. There was still no HH offered after eating her lunch. During an observation on 12/14/23 at 5:49 a.m., Dietary Aide 2 did not perform HH prior to donning gloves. During an interview on 12/14/23 at 6:19 a.m., the Dietary Manager (DM) stated the moist towelette were placed at residents' tray for HH before meals. During an observation on 12/14/23 at 6:25 a.m., Cook 1 scooped ice in the ice machine with no gloves. During an interview on 12/14/23 at 6:44 a.m., the RD verified staff should wear gloves whenever they were scooping ice in the ice machine. During an observation on 12/14/23 at 6:50 a.m., Cook 1 removed the glove mittens he was using and proceeded to take the temperature of the chicken with no HH. The glove mitten was dirty. During an observation on 12/14/23 at 7:03 a.m., Cook 1 was frying eggs. Cook 1 wiped his gloved hand in front of his shirt. The cook did not discard his gloves and did not perform HH. Cook 1 continued to fry the eggs. During an observation on 12/14/23 at 7:15 a.m., Dietary Aide 3 did not perform HH prior to donning gloves. During an observation on 12/14/23 at 11:59 a.m., Dietary Aide 4's beard net was worn where it was not adequately covering his facial hair. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff D stated staff should perform HH before and after gloving and HH should be offered to the residents before and after meals. Unlicensed Staff D stated if there was no HH offered to the residents before and after meals, residents would be at risk for infections and gastrointestinal infections. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated HH should be performed before and after gloving and HH should be offered to the residents before and after meals. Licensed Staff P stated if staff was cooking and he wiped his gloved hand on his shirt, he needs to remove his gloves, perform HH and then put on a new glove. Licensed Staff P stated not performing HH and not following the PPE protocol could result to potential contamination and GI infection. During an interview on 12/15/23 at 11:34 a.m., the Director of Staff Development (DSD) stated HH should be offered to the residents before and after meals and HH should be performed prior to donning and after doffing gloves. The DSD stated the cook should have performed HH and donned new gloves when he wiped his gloved hands in front his shirt. The DSD stated not adhering to HH protocol and not adhering to PPE protocol meant the facility policy was not followed and expectations were not met. The DSD stated not adhering to HH and PPE protocol could result to contamination and residents could get sick. During an interview on 12/15/23 at 12:46 p.m., the DON stated residents should be offered HH before and after meals, and staff should perform HH before donning and after doffing gloves. The DON stated there would be a risk of contamination if the HH and the PPE protocol was not followed. The DON was silent when asked what the risks for residents were when the HH and the PPE protocol was not followed. During an interview on 12/15/23 at 1:17 p.m., the RD stated there could be a possible cross contamination if HH were not being offered or done to all residents before and after meals. The RD stated this could result to food borne illness. Based on the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised 10/2023, the P&P indicated hand hygiene indicated hand hygiene as the primary means to prevent the spread of healthcare associated infections .all personnel were expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors .hand hygiene was indicated immediately after glove removal . 2. During a concurrent observation and interview on 12/11/23 at 1:36 p.m., Anonymous Resident was using an oxygen concentrator with no humidifier and the oxygen tubing was not dated. Anonymous Resident stated her nose gets irritated, but staff don't do anything. During an observation on 12/14/23 at 8:16 a.m., Anonymous Resident oxygen tubing was still not dated and there was still no humidifier attached to the concentrator. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated oxygen tubing had to have an exact date when it was changed. Licensed Staff P stated not dating the oxygen tubing could lead to staff assuming it was recently changed even though it was not. Unlicensed Staff P stated this could cause bacteria to accumulate and could cause respiratory infections. Licensed Staff P stated if a concentrator was used, a humidifier should be added. Licensed Staff P stated not using a humidifier while on oxygen could lead to nasal passages irritation, nose bleeding and dry nose. During an interview on 12/15/23 at 11:34 a.m., the DSD stated the oxygen tubing orange sticker indicated the oxygen tubing was changed. The DSD stated the orange sticker still needed to have the date on when the oxygen tubing was changed. The DSD stated it was important to put on the date on when oxygen tubing was changed because debris could accumulate in the oxygen tubing and this could lead to respiratory infection. The DSD stated using a humidifier was important to keep nasal passages moist. The DSD stated if a humidifier was not used while on oxygen therapy, it could lead to dry nasal passages which could be painful, and could lead to nosebleed. The DSD stated residents would feel uncomfortable. The DSD stated residents then might not want to use oxygen which could lead to respiratory issues. During an interview on 12/15/23 at 12:46 p.m., the DON stated it was the facility's expectation to have a date on the orange sticker attached to the oxygen tubing to identify when it was last changed. The DON did not respond when asked what could happen or what the risks were for residents if an oxygen tubing were not dated to indicate when it was last changed. A review of the facility's policy and procedure (P&P) titled Oxygen Therapy- Mask and Nasal Cannula, undated, the P&P indicated humidifier bottle should be changed every 10 days and humidifier bottle must be dated. 3. During an observation on 12/11/23 at 11:17 a.m., a fly was noted in the kitchen. During a concurrent observation and interview on 12/11/23 at 1:05 p.m., Resident 50 stated there were flies in the dining room. Resident 50 stated he would slap the flies but he couldn't. Resident 50 stated the flies had been an issue because it can get into their food. During a concurrent observation and interview on 12/11/23 at 11:25 a.m., more flies were noted in the kitchen. The registered dietician (RD) stated they knew about the flies but they could not identify the source. The RD stated this was not the first time the kitchen had flies. During a concurrent observation and interview on 12/12/23 at 11:52 a.m., Resident 50 came in the dining room with red, hand shaped fly swatter. When asked what was that for, Resident 50 stated it was to kill the flies. Resident 50 stated the flies bothered him a lot as there were flies where he was eating. During an observation on 12/13/23 at 9:35 a.m., there was an uncovered thickener scoop left on top of the thickener bucket. During an observation on 12/13/23 at 9:36 a.m., the RD also saw the flies in the kitchen. The RD stated, I know. During an observation on 12/13/23 at 9:49 a.m., there were cut up eggs left uncovered in the kitchen where flies were noted. During a concurrent observation and interview on 12/13/23 at 9:56 a.m., Dietary Aide 1 was notified there was a fly that landed on the cut up eggs. Dietary Aide 1 responded by covering the cut up eggs with aluminum foil. Dietary Aide 1 did not throw the cut up eggs in the trash at that time. During a concurrent observation and interview on 12/14/23 at 6:20 a.m., there were flies noted on the uncovered butter and whisk. Dietary Aide 2 was notified, he stated oh yeah. Butter and whisk remained in the area between the oven and the stove. Dietary Aide 2 did not throw the butter nor remove the whisk in the area between the oven and the stove at that time. During an observation on 12/14/23 at 6:30 a.m., the butter and whisk that was touched by a fly was still in the area between the stove and the oven. During an observation on 12/14/23 at 7:10 a.m., Cook 1 transferred a scoop of brown sugar from a large tub to a little container. When done, cook 1 did not cover the large tub of brown sugar and the scoop. A fly was then noted on the brown sugar inside the tub, then it flew to the scoop that was left inside the uncovered brown sugar tub. During an interview on 12/14/23 at 7:37 a.m., the Director of Nursing (DON) asked how the facility survey was doing. She was notified there were flies in the kitchen, the dining room, and the hallways. The DON stated she didn't really knew about the flies, but she had heard it from the grapevine. During an interview on 12/14/23 at 12:12 p.m., the Maintenance Director stated he did not know why there were flies in the facility. The Maintenance Director stated it was important not to have flies in the kitchen for safety and hygienic purposes. The Maintenance Director stated flies could cause residents to get sick. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff D made a face and appeared disgusted when asked what could potentially happen if a fly landed on uncovered kitchen items for cooking or on residents' food. Unlicensed Staff D stated residents could get sick, there would be contamination as flies could have landed on a fecal matter before landing on uncovered kitchen items for cooking and residents' food. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated the facility had flies. Licensed Staff P stated flies could lead to GI infection. During an interview on 12/15/23 at 11:34 a.m., the DSD stated flies were an infection control issue. The DSD stated flies throw up, could land on food after they had landed on fecal matter or trash. The DSD stated the kitchen items and food use for cooking should be covered at all times to ensure flies does not land on cooking items and food. During an interview on 12/15/23 at 12:46 p.m., the DON stated flies in the facility could lead to vector borne illness and could possibly cause residents to get sick. During an interview on 12/15/23 at 1:17 p.m., the RD stated flies carried a risk and potential for food borne illness. A review of the facility's policy and procedure (P&P) titled Pest Control, revised 5/2008, the P&P indicated the facility shall maintain an effective pest control program. 4. During an observation on 12/14/23 at 8:27 a.m., Resident 48 was eating his breakfast, and a urinal with minimal amount of urine was at his overbed table along with his meal. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O stated there should be no urinals at the overbed table while resident was eating for infection control purposes. Unlicensed Staff O stated there should be nothing on top of a resident commode for infection control issues and dignity. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated urinals at the overbed table while resident was eating and putting food items on top of the commode was not acceptable and runs the risk for contamination. Unlicensed Staff P stated residents could get sick and could have GI infection. During an interview on 12/15/23 at 11:34 a.m., the DSD stated residents should not have a urinal at the overbed table while they were eating. The DSD stated if a resident was confused, resident might consume the fluid in the urinal, or the contents of the urinal might spill on residents' food. The DSD stated this was an infection control issue and residents could get sick. The DSD stated it was not okay to have a food item on top of the commode. The DSD stated putting food item on top of the commode was a risk for infection as commode was used for bowel and bladder elimination. The DSD stated food could land on the commode, if not adequately cleaned, residents could get sick with GI infection. A review of the facility's policy and procedure (P&P) titled Resident Rights, revised 2/2021, the P&P indicated residents have a right to a dignified existence.

Based on observation, interview and record review, the Governing Body (a group of people that has the authority to exercise governance over an organization) failed to ensure to designate or appoint a California Licensed Nursing Home Administrator (NHA) (Administrator is responsible for establishing and implementing policies regarding the management of the facility) who would be legally responsible for establishing and implementing policies regarding the management and operation when: 1) The Administrator in training (AIT) claimed to be the Administrator of the facility, for over 6 weeks including during the recertification survey dated 12/11/23 - 12/14/23. 2) The AIT was licensed by the State of Montana and was currently scheduled to take the reciprocity administrator licensing exam on 12/14/23. 3) The current licensee Administrator for the facility was not present in the building to provide oversite since October 2023 and during the survey on 12/11/-12/14/23. The current administrator was supervising other two facilities which were more than two hours away from this facility, a facility that he was the designated licensee Administrator. This failure had the potential to result in mismanagement and misguided of the care of vulnerable residents and false information provided by the AIT that he was the Administrator to the vulnerable residents, staff, and visitors. Findings: (1) During a concurrent observation and interview on 12/11/23 at 9:15 a.m., at the initiation of the recertification survey, the Administrator in Training (AIT) greeted the surveyors. When asked if he was the Administrator, he answered yes. The AIT stated that he had been the Administrator for 6 weeks. AIT stated that he was previously the AIT at the other affiliated facility. (2) During a concurrent observation and interview on 12/14/23 at 2 p.m., inside the glass of the bulletin board in Hall 500 was an approximately a 3x5 inches white paper with posting indicated [the name of the licensee Administrator], which was not the AIT present. When asked the AIT, who was this licensee Administrator whose name was posted on the bulletin board, the AIT stated that he was the licensee Administrator but had not been there for over 6 weeks. When the AIT was asked where the licensee Administrator was, the AIT replied, he had not been there. The AIT was asked for a copy of his current Nursing Home Administrator (NHA) license and the phone number of the licensee Administrator. A record review of AIT's Licensure provided by AIT titled Licensure as Nursing Home Administrator indicated that he was Licensed under the State of Montana active, expires at 12/31/2023. A concurrent interview and record review titled Master's or Reciprocity Application for Nursing Home Administrator Examination application on 12/14/23 at 2:30 pm. AIT stated that he applied for California Licensure for NHA. A review of an email provided by AIT from the NHA to confirm an approval for California Nursing Home Administrator State Examination for December 14, 2023, at 2 p.m. to 4 p.m. AIT stated that he was scheduled to take the test for California License for Nursing Home Administrator on 12/14/2023. When asked AIT, if he had a California Nursing Home Administrator License, AIT stated, No but he said that he was licensed in the State of Montana. AIT stated that he was in telephone contact with the Licensee Administrator regarding the current recertification Survey. During a concurrent interview and record review of the Quality Assurance Program Improvement (QAPI) on 12/15/23 at 4:3 p.m. in the large conference room, the attendance sheets dated 10/24/23 and 11/28/23 were signed by the AIT under Administrator. The licensee Administrator did not sign the attendance sheet dated 10/24/23 and 11/28/23. When the licensee Administrator (who arrived in the facility on 12/15/23) was asked about his signature in the attendance sheet for QAPI meeting, Licensee Administator stated, he was not in the facility anymore during that time. Licensee Administrator stated that he left the facility in the middle of October 2023. (3) During a telephone interview on 12/14/23 at 3:04 p.m., the Licensee Administrator stated that he was assigned to oversee other two facilities out of the area. Licensee Administrator stated that he was aware that there was a recertification survey happening in the facility and that AIT was in contact with him constantly. When asked the Administrator if the AIT should identify himself as the Administrator, Licensee Administrator stated, AIT should not have identified himself as the Administrator. When asked the Licensee Administrator if he was aware that AIT did not have a current California NHA license, Licensee Administrator answered yes. When asked Licensee Administrator, if he felt it was acceptable to assign or appoint a non-California Licensed NHA to your facility, Licensee Administrator did not respond. Licensee Administrator stated that he provided oversite of AIT over the phone. When asked Licensee Administrator if he was aware of the mileage difference between facilities that he oversees, Licensee Administrator stated, not sure. A review of the regulatory of Health and Safety code S483.70(d)(3) The governing body is responsible and accountable for the QAPI program, in accordance with S483.75(f). [S483.70(d)(3) Governing body responsibility of QAPI program will be implemented beginning November 28, 2019 (Phase 3).] A review of the regulatory of Health and Safety Code S483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. A review of the regulatory of health and Safety Code S483.70(d)(2) The governing body appoints the administrator who is- (i) Licensed by the State, where licensing is required. (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body.

Based on observation and interviews, the facility failed to ensure 1. residents' food items were labeled with name and dated and expired food items were discarded. These failures led to unsafe and unsanitary storage of food. These failures were also a safety risk that could lead to accidental ingestion of expired food items. Findings: During an observation on [DATE] at 1:40 p.m., resident's refrigerator was in the staff breakroom. The refrigerator side was broken. During a concurrent observation and interview on [DATE] at 1:47 p.m., Unlicensed Staff AA verified she put the jar of minced garlic for the resident in room [ROOM NUMBER] in the refrigerator. Unlicensed Staff AA stated there was no name to identify who this jar of minced garlic belonged to. Unlicensed Staff AA verified the jar of minced garlic was opened but not dated. Unlicensed Staff AA stated she was unable to read the jar of minced garlic expiration date. Unlicensed Staff AA stated resident's food items should be labeled with their name, should have date on when it was opened and should have a use by date. Unlicensed Staff AA stated residents' food brought in from outside should be labeled with their name instead of room number because resident could switch rooms. Unlicensed Staff AA stated residents' food brought in from outside should be open dated and should have a use by date for safety purposes because food could get spoiled and resident could get sick if they eat it. During a concurrent observation and interview on [DATE] at 1:59 p.m., Licensed Staff BB verified the box of cookie dough from the freezer did not have an expiration date and there was also no indication it was dated when they received it. Licensed Staff BB stated this should be dated when staff received it. Licensed Staff BB stated this cookie dough should have been discarded for safety purposes. During a concurrent observation and interview on [DATE] at 2:05 p.m., Dietary Aide 1 stated he cleans the refrigerator daily and would throw away expired food items. Dietary Aide 1 verified 1 small tub of jello in the refrigerator should have been discarded on [DATE]. Dietary Aide 1 verified the 2 prebiotic squeeze snacks did not indicate who this belonged to. Dietary Aide 1 verified the fruit and yogurt blueberry pear squeeze snack expired on [DATE]. Dietary Aide 1 stated these items should have been discarded for residents' safety. During an observation on [DATE] at 2:12 p.m., a carbonated drink was noted to be opened, there was no name on the drink only a room number. The carbonated drink did not indicate when it was opened and when it should be discarded. During a concurrent observation and interview on [DATE] at 2:15 p.m., there were 2 supplement drinks in the resident's refrigerator with no name to indicate who these belonged to. Licensed Staff BB and CC stated resident could have brought it from home. Licensed Staff CC stated these supplemental drinks should be discarded. During an observation on [DATE] at 2:19 p.m., a bottle of organic prune juice was in the resident's refrigerator with no name just a room number. During an interview on [DATE] at 2:31 p.m., the Registered Dietician (RD) stated residents' food coming from outside had to labeled with the residents name, dated when it was received or opened and dated when it should be discarded. If there was no discard date, the food item had to be thrown within 3 days of opening it. The RD stated the rule was if 3 days had passed since it was brought in, it had to be tossed out. The RD stated food items should be labeled with resident's name and not room number because residents could change rooms. The RD stated food items should also be labeled with use by date and expired food items should be discarded for residents' safety. The RD stated residents could get sick if they consume food that was potentially expired or contaminated. During an observation on [DATE] at 8:20 a.m., a smoothie squeeze pack was noted in the resident's refrigerator in the staff breakroom. The smoothie squeeze pack was not labeled with name and was expired since [DATE]. A review of the facility's policy and procedure (P&P) titled Bringing in Food for a Resident, undated, the P&P indicated food and beverages should be labeled and dated to monitor for safety .food or beverages need to be marked with residents name .food or beverage items without manufacturers expiration date will be dated upon arrival at the facility and thrown away 2 days after the date marked or if frozen 30 days. A review of the facility's policy and procedure (P&P) titled Food for Residents from Outside Sources, undated, the P&P stated food brought in from outside the facility kitchen for residents' consumption will be monitored .if opened, food must be sealed, dated to the date opened and disposed of in 2 days after opening .frozen items will be disposed of in 30 days.

Based on observations, interviews and record reviews, the facility failed to ensure the food was palatable, was served timely and was served at temperatures in accordance with resident preferences for seven out of seven sampled residents (Residents 376, 68, 65, 375, 226, 52 and 50). These failures had the potential to result in residents not eating the food served which could result in weight loss and further compromise their medical status. Findings: During an interview on 12/11/23 at 1:49 p.m., Resident 376 stated he dislike the food at the facility. Resident 376 stated food had no taste and vegetables were soggy. During an interview on 12/11/23 at 1:52 p.m., Resident 68 stated food comes in late, so it was usually cold by the time he gets it. Resident 68 stated food at the facility was not good, bland and had no taste. During an interview on 12/12/23 at 9:10 a.m., Resident 65 stated food at the facility was not great. Resident 65 stated food was very bland and had no taste. Resident 65 stated meal trays comes late so food was already cold when it gets to her. During an interview on 12/12/23 at 9:17 a.m., Resident 375 stated the facility food was so-so, and did not have a lot of taste. Resident 375 stated vegetables were usually mushy and soggy. During an interview on 12/12/23 at 9:52 a.m., Resident 226 stated the food at the facility was not good and had no taste. During an interview on 12/12/23 at 12:49 p.m., Resident 52 stated the facility food was sometimes good and sometimes it's not. Resident 52 stated sometimes food was already cold when they serve it. Resident 52 stated sometimes food arrives late and she gets hungry. During a concurrent observation and interview on 12/14/23 at 8:25 a.m., Resident 50 stated he received his meal tray at 8:20 a.m. Resident 50 stated his tray was late, just like every day his meal tray was late. During a concurrent observation and interview on 12/14/23 at 1:01 p.m., the food was sampled by the facility Registered Dietician (RD) and the surveyor. The chicken was dry, chewy, bland and needed seasoning. The peas and the cauliflower were bland and lacked flavor as well. The food was all lukewarm, the chicken temperature was 132 F, the cauliflower and peas mixture were 120 F and the pasta with sauce was 128 F. The RD stated the cauliflower was warm, the peas were less warm and the chicken had cooled down. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O stated if food was bland, had no taste and cold, residents might not want to eat it. Unlicensed Staff O stated a meal tray arriving 1 hour late was not acceptable. Unlicensed Staff O stated residents might lose interest in their food which could result to weight loss. During an interview on 12/15/23 at 10:20 a.m., Licensed Staff P stated late meal tray affects food palatability, temperature and the flavor would be altered. Licensed Staff P stated it would affect how much resident would consume and could possibly lead to weight loss. During an interview on 12/15/23 at 10:56 a.m., the Director of Staff Development (DSD) stated meals should arrived at residents within specified time frames and not 1 hour or more late. The DSD stated late meal tray could result in food getting cold, resident getting upset, resident losing appetite which could possibly lead to weight loss and resident not receiving their optimal nutritional needs. Based on the facility's policy and procedure (P&P) titled Food Preparation, undated, the P&P indicated food shall be prepared by methods that conserve nutritive value, flavor and appearance .poorly prepared food will not be served .may add increased amount of herbs and spices (not salt) since potency of produce may vary .prepare foods as close as possible to serving time in order to preserve nutrition, freshness and to prevent overcooking .hot foods should be held prior to service at 140 F or above .

Based on observation, interview and record review, the facility failed to ensure that the list of information such as the name and the correct Department of the State Survey Agency, & the State Licensure were accurate and written visibly available to all vulnerable residents, staff and visitors. This failure had the potential to result in unreported and uninvestigated complaint or any incident to the State Agency or State Licensing by a resident/s, staff and visitors who may have had concerns and requires advocacy. Findings: During an observation of the facility on 12/14/23 at 2 p.m., inside the glass of the bulletin board in Hall 500 was an approximately a 3x5 inches white paper with posting indicated The Licensing Agency having authority over this facility is: Department of Health Services, Licensing and Certification Division. During a Resident Meeting on 12/13/23 at 2:30 p.m., when residents were asked who attended the Resident Council Meetings, they stated they only knew that there was Ombudsman information posted but were not aware of the name of the State Agency or State Licensure information, which they could call for concerns about their care. During an interview on 12/ 14/23 at 3:30 p.m., Social Services (was previously the Admission Coordinator) stated, the information of the State Agency & State Licensure was not included in the Welcome Packet. A review of the Health & Safety Code S483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes - (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit;

Based on observation, interviews and record reviews, the facility failed to ensure 1. they were adequately staffed for 21 out of 31 days for CNAs and nine out of 31 days for licensed nurses in 10/2023, 19 out of 30 days for CNAS and 8 out of 30 days for licensed nurses for 11/2023 and 8 out of 12 days for CNAs and 4 out of 12 days for licensed nurses for 12/2023 which resulted in residents' complaints of assistance not being provided by staff in a timely manner and call light not being answered timely for five out of five sampled residents (Residents 380, 376, 68, 332 and 226 ) and residents feeling scared and anxious staff would not get to them on time in case of medical emergency 2. staff were provided in service on Trauma Informed Care (TIC, eliminate or mitigate triggers that may cause re-traumatization of the resident) which could result in staff not knowing how to properly and competently care for residents with trauma and staff inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience) of a resident with trauma. Findings: During an interview on 12/11/23 at 1:36 p.m., Resident 380 stated staff call light response time was an issue. Resident 380 stated the facility was short staffed but staffing at night was the worst. Resident 380 stated she had experienced having had to wait for an hour to receive her pain medication. Resident 380 stated you know it's a long time to wait especially if you were in pain. I started shaking because I was in so much pain. Anonymous Resident 1 stated the facility would do well if they add more staff at night or at least 2 more staff in the hallways to attend to the resident needs timely. During an interview on 12/11/23 at 1:49 p.m., Resident 376 stated staff answers call light between 10 to 20 mins. Resident 376 stated the facility could benefit from having more staff so they could respond to residents' needs on time. During a concurrent observation and interview on 12/11/23 at 1:52 p.m., Resident 68's call light was on. Resident 68 stated his call light had been on for a while. Resident 68 stated he had been waiting for a while for staff to help him. Resident 68 stated that so far, he had not received help from the staff yet. Resident 68 stated he probably had to wait for a while because the facility might be short staffed again. During an observation on 12/11/23 at 2:03 p.m., Resident 68's call light was still on. During an observation on 12/11/23 at 2:06 p.m., Resident 68's call light was still. Resident 68 call light was now on for the last 17 minutes. During an interview on 12/12/23 at 9:10 a.m., Resident 65 stated the facility was short staffed. Resident 65 stated she had to wait for hours before staff came to help her. Resident 65 stated staffing at night was worst. Resident 65 stated the facility did not have enough staff to care for all the residents at the facility. Resident 65 stated this made her anxious because if she needed an emergency medical attention, nobody could get to her on time. During an interview on 12/12/23 at 9:17 a.m., Resident 375 stated the facility was short staffed. Resident 375 stated he felt frustrated he had to wait for hours, especially at night, before staff comes to help him. Resident 375 stated he wondered what could happen if there was a medical emergency. During an interview on 12/12/23 at 9:52 a.m., Resident 226 stated the facility was short staffed and could do well to hire more professional staff. Resident 226 stated the facility was short staffed. Resident 226 stated it takes forever for staff to answer their call light. Resident 226 stated it scared her to think there could be a medical emergency and there were no staff that could get to her on time. During an interview on 12/12/23 at 12:59 p.m., Management Staff F stated she was the only one in charge of staffing the facility with nurses and certified nursing assistants (CNAs). Management Staff F stated she staffed the facility based on census and uses the hours patient per day (HPPD, the total number of nursing hours in a unit in a 24-hour period.) census (a complete count of residents in the facility) calculation guideline by the facility. Management Staff F stated she does not use any other guidelines when ensuring the facility was adequately staffed. During an interview on 12/13/23 at 9:00 a.m., the facility nursing consultant (NC) stated the tab that stated nurses and CNAs on the HPPD census calculation corresponds to the total number of CNAs and nurses needed in a 24 hour period based on the facility census. A record review of the HPPD census calculations indicated the facility needs in a 24 hour period based on census. For a census of 62 to 65, the facility needed 8 nurses, census of 66-72, the facility needed 9 nurses, for a census of 73 to 79, the facility needed 10 nurses and for a census of 80 to 81, the facility needed 11 nurses. For CNAs, in a 24 hour period, the facility needed for a census of 62 to 63, 18 CNAs, for a census of 64 to 66, the facility needed 19 CNAs, for a census of 67 to 69, the facility needed 20 CNAs, for a census of 70 to 73, the facility needed 21 CNAs, for a census of 74 to 76, the facility needed 22 CNAs, for a census of 77 to 79, the facility needed 23 CNAs, for a census of 80 to 81, the facility needed 24 CNAs. A review of the facility's staffing for October 2023 indicated the staffing for CNAs were not met for 21 out of 31 days on these dates: 10/1/23 Census of 81, 21 CNAs 10/2/23 Census of 80, 22 CNAs 10/6/23 Census of 79, 21 CNAs 10/7 /23 Census of 79, 21 CNAs 10/8/23 Census of 80, 21 CNAs 10/9/23 Census of 81, 22 CNAs 10/13 /23 Census of 79, 22 CNAs 10/14 /23 Census of 79, 20 CNAs 10/ 15/23 Census of 79, 21 CNAs 10/16 /23 Census of 80, 22 CNAs 10/18/23 Census of 80, 22 CNAs 10/ 20/23 Census of 79, 21 CNAs 10/21/23 Census of 80, 21 CNAs 10/22 /23 Census of 80, 20 CNAs 10/23/23 Census of 80, 21 CNAs 10/24/23 Census of 80, 22 CNAs 10/ 25/23 Census of 81, 22 CNAs 10/26/23 Census of 81, 23.5 CNAs 10/28/23 Census of 78, 22 CNAs 10/29/23 Census of 77, 20 CNAs 10/ 31/23 Census of 77, 21 CNAs A review of the facility's staffing for October 2023 indicated the staffing for licensed nurses were not met for 9 out of 31 days on these dates: 10/1/23 Census of 81, 8 licensed nurses 10/7 /23 Census of 79, 7 licensed nurses 10/8/23 Census of 80, 7 licensed nurses 10/14 /23 Census of 79, 7 licensed nurses 10/ 15/23 Census of 79, 7 licensed nurses 10/21/23 Census of 80, 7 licensed nurses 10/22 /23 Census of 80, 7 licensed nurses 10/28/23 Census of 78, 7 licensed nurses 10/29/23 Census of 77, 7 licensed nurses A review of the facility's staffing for November 2023 indicated the staffing for CNAs were not met for 19 out of 30 days on these dates: 11/4/23 Census of 74, 21 CNAs 11/5/23 Census of 74, 19 CNA's 11/6/23 Census of 73 20 CNA's 11/11/23 Census of 74, 20 CNAs 11/12/23 Census of 75, 20 CNAs 11/13/23 Census of 75, 21 CNAs 11/14/23 Census of 79, 20 CNAs 11/15/23: data requested but not provided. 11/16/23 Census of 80, 23 CNAs 11/17/23 Census of 80, 22 CNAs 11/18/23 Census of 79, 20 CNAs 11/19/23 Census of 79, 20 CNAs 11/20/23 Census of 79, 21 CNAs 11/23/23 Census of 78, 21 CNAs 11/24/23 Census of 80, 21 CNAs 11/25/23 Census of 80, 20 CNAs 11/26/23 Census of 80, 21 CNAs 11/27/23 Census of 81, 21 CNAs 11/28/23 Census of 81, 23 CNAs A review of the facility's staffing for November 2023 indicated the staffing for licensed nurses were not met for 8 out of 30 days on these dates: 11/5/23 Census of 74, 7 licensed nurses 11/11/23 Census of 74, 7 licensed nurses 11/12/23 Census of 75, 7 licensed nurses 11/15/23 data requested but not provided 11/19/23 Census of 79, 7 licensed nurses 11/23/23 Census of 78, 7 licensed nurses 11/24/23 Census of 80, 7 licensed nurses 11/25/23 Census of 80, 7 licensed nurses 11/26/23 Census of 80, 7 licensed nurses A review of the facility's staffing for December 2023 indicated the staffing for CNAs were not met for 8 out of 12 days on these dates: 12/1/23 Census of 81, 20 CNA 12/2/23 Census of 78, 19 CNAs 12/3/23 Census of 78, 18 CNAs 12/4/23 Census of 78, 21 CNAs 12/6/23 Census of 78, 20 CNAs 12/7/23 Census of 81, 22 CNAs 12/8/23 Census of 80, 22 CNAs 12/9/23 Census of 79, 20 CNAs A review of the facility's staffing for December 2023 indicated the staffing for licensed nurses were not met for 4 out of 12 days on these dates: 12/2/23 Census of 78; 7 licensed nurses 12/3/23 Census of 78; 7 licensed nurses 12/9/23 Census of 79; 8 licensed nurses 12/10/23 Census of 78; 8 licensed nurses During an interview on 12/14/23 at 11:37 a.m., Unlicensed Staff N stated sometimes the facility was short staffed and the patient load could be heavy. When asked what risk would be for the residents if the facility was short staffed, he did not respond. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O the facility was short staffed. When asked what risk would be for the residents if the facility was short staffed, Unlicensed Staff O stated short staffing could led to staff not giving enough time to residents so there was less individualized care time for residents. During an interview on 12/15/23at 10:20 a.m., Licensed Staff P stated there were times when the facility was short staffed. When asked what risk would be for the residents if the facility was short staffed, Licensed Staff B stated staff could get stressed out temperamental, which could lead to residents feeling anxious. Licensed Staff P stated short staffing could also lead to decreased amount of care rendered to residents. Licensed Staff P stated staff could skip care if trying to meet needs of multiple residents and staff could be not as thorough when providing care for the residents. 2. During an interview on 12/15/23 at 9:58 a.m., Unlicensed Staff O stated she could not recall if she had received an in service regarding TIC. Unlicensed Staff O stated she did not know what trauma informed care was. Unlicensed Staff O stated she would not know how to properly care for residents with trauma. Unlicensed Staff O stated not knowing how to properly care for residents with trauma could be a safety issue and could lead to inadequate care. During an interview on 2/15/23 at 10:20 a.m., Licensed Staff P stated she did not receive any in service regarding trauma informed care but would love to receive it to properly care for residents with trauma. During an interview on 12/15/23 at 11:34 a.m., the Director of Staff Development (DSD) stated she did not give an in service about trauma informed care. The DSD stated it was important staff knew how to deal with residents who had emotional, psychological and physical trauma. When asked what risk would be for the residents if staff did not receive training or in services regarding trauma informed care, the DSD stated trauma survivor residents could receive less than optimal care, staff could be insensitive and would not know what could trigger the behavior. The DSD stated it becomes counterproductive for the residents. During an interview on 12/15/23 at 2:57 p.m., Unlicensed Staff U stated he did not receive in service or training about TIC. Unlicensed Staff U stated he would not know how to properly provide care for residents who had trauma. During an interview on 12/15/23 at 2:58 p.m., Licensed Staff V she had not received a TIC training or in service. Licensed Staff V stated it was important to receive TIC training, so staff knew how to care for residents adequately and properly with trauma. A policy and procedure for Trauma Informed Care was requested but was not provided. A review of the facility assessment attachment 1 titled Medicare and Medicaid Programs; Reform of requirements for Long Term Care Facilities indicated the facility must have a sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure residents safety and attain or maintain the highest practicable physical, mental and psychosocial well being of each residents

Based on interview and record review, the facility did not ensure training materials, resources, and policies and procedures explained all allegations of abuse must be reported in two hours. This failure resulted in staff not knowing the correct timeline to submit an SOC341 (State of California Report of Suspected Dependent Adult / Elder Abuse) (This form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult.), after they had become aware of an allegation of abuse. Finding: During an interview on 12/13/23, at 12:00 PM, CNA Q stated she would report allegations of abuse to charge nurse and the nurse would report and file an SOC 341. She stated the time to report is 24 hours. During an interview and record review with Director of Staff Development (DSD), on 12/14/23, at 11:15 a.m., she stated Abuse Prevention and Reporting was completed for every new hire and at annual in-services. She stated Abuse Reporting time frame was Two hours if harm and 24 hours if no harm. A review of the resources and documents used for Abuse Prevention and Reporting training indicated a document titled, Mandated Reporter California Long Term Care Ombudsman Association, not dated, indicated for allegations of Physical Abuse Serious Bodily Injury within 2 Hours Written Report SOC341 to: Licensing Agency. Physical Abuse No Serious Bodily Injury Within 24 hours: Written Report SOC341 to: Licensing Agency. Licensed Nurse O stated The Abuse Training Program information was here when I started and I did not know where it came from. During an interview and record review on 12/14/23, at 11:52 a.m., Unlicensed Staff N stated staff needed to report any abuse immediately or in two hours. He stated he was unsure but there was a resource binder at the nursing station with information on reporting abuse. Review of a document titled Mandated Reporter California Long-Term Ombudsman Association, dated 1/1/2013, Indicated Observes, has knowledge of, or reasonably suspects Physical Abuse in a Long-Term Care Facility, Serious Bodily Injury, Within 2 Hours: Written Report SOC341 to Licensing Agency. No Serious Bodily Injury Within 24 hours: Written Report SOC341 to Licensing Agency. Unlicensed Staff P stated the document was confusing. During an interview on 11/14/23 at 11:49 a.m., Licensed Nurse A stated she did not know when to report abuse to the Licensing Agency and asked Was it two hours? During an interview on 11/14/23 at 11:55 a.m., at 11:55 a.m., Licensed Nurse A stated reporting abuse should occur immediately or within 24 hours. She stated I don't know the difference for reporting abuse. During an interview on 11/14/23 at 12 p.m. Unlicensed Staff T stated Abuse reporting should be done in 36 hours? During an interview with Licensed Nurse K she stated all competency orientation documents included abuse training, and stated all staff were educated about filling out the SOC341. She stated if something happened they would have called the Director of Nursing, or Administrator. She stated an abuse allegation, if serious, would be reported in two hours or 24 hours if the abuse was non serious. She stated non serious was defined as when two residents with dementia have an exchange but then forget about it and there was no visible sign of injury. During a concurrent interview and record review, on 12/15/23, at 10:15 AM, CNA R stated she would report abuse to the abuse coordinator immediately. Review of a card in her badge carrier indicated to report abuse within 24 hours. She stated the card was given to her by the Director of Staff Development (DSD) as part of abuse training. During an interview and record review, on 12/15/23, at 11:10 a.m., Administrator In Training (AIT), stated he was the abuse coordinator for the facility and thought an Abuse allegation and a completed SOC341 should be reported immediately, or between two to 24 hours. He stated two hour reporting was for serious bodily injury and 24 hours was no visible resident injury. During a review of a document titled Mandated Reporter California Long-Term Ombudsman Association, dated 1/1/2013, it indicated Observes, has knowledge of, or reasonably suspects Physical Abuse in a Long-Term Care Facility, Serious Bodily Injury, Within 2 Hours: Written Report SOC341 to Licensing Agency. No Serious Bodily Injury Within 24 hours: Written Report SOC341 to Licensing Agency. Administrator in training stated he not aware of the requirement to report all allegations of abuse in two hours. He stated he did not know the regulation. He stated the risk of not reporting allegations of abuse in two hours to state agency was the risk being inconsistent with reporting and losing trust with resident's, resident families, and facility staff. He stated it resulted in staff confusion about required two hour reporting times. He provided a document titled, Abuse Reporting Requirements (name) Healthcare , dated 2017, indicated All alleged violations immediately but not later than 1) 2 hours-If the alleged violation involves abuse . Review of a document titled Policy: Abuse Reporting and Response, dated 9/2017, indicated The Center immediately reports all suspected and / or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law. The Executive Director or designee reports alleged violations to the state survey agency and other officials in accordance with state law (such as Adult Protective Services and local law enforcement) as follow: a. Immediately but not later than 2 hours . Review of a document titled (Place Building Logo here) Reportable Incident Investigation Tool, dated 07/2017, indicated Initial reporting: .Submit the appropriate state specific form (initial report) within the state's mandated reporting requirement (2 or 24 hours). Review of the State Operating Manual, dated 2017, indicated S483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Request for a copy of the Federal Regulation about abuse reporting timeline was made to the facility, and not received before the end of survey. 48660

Based on interview and record review, the facility failed to ensure five sampled residents (Resident 1, Resident 14, Resident 35, and Resident 38, Resident 51) and resident's representative(s) participated in the plan of care when Care Conferences were not held for the last two quarters according to facility Policy and Procedure. This failure had the potential to interfere with the five resident's ability to achieve and maintain their highest level of activity and independent. Findings: (Refer F 745) During an interview with Resident 14 on 12/12/23, at 9:45 a.m., he stated he was concerned about getting out of the facility and back to his apartment. He stated he wanted to be back in (name of town), a town located 43 miles away, where all his friends and family were located. He stated there were rehabilitation facilities in (name of town) he wanted to transfer to, and had told staff of his desire to transfer, but staff had told him that he could not. Resident 14 stated he did not remember being involved in a Care Conference or Team Meeting to talk about his plan of care. He stated it made him feel like he did not matter. During an interview on 12/12/23, at 12:50 a.m., Resident 38 stated she wanted to go home. She stated she would like to go to a group home. She stated she did not remember a meeting with staff to discuss her care while in the facility and did not know what discharge planning had been done and would like to know. During an observation and interview on 12/12/23 at 12:58 p.m., Resident 1 was observed to be wringing her hands and furrowing her eyebrows. She stated she wanted to go home. She stated she has told the staff about it and did not understand why she could not go home. She stated it had been months since she talked to someone about it and it made her feel ignored and sad. She stated it was close to Christmas and she did not want to be in the facility. During a telephone interview on 12/12/23 at 11:57 a.m., with Responsible Party S, she stated I have not been asked to participate in a Care Conference since Resident 51 was admitted . She stated she made phone calls to the facility to find out how the resident was doing but a lot of times no one would answer the phone. She stated she had cancer and could not come into the facility and no one from the facility had called her about anything unless Resident 51 falls. She stated the last Care Conference she participated in was when they decided to put the Resident 51 in long term care and that has been over a year. She stated she had not participated in the plan of care for Resident 51 since he went into long term care and it made her miss Resident 51 even more. During an interview with Social Services Director on 12/14/23, at 9:44 a.m., she stated she had been in role for only three weeks and Resident 1 was one of the cases that she became aware of early in her role that she knew the previous person in this role had messed up. She stated there had been a lack of discharge planning for Resident 1 and she had to start the planning over again from the beginning. She stated this had delayed Resident 1's discharge and made the resident feel anxious and sad. During an interview with Social Services Director and Administrator in Training 12/14/23, at 2:37 p.m. Social Service Director stated she had only been in current role for three weeks and knew the previous person had not conducted Care Conferences regularly. She stated the Care Conferences should have been done once a quarter and whenever needed. During an interview on 12/15/23 at 1:27 p.m., FACILITY CONSULTANT T stated there was no documentation of Care Conferences or Interdisciplinary Team Meetings, for the past two quarters for the Resident / Responsible party for Resident 14, Resident 35, Resident 38, Resident 1 or Resident 51. During a review of a document titled Admission Record, it indicated Resident 14 was admitted [DATE] with diagnoses that included Hemiplegia (Paralysis of one side of the body) and Hemiparesis (Weakness in your arms, hands, face, chest, legs and or feet that can make it hard to perform everyday activities like eating or dressing.) following Cerebral Infarction (Stroke) Affecting Right Non-Dominant (Right Side), Chronic Obstructive Pulmonary Disease (COPD) (A type of progressive lung disease that limits airflow and results in shortness of breath and a cough that worsens with time.) and Ataxia (Lack of coordination of arms and legs resulting in lack of balance, and trouble walking.). During review of a document for Resident 14, titled Minimum Data Set (MDS) summary of information to assess and manage care of residents in skilled nursing homes.) Section C Cognitive Patterns, the Brief Interview Mental Status (BIMS) (A scoring assessment system used to determine how mentally intact a resident is. 0-7 points is severely impaired, 8-12 moderately impaired and 13-15 no impairment.) indicated Resident 1 had a score of 14. During a review of a document titled Admission Record, it indicated Resident 35 was admitted [DATE] with diagnoses that included Brain Injury, Muscle weakness, and chronic pain. During a review of a document for Resident 35, titled MDS, Section C Cognitive Patterns, the BIMS inicated Resident 35 had a score of 14. During a review of a document titled Admission Record, it indicated Resident 38 was admitted [DATE] with diagnoses that included Unspecified Lack of Expected Normal Physiological Development in Childhood (Someone who did not developed physically or mentally during childhood.), Obsessive-Compulsive Disorder, Unspecified (repetitive thoughts or actions without a specific diagnosis.) During review of a document for Resident 38, titled Minimum Data Set (MDS) indicated Resident 38 had a score of 13. During a review of document titled Admission Record, it indicated Resident 1 was admitted [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant (Left Side), COPD. During review of a document for Resident 1, titled Minimum Data Set (MDS) summary of information to assess and manage care of residents in skilled nursing homes.) Section C Cognitive Patterns, the Brief Interview Mental Status (BIMS) indicated Resident 1 had a score of 14. During a review of document titled Admission Record, it indicated Resident 51 was admitted [DATE] with diagnoses of Hemiplegia following Cerebral Infarction Affecting Left Non-Dominant Side, Aphasia (Difficulty / inability to talk), Unspecified Dementia with other Behavioral Disturbance (Impaired concentration, apathy, agitation) During review of a document for Resident 51, titled Minimum Data Set (MDS) Section C Cognitive Patterns, the Brief Interview Mental Status (BIMS) indicated Resident 51 had a score of 4. A document for Resident 51, titled Baseline Care Plan Person-Centered Care Planning, dated 9/7/23, indicated Social Services Resident and/or Resident Representative (RR) Interview 1. Initial Plan for Placement: a. Short Term. Review of a facility Policy and Procedure titled INTERDISCIPLINARY PLAN OF CARE CONFERENCE, not dated, indicated An Interdisciplinary Care Planning Conference identifies resident needs and establishes obtainable goals. An appropriate plan of action is designed to ensure optimal levels of activity and independence for all residents . The MDS Coordinator chairs all POC Review meetings. Conferences for all residents are held within seven (7) days following admission and every 90 days thereafter or when a change in condition occurs. The review includes the following: A review of current long-term and short-term goals. Resident care problems, goals and approaches with appropriate time frames. Discharge Planning. Resident and family education .

Based on observation and interview: 1. The facility failed to ensure a comfortable environment when the facility did not maintain comfortable room temperature (standard room temperatures are to be from 71-81 degrees F) in 8 out of 10 (rooms,101, 103, 104, 105, 106, 107, 108 and 109) when temperatures measured were from 66 degrees to 68.9 degrees and (Resident 6 and 9) complained of being cold inside of their rooms. 2. The facility did not maintain comforatable room resident room temperatures safely by using space heaters in five out eight resident rooms (room [ROOM NUMBER], 327, 328, 331 and 329) which had the potential of causing a fire resulting in injury or death. Two rooms (room [ROOM NUMBER] and 332)which were not heated by space heaters were not maintained to the appropriate temperature resulting in two residents (Resident 21 and 23) stating they were cold and uncomfortable. On 12/18/19 at 4:14 p.m., due to the facility failure to provide a functional heating system to provide comfortable room tempertures, Administrative Staff A and Director of Nursing (DON) were verbally notified of the Immediate Jeopardy (Immediate Jeopardy is a situation in which provider's noncompliance with one or more requirements of participation has caused or like to cause serious injury, harm, impairment or death to a resident ((State Operations Manual, Appendix Q)). Administrative Staff A and DON were informed of the temperature readings of 8 rooms (rooms 101, 103, 104, 105, 106, 107, 108 and 109) which were all below the required temperature of at least 71 degrees as obtained by maintenance. On 12/18/19, at 4:558 p.m., the facility presented a corrective plan of action, including but not limited to: 1) moving all of the residents out hallway 100 and into resident rooms located in hallway 200, 2) installing a temporary heating system to heat hallway 100, which would be OSHPD (California Office of Statewide Health Planning and Development) approved and 3) residents would be moved backed into their rooms after the temporary heating system was installed and two consecutive hours of temperatures measured over 71 degrees were documented. On 12/18/19 at 4:58 p.m., the abatement (lifted) of Immediate Jeopardy occurred in the presence of Administrative Staff A and DON after concurrent observations and temperature measurements were obtained throughout hallway 200 and resident rooms were observed to have two call lights and additional privacy curtains to accommodate two residents per room. Administrative Staff A and DON stated the facility would continue to complete a plan of action to replace the heating and air-conditioning systems, since they were not consistently functioning. During a revisit to facility on 12/31/19 at 12:41 p.m., space heaters were observed in 5 out of 8 resident rooms (room [ROOM NUMBER], 327, 328, 331 and 329) in hallway 300. Three resident room (325, 327 and 331) which were not occupied so the space heaters were unattended and two rooms ( 332 and 330) were inadequately heated for the residents (Resident 21 and 23) and they stated there were cold. Administrative Staff A and DON were verbally notified of the second Immediate Jeopardy. On 12/31/19 at 3:43 p.m., the abatement (lift) of Immediate Jeopardy occurred in the presence of Administrative Staff A and DON after every resident in Hallway 300 was moved to resident rooms located in Hallway 200. Concurrent observation and temperature measurements were obtained throughout hallway 200 and resident rooms were observed to have two call lights and additional privacy curtains to accommodate two residents per room. Administrative Staff A and DON stated the facility would continue to complete a plan of action to replace the heating and air-conditioning systems, since they were not consistently functioning. These failures had the potential to cause: a) Resident's susceptibility to loss of body heat and risk of hypothermia (medical emergency that occurs when your body lose heat faster than it can produce, causing dangerous low body temperature) or susceptibility to respiratory aliments and colds, b) immobility issues related to not wanted to get out of bed due to the cold, and c) negatively impact residents comfort and homelike environment and potential for risk of fire, bodily injury (burns) and death. Findings: 1. During concurrent observation and interview on 12/18/19 at 3:25 p.m., the 100 section of the facility felt cold and during an observation of room [ROOM NUMBER], the room felt colder than the hallway. Resident 1 stated he was cold and fully clothed with a heavy jacket and curled up on the top of his bed with multiple blankets. Resident 1 would not answer any further questions and remained curled up in a ball. During an interview on 12/18/19 at 3:31 p.m., with Unlicensed Staff B, she indicated there was no heat in the hallway and she was not sure how long the heater had been broken. During a concurrent interview and observation with Administrator Staff A on 12/18/19 at 3:32 p.m., he stated there was no heat in hallway 100 and there was a plan to expedite the work to replace the heating system first in hallway 100. Administrator Staff A indicated the whole heating and air conditioning system would be replaced in phases and the first phase would start with hallway 100 with the plan to complete the installation within six weeks. Administrator Staff A indicated the plan in the meantime was to give the residents an additional blanket at night. 12/18/19 the temperatures ranges indicated to a low of 43 degrees to a high of 48 degrees as indicated by weather.com website. During concurrent observation and interview on 12/18/19 at 3:39 p.m., Maintenance Manager (MM) measured the temperatures in hallway 100 and resident rooms. *room [ROOM NUMBER] measured 67.1 degrees, Resident 6, who was observed to be in bed with jeans, multiple top layers, jacket and shoes on his bed, stated he was cold. *room [ROOM NUMBER] measured 66 degrees *room [ROOM NUMBER] measured 67.4 degrees, Resident 9, who was observed to be in bed with a robe and multiple blankets on the bed, stated she felt cold. *room [ROOM NUMBER] measured 68.3 degrees *room [ROOM NUMBER] measured 68.9 degrees *room [ROOM NUMBER] measured 67.8 degrees *room [ROOM NUMBER] measured 66.3 degrees *room [ROOM NUMBER] measured 66.3 degrees During an interview on 12/18/19 at 3:55 p.m., Administrator Staff A presented a work order indicating five infrared space heaters had been purchased and would be delivered that night. Administrator Staff A indicated he was not aware of the safety problems with having portable space heaters with regards to tripping hazards and electrical cord safety concerns. During concurrent observation and interview on 12/18/19 at 4:53 p.m., Maintenance Manager (MM) measured the temperature in hallway 200 which was indicated to be 79.5 degrees at the beginning of the hallway and 73 degrees at the end of the hallway. Maintenance Manager measured room [ROOM NUMBER] which was measured 74.6 degrees and room [ROOM NUMBER] was measured at 78 degrees. 2. During a concurrent observation and interview on 12/31/19 at 11:32 a.m., with MM, room [ROOM NUMBER] had a portable space heater and no one was in the room. MM stated he did not know where the space heater came from. The space heater looked exactly like the space heater on the purchase order dated (12/18/19), the space heater had not been placed there by the facility. MM stated he thought the space heater was placed by a family member but upon observation, the back of the heater did not reveal a name regarding ownership. *room [ROOM NUMBER] was observed to have a portable heater, Resident 19 stated, she did not want the portable heater removed because the room was freezing. * room [ROOM NUMBER] was observed to have a portable space heater and no one was in the room. *room [ROOM NUMBER] was observed to have a portable space heater and no one was in the room. *room [ROOM NUMBER] measured at 74 degrees, Resident 21 who resides in that room stated it was generally cold in the room. Resident 21 was observed to be in bed, with a sweater on and four blankets on her bed. Resident 23 who resides in room [ROOM NUMBER] was visiting Resident 21 in her room and she sated the room was cold as well as her own room. Resident 23 stated she had told MM that her room was cold and a portable heater had been plugged into the electrical outlet for a short time but did not heat the room adequately, so it was removed. Resident 23 indicated the mornings were especially cold until the sun could warm the room slightly. (weather temperatures for Lakeport, California for 12/30/19 ranged from a low of 37 degrees to a high of 46 degrees and on 12/31/19 the temperature low ranged from 37 degrees to a high of 52 degrees) and was observed to be in a wheelchair, fully clothed with multiple top layers including a sweatshirt and a knit hat. *room [ROOM NUMBER] was measured at 72 degrees with the sun shining into the window at 12:05 p.m. and was not observed to have a space heater. *room [ROOM NUMBER] was measured at 76 degrees with a portable heater with no one in the room During an interview on 12/31/9 at 12:09 p.m., Administrator A, DON and MM were informed that 5 out of 8 resident rooms located in Hallway 300 had portable space heaters. Administrator A, DON and MM indicated they were aware that portable space heaters were not appropriate method of heating resident rooms. MM indicated the heating system had not been working well for a long time. During an interview with Resident 3 on 12/31/19 at 12:25 p.m., she stated she had been residing in the room for approximately 3 weeks and had a space heater to keep the room warm. Resident 3 indicated by lunchtime to early afternoon the room would be warm enough to turn off the space heater but at night the room would be very cold without a space heater. During an interview with Resident 1 on 12/31/19 at 12:33 p.m., he indicated he had been using the space heater for the last 2-3 days and it was especially necessary in the mornings when it's so cold outside. On 12/31/19 at 12:41 p.m., due to the facilities failure to provide comfortable facility temperatures without the use of portable space heaters, Administrator Staff A and DON were verbally notified of the Immediate Jeopardy. Administrator Staff A and DON were informed of 5 space heaters, three of which were in use and unsupervised, the interviews of residents who were complaining of being cold and not wanting the space heaters removed. On 12/31/19 at 3:08 p.m., the facility presented a corrective plan of action, including but not limited to: 1) the 5 space heaters were removed from the resident's rooms, 2) all other resident rooms were searched for space heaters, 3) residents in hallway 300 were temporarily relocated to resident rooms in Hallway 200 until an Office of Statewide Health Planning and Development (OSHPD) approved temporary heating system was installed in hallway 300 and after two hours of consecutive temperature readings above 71 degrees was documented. On 12/31/19 at 3:45 p.m., the abatement was (lift) of Immediate Jeopardy occurred after the last resident was relocated in hallway 200, where it was deemed each individual room could accommodate two residents by having two call lights and privacy curtains. Administrative Staff A understood the facility would continue to complete the plan of action to replace the heating and air-conditioning system. On 1/28/20 at 10:25 a.m., Administrative Staff A and DON were notified of substandard quality of care identified and the facility was on an abbreviated extended survey. Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 486.10 resident rights that constitute immediate jeopardy to resident health or safety (level J, K or L) (State Operations's Manuel, Appendix P).

Based on observation, interview and record review, the facility failed to take pressure sore precautions for one of eight sampled residents (Resident 11) at risk for skin breakdown. This lead to the development of two unstageable pressure ulcers to Resident 11's heels. Findings: Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Face Sheet. physician's orders [REDACTED]. A document titled, Physician order [REDACTED]. According to Resident 11's MDS (Minimum Data Set-Federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessment dated [DATE], his BIMS (Brief Interview of Mental Status- required screening tool used in nursing homes to assess cognition) score was 13, which indicated his cognition was intact. Resident 11's Admission/Readmission assessment dated [DATE] at 5:05 p.m., indicated Resident 11 had limited mobility and required assistance with transfers and toileting. This document also indicated that the only skin impairment issue noted on admission was the transmetatarsal amputation of the right foot. During an interview on 3/26/19 at 10:30 a.m., Resident 11 stated he was admitted to the facility with an amputated right foot. The surgeon who amputated his foot told him to keep weight off his feet for at least four weeks. He stayed in bed for the next four weeks after his admission to the facility. Resident 11 stated the facility did not do anything to elevate his legs. Resident 11 was not aware that he was supposed to elevate his feet or float his heels, causing them to break down from being in bed. A nurse was attending to the amputation wound but never checked for pressure sores. One day he was trying to look at his amputation wound and discovered a pressure sore on his right heel. He brought it to the staff's attention. Staff checked it but failed to check the other heel. Two days later, he found a pressure sore on the other heel (left heel). Resident 11 stated that he felt no pain from the pressure sores before discovering them. He was taking strong narcotics around the clock for pain control of his amputated foot, which could have masked the pain from the pressure sores. During an observation on 3/27/19 at 10:25 a.m., the pressure wound on the right heel measured 3 centimeters long by 2 centimeters wide, and was covered in black eschar (destroyed tissue). This pressure wound was 2.5 centimeters above the plantar (bottom) skin of the foot. It was unlikely to have been caused by bearing weight on the right foot, since it was 2.5 centimeters above the weight bearing plantar skin. The pressure wound on the left heel measured 1-centimeter-long by 1-centimeter-wide, and was covered with a brown scab. This pressure wound was 2.5 centimeters above the plantar skin of the foot. It was unlikely to have been caused by bearing weight on the left foot since it was 2.5 centimeters above the weight bearing plantar skin. During an interview on 3/26/19 at 2:40 p.m., Licensed Staff D (Resident 11's assigned License Nurse for PM shift) stated that after Resident 11's admission, they immediately started the following interventions to prevent pressure sores: Increase in fluids, a pole to offload the pressure (in bed) and help with repositioning. Licensed Staff D did not mention any interventions to keep pressure off Resident 11's heels. During an interview on 3/26/19 at 3 p.m., the DON stated Resident 11 developed pressure ulcers on his heels because he was non-compliant with care and refused to stay off his feet. She stated Resident 11 had half his foot amputated, but continued to walk on it. The DON stated Resident 11 was observed resting his heels on the end of the bed. There was no documentation prior to the discovery of the pressure wounds, that Resident 11 was observed resting his heels on the end of the bed. During an interview on 3/27/19 at 2:40 p.m., Certified Nursing Assistant A (Resident 11's assigned Certified Nursing Assistant for AM shift) stated the only pressure sore precaution taken with Resident 11, on admission, was a leg treatment which the wound nurse would do. A Nursing Plan of Care initiated on 12/6/18, to prevent skin impairment, indicated, Focus Actual or potential for skin impairment r/t (related to) impaired bed mobility. Goal Will minimize skin risks daily. Interventions/Tasks Other interventions r/t skin: (blank) Physician Orders/Treatments r/t skin: (blank). The interventions were left blank, therefore, there were no interventions to prevent skin impairment in the Nursing Plan of Care. physician's orders [REDACTED]. Document + Indicates skin impairment. -Indicates no Impairment. (If problem identified, complete wound documentation for each site). Every evening shift every Thu for Weekly Summary. The first weekly skin assessment for Resident 11 was documented on 12/20/18 at 12:53 p.m., 15 days after the physician ordered the weekly skin assessment head-to-toe. This was confirmed by the MDS Coordinator who provided the head-to-toe skin assessments on 3/28/19 at 2:10 p.m. The skin assessment dated [DATE] at 12:53 p.m., discussed the wound healing process of the amputated foot. There was no indication of any pressure sores noted during the skin assessment on 12/20/18. A Nursing Note documented on 12/31/18 at 2:34 p.m., indicated, NEW SKIN WOUND NOTED TO RIGHT HEEL. THERE IS A NON STAGEABLE PRESSURE WOUND TO THE HEEL. THE MEASUREMENTS ARE 3.5 X 2.5 X 0.0. THE WOUND IS COVERED WITH 100% ESCHAR. EDUCATION PROVIDED ON THE IMPORTANCE OF KEEPING HIS FOOT FLOATED. Prior to 12/31/18, there was no clinical documentation that mentioned floating the heels for Resident 11. There was no clinical documentation that mentioned providing education to Resident 11 on keeping pressure off his heels. A nursing note documented on 1/1/19 at 9:45 a.m., indicated, RESIDENT HAS A DTI (Deep Tissue Injury) TO THE LEFT HEEL. MEASUREMENTS ARE 1.2 X 1.0. SKIN PREP APPLIED AND COVERED WITH FOAM AND A ISLAND DRESSING. EDUCATION PROVIDED ON THE IMPORTANCE OF KEEPING HEELS FLOATED AT ALL TIMES. WILL CONTINUE TO MONITOR. The deep tissue injury to the left heel was discovered one day after the discovery of the skin wound to the right heel, consistent with Resident 11's statements during an interview on 3/26/19 at 10:30 a.m., when he explained that he told staff of the pressure wound to the right heel, but staff failed to assess the other heel. Resident 11 stated he later found the other pressure sore and notified staff about it. A nursing note dated 1/2/19 at 1:35 p.m., indicated, RESIDENT HAS NEW WOUNDS TO BOTH THE LEFT AND RIGHT HEELS. BOTH WOUND ARE UNSTAGEABLE AT THIS POINT .A LOW AIR LOSS BED IS ON ORDER. There was no documentation that an air loss bed or specialty bed was in use by Resident 11, prior to the discovery of the pressure wounds, to help prevent skin breakdown. The facility's policy titled, Pressure Ulcer/Injury Risk Assessment, last revised in (MONTH) of (YEAR), indicated, Risk factors that increase a resident's susceptibility to develop or to not heal PU/PIs (Pressure ulcers/Pressure Injuries) include, but are not limited to: a. Impaired/decreased mobility and decreased functional ability; e. Impaired diffuse or localized blood flow, for example, generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency; f. Co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes mellitus. This policy also indicated, Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain one of two sampled residents' (Resident 1) highest practicable physical well-being when: 1. Staff did not apply the Velcro cast/boot to Resident 1's left foot, as his physician ordered, after Resident 1 sustained a [MEDICAL CONDITION] third and fourth metatarsal heads (foot fracture, metatarsal head is the head of the long bone in the foot that connects the ankle to the toe); and 2. Staff did not adequately assess, monitor, or treat Resident 1's left foot/toes swelling after he sustained a left foot fracture. These failures caused Resident 1 to have pain, toe/foot swelling and not being able to move his toes, and had difficulty walking. These failures also resulted in the potential for further injuries or deformity of the left foot, arthritis (inflammation of the joints), chronic pain, and potential to compromise Resident 1's physical and psychosocial well-being. Findings: Resident 1's face sheet (admission record) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 6/5/17, and 8/21/17, revealed Resident 1's BIMS (Brief Interview for Mental Status) scores were 13, which indicated Resident 1 was cognitively intact. The intake information sheet, dated 8/21/17, and the facility's Summary of Investigative Report, dated 8/22/17, indicated on 8/17/17, Unlicensed Staff C tripped on her own foot and accidentally stepped on Resident 1's left foot during transfer from his wheelchair to his bed. Three days later, Resident 1 complained of left foot pain, and slight swelling was noted. X-ray results confirmed an acute fracture of Resident 1's third and fourth metatarsal heads. Resident 1's Physician Order, dated 8/21/17, indicated, Velcro Cast for (left) foot fractures (for eight) weeks minimum then (evaluate). During a concurrent observation and interview on 10/3/17, at 10:30 a.m., in Resident 1's room, Resident 1 was sitting in a wheelchair at his bedside. Resident 1 was alert and awake and was wearing his shoes on both feet with no Velcro cast or boot. Resident 1 stated he was not sent to the hospital nor received any treatment or cast for his left foot fractures. Resident 1 stated after the incident, he has had left foot pain of 6/10 (pain scale 0-10, 0 indicates no pain and 10 indicates most severe pain) and made it difficult to walk. Resident 1 stated he had to take pain medication for the pain. He stated he did not have pain on the left foot before this incident. During a concurrent observation and interview on 10/3/17, at 11 a.m., Licensed Staff A assisted Resident 1 to take off the shoe of his left foot and observed the left foot. All the toes, except the great toe, appeared swollen and red/purplish. Resident 1 stated after the transfer incident, his toes had been swollen and he could not move his toes. Resident 1 stated he still had pain of 6/10 on his second, third, and fourth toes. Licensed Staff A told Resident 1 that he just took the pain pill and needed a little time for the medication to work. Licensed Staff A stated podiatry would come and care for his toe nails. Licensed Staff A did not address the swollen toes. During an interview on 10/3/17, at 11:50 a.m., the Assistant DON (Assistant Director of Nursing) stated there was no specific treatment for [REDACTED]. According to the MedlinePlus, updated 10/3/17, after a non-displaced metatarsal fracture, the resident would probably wear a cast or splint for 6-8 weeks, may not put weight on the fractured foot, may need crutches or other support to help to get around, may also be fitted for a special shoe or boot that may allow the resident to bear weight. Interventions to decrease the swelling included: Resting and not putting weight on the foot, elevating the foot, applying ice pack to the foot for about 20 minutes every hour while awake for the first 48 hours, then 2 to 3 times a day. According to Foot Health Facts, 2017, it was incorrect to say, the doctor can't do anything for a broken bone in the foot. Improper treatment of [REDACTED]. Resident 1's Treatment Sheet, dated August 2017, indicated an order for [REDACTED]. The areas of the treatment sheet, under each day of the month, were blank, with no staff initials or documentation regarding the Velcro cast, from 8/21/17 to 8/31/17. Resident 1's Treatment Sheet, dated September 2017, indicated an order for [REDACTED]. During an interview on 10/19/17, at 2:30 p.m., the Nursing Supervisor stated, Velcro Cast FYI was written in the Treatment Sheet. The Nursing Supervisor stated she was not able to tell when to put on, or take off, the Velcro cast. The Nursing Supervisor stated they had already clarified the order, on 10/13/17, to write Velcro Cast to put on when Resident 1 was out-of-bed and to take off when Resident 1 was in bed. She stated no staff clarified the order, before 10/13/17. When mentioned to her that Resident 1 was not wearing the Velcro Cast during the observation on 10/3/17, the Nursing Supervisor stated she did not know because she did not do treatment until a couple weeks ago. The October 2017, Physician order [REDACTED]. The Medication Sheet, dated October 2017, indicated an order, Velcro boot to (left) foot and scheduled for PRN (as needed), which was discontinued on 10/10/17. The Medication Sheet indicated another order, apply Velcro boot when out of bed and scheduled for PRN, which was started on 10/10/17. The Medication Sheet revealed the order was discontinued on 10/25/17. The Medication Sheet revealed a staff member signed on 10/13/17, for applying the Velcro boot and on 10/23/17, for Resident 1 refusing the Velcro boot. The areas of the Medication Sheet for all other days, prior to 10/25/17, under the above two orders, did not have staff initials or documentation for applying the Velcro boot. Review of the Nurses' Notes, from 8/21/17 to 10/25/17, revealed a Nurse's Note, dated 8/21/17 at 6:30 p.m., which indicated, .new order noted to get Velcro Cast for (left foot for 8-12 (weeks) . Another Nurse's Note, dated 8/22/17 at 1:10 a.m., indicated, (New order) for Velcro Cast For (left) Foot (for) 8 weeks . These two Nurses' Notes did not indicate when, and how to apply the Velcro cast. The rest of the Nurses' Notes did not indicate staff applied the Velcro cast/boot for Resident 1. During an interview on 10/13/17, at 3:20 p.m., Licensed Staff B stated she took care of Resident 1 once every two weeks. Licensed Staff B stated today (10/13/17) she had been on shift for approximately 1.5 hours, but she did not know about the Velcro cast/boot. During an interview on 10/25/17, at 3:46 p.m., Unlicensed Staff D stated Resident 1 was on RNA (Restorative Nursing Assistant) Program for ROM (Range of Motion) on August 2017. Unlicensed Staff D stated between the end of August and the beginning of September 2017, the Physical Therapist screened Resident 1 and referred him to the RNA Program for ambulation because Resident 1 wanted to walk. Unlicensed Staff D stated after the referral, she walked with Resident 1 with a front-wheel walker. Unlicensed Staff D stated she did not know about the Velcro cast/boot. She stated she saw a boot in Resident 1's room, but it was not applied on Resident 1 when she walked with Resident 1. Unlicensed Staff D stated she was not instructed to put the boot on Resident 1. During an interview on 10/27/17, at 9:30 a.m., the PT (Physical Therapist) stated she screened Resident 1 on 9/7/17, because Resident 1 wanted to ambulate. The PT stated she referred Resident 1 to the RNA Program for ambulation with a front-wheel walker. The PT stated she was not notified of Resident 1's left foot fractures, but stated if she knew about the fractures, the screening would be different because she had to follow the Physician's instructions for weight bearing. When asked if Resident 1 wearing a Velcro cast made any difference, the PT stated it depended on how the Physician ordered it. Resident 1's Interdisciplinary Therapy Screen, dated 9/7/17, indicated Resident 1 was screened for ambulation with front-wheel walker and referred to the RNA program. The document did not address left foot fractures or weight bearing. The Nurse's Note, dated 9/12/17, revealed Resident 1 to have RNA Program ambulation with a front-wheel walker, three times per week for 90 days. During an interview on 10/19/17, at 3:40 p.m., Physician G stated he expected the nurse to apply the Velcro cast/boot for Resident 1, when Resident 1 was out of bed. Physician G stated if the order did not specify the time to apply the Velcro cast/boot, the nurse should have called him for clarification. Physician G stated the Velcro cast/boot was used to stabilize the foot. Physician G stated if the Velcro cast/boot was not applied, the fractures could be displaced. When mentioned about Resident 1's toes still being swollen during the observation on 10/3/17, Physician G stated he did not remember if the facility updated him for the information, and he did not have the chart with him. The Nurses' Notes, dated from 7/18/17 to 1/9/18, revealed nurses documented on 8/21/17, 8/23/17, and 8/28/17, that Resident 1 had left foot swelling after the fracture. After the last documentation of the swelling on 8/28/17, the Nurses' Notes did not indicate assessment, evaluation, monitoring, or treatment for [REDACTED]. During a concurrent interview and record review on 1/11/18, at 10:45 a.m., the Acting DON reviewed Resident 1's medical records and stated she could not tell if the Velcro boot was applied to Resident 1. Also, the Acting DON stated the nurses documented the left foot swelling on the day the incident was discovered, on 8/21/17, and monitored it for a few days after 8/21/17. She stated the weekly summaries documented resident weekly assessment, but did not mention if left foot swelling was still present. The Acting DON stated Resident 1 was referred to PT for screening for walking but did not indicate the fractures. The Acting DON stated the PT might have evaluated Resident 1 differently for screening or evaluation, but the PT still should review Resident 1's chart, assess Resident 1 and should know about the fractures. Upon request for the policy and procedure regarding quality of life and quality of care, the Acting DON stated the facility did not have a policy and procedure. The facility's policy and procedure titled, Resident Rights, updated 9/17, indicated, .The Center presents federal and state specific resident rights and all rules and regulations governing resident conduct and responsibilities (orally and in writing) in a language that the resident understands at admission and annually to the resident and/or resident representative . Under Notice of Resident Rights under Federal Law, updated 11/16, indicated .21. The Resident has the right to reside and receive services in the Center .

Based on observation, interview, and record review, the facility failed to ensure staff transferred a resident properly and provided adequate supervision or assistance to prevent accidents or injuries, for two of two sampled residents (Resident 1 and 2) when: 1. a. Unlicensed Staff C did not properly transfer Resident 1 from a wheelchair to his bed on 8/17/17. b. Unlicensed Staff C did not report the incident to the licensed nurse when Resident 1 complained of his left foot being caught on the floor and left foot pain or Unlicensed Staff C tripped herself and stepped on Resident 1's left foot during the transfer on 8/17/17. These failures caused Resident 1 to sustain a fracture of the left third and fourth metatarsal heads (foot fracture, metatarsal head is the head of the long bone in the foot that connects the ankle to the toe), and the fractures were not detected until four days after the incident. These failures also caused Resident 1 to have pain, left foot/toes swelling and not being able to move his toes, and difficulty in walking. 2. Nursing staff did not address how to transfer Resident 1 and the Velcro cast/boot for the left foot fractures in his care plans. These failures resulted in the CNA (certified nursing assistant) not properly transferring Resident 1 and his not receiving a Velcro cast/boot for the left foot fractures, as the physician ordered. 3. Staff did not adequately supervise/monitor Resident 2, which resulted in Resident 2 staying in the parking lot driveway alone, which resulted in the potential for accidents, injuries, or death. Findings: 1. Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 6/5/17, and 8/21/17, revealed Resident 1's BIMS (Brief Interview for Mental Status) scores were 13, which indicated Resident 1 was cognitively intact. The Intake Information Sheet, dated 8/21/17, and the facility's Summary of Investigative Report, dated 8/22/17, indicated on 8/17/17, Unlicensed Staff C tripped on her own foot and accidentally stepped on Resident 1's left foot during transfer from his wheelchair to his bed. Three days later, Resident 1 complained of pain in his left foot, and slight swelling was noted. X-ray results confirmed an acute fracture of his third and fourth metatarsal heads. During a concurrent observation and interview on 10/3/17, at 10:30 a.m., in Resident 1's room, Resident 1 was sitting in a wheelchair at his bedside. Resident 1 was alert and awake. Resident 1 was wearing his shoes on both feet with no Velcro cast or boot. Resident 1 stated on August 2017, when a CNA transferred him from his wheelchair to his bed before lunch, the CNA grabbed his left arm very hard, which made his arm hurt. Resident 1 stated when he stood up with the CNA grabbing his arm, his left foot got caught on the floor with his foot and toes bent against the floor and hurt. Resident 1 stated he told the CNA he was hurting, but the CNA did not say anything nor did she stop the transfer to check on him. Resident 1 stated the CNA did not use any belt, machine, or device for transfer, just grabbed his arm with her hand. Resident 1 stated the CNA was usually nice to him, but that day the CNA looked angry. Resident 1 stated he was not examined by a nurse or other staff. Resident 1 stated he told another CNA later and that CNA asked a nurse to check on him. He stated they did an x-ray and found his toes cracked. Resident 1 stated he was not sent to the hospital and did not receive any treatment or cast for the fractures. Resident 1 stated he has had pain 6/10 (pain scale 0-10, 0 indicates no pain and 10 indicates most severe pain) after the incident and made it difficult to walk. Resident 1 stated he had to take pain medication for the left foot pain. He stated he did not have left foot pain before this incident. During a concurrent observation and interview on 10/3/17, at 11 a.m., in Resident 1's room, Licensed Staff A assisted Resident 1 to take off the shoe for his left foot and observed the left foot. All the toes, except the great toe, appeared swollen and red/purplish. Resident 1 stated after the incident, his toes had been swollen, and he could not move them. Resident 1 stated he still had pain 6/10 on his second, third, and fourth toes. Licensed Staff A told Resident 1 that he just took the pain pill and needed a little time for the medication to work. Licensed Staff A stated podiatry (related to the study, diagnosis, and treatment of [REDACTED]. Licensed Staff A did not address the toes swelling. During an interview on 10/3/17, at 2:57 p.m., regarding incident on 8/17/17, Unlicensed Staff C stated she assisted Resident 1 to transfer from his wheelchair to his bed. Unlicensed Staff C stated she lost her balance and struck/bumped into Resident 1's right foot. She stated she stepped on Resident 1's toes but not the whole foot. Unlicensed Staff C stated she helped Resident 1 to bed and checked Resident 1's foot with no concerns and saw everything was fine. Unlicensed Staff C stated she did not tell the nurse because she had no concerns. She stated she should have told the nurse. When asked how she transferred Resident 1, Unlicensed Staff C stated she used a gait belt (resident transfer belt) around him, then he stood up. She stated she did not grab Resident 1's arm. The Nurse's Notes, dated 8/21/17, at 2 p.m., revealed Resident 1 told the nurse, On Thursday at (approximately) 1230 around lunch time a CNA (Certified Nursing Assistant) .transferred the resident from (wheelchair) to bed .CNA grabbed resident by his (left) arm and put him into bed causing his (left) foot to get stuck under him during transfer. Causing increased pain .(left) foot/ankle (with) (mild/moderate) swelling and resident reports 8/10 pain . During an interview on 10/3/17, at 11:50 a.m., the Assistant DON (Assistant Director of Nursing, who stated she was also the Director of Staff Development) stated staff may or may not use a gait belt for transfer depending on the level of assist. During an interview on 10/3/17, at 1:56 p.m., Unlicensed Staff D stated if one-person assist for transfer, it always required a gait belt. During an interview on 10/12/17, at 2:45 p.m., the Assistant DON stated the CNA should report any unusual occurrence to the nurse. During a concurrent interview and record review on 1/11/18, at 10:45 a.m., the Acting DON (Director of Nursing) stated the CNA should report to the nurse when a resident complained of pain or got his foot caught. The Acting DON stated the CNA also should report to the nurse when the CNA tripped herself and stepped on the resident. The Acting DON stated the CNA should not assess the resident and determine what to do because CNAs were not trained for assessment. The Acting DON stated CNAs were trained to see something different and notify the nurse so the nurse could assess the resident. The x-ray result, dated 8/21/17, indicated Resident 1 had acute fractures of the third and fourth metatarsal heads, and the fractures did not appear to be pathologic fractures (A pathologic fracture is a bone fracture caused by disease that led to weakness of the bone structure). Upon request for the facility policy and procedure regarding resident safety and transfer, the facility provided a policy and procedure titled, EMPLOYEE SAFETY: NURSING, updated March 2015, under lifting and transfer, which indicated, Be sure to obtain assistance when necessary . Under gait belt, indicated, Wear and use gait belts while on duty. They are considered a part of the uniform. Gait belts will be used by employees to transfer and ambulate residents unless contraindicated on the resident's care plan . The policy did not specify transfer procedures. The facility also provided training material for transfer. The Assistant DON stated, on 10/12/17, that the facility did not have a policy and procedure for transfer. 2a. Resident 1's MDS dated [DATE], and 8/21/17, revealed Resident 1 required extensive assistance with two persons or one person to physically assist for transfers. Resident 1's Physical Therapy Discharge Summary, dated 6/16/17, indicated Resident 1 required minimal assistance. Resident 1's Fall Risk Care Plan, initiated on 5/29/17, Self-Care Deficit Care Plan, initiated on 5/29/17, and the Fracture(s) - Trauma Care Plan, initiated on 8/21/17, did not address how the staff assisted Resident 1 for transfer. During a concurrent interview and record review on 1/11/18, at 10:45 a.m., the Acting DON reviewed care plans and stated the care plans did not address how the staff transferred the resident. 2b. Resident 1's Physician Order, dated 8/21/17 and 10/10/17, indicated Velcro cast/boot for a left foot fracture for eight weeks. Resident 1's care plan for fractures, initiated on 8/21/17, did not indicate Velcro cast. During a concurrent observation and interview on 10/3/17, at 10:30 a.m., in Resident 1's room, Resident 1 was sitting in a wheelchair at his bedside. Resident 1 was alert and awake. Resident 1 was wearing his shoes on both feet with no Velcro cast or boots. Resident 1 stated he was not sent to the hospital nor did he receive any treatment or cast for his left foot fractures. During a concurrent interview with the Assistant DON and Nursing Supervisor on 10/25/17, at 2:25 p.m., the Assistant DON stated she was not the one who developed the care plan and did not know why the nurse did not include the Velcro cast. The Nursing Supervisor stated if she were the treatment nurse, she would ask the nurse to include the Velcro cast in the care plan. During a concurrent interview and record review on 1/11/18, at 10:45 a.m., the Acting DON reviewed the care plans and stated the care plans did not address the Velcro cast/boot. The Acting DON stated nurses should update the care plans to address the Velcro cast/boot. Upon request for policy for care planning on 10/25/17 and 1/11/18, the Assistant DON and the Acting DON stated the facility did not have a policy for care planning. 3. During a concurrent observation and interview on 10/3/17, at 1:30 p.m., in the entrance of the parking lot, Resident 2 was alone sitting in a wheelchair, in the driveway near the bushes, with his eyes closed. Resident 2 stated he liked to be out here (at the parking lot entrance driveway) two times a day after lunch for a quick nap. Resident 2 stated he had been out there for a while, and it was time to go back. Resident 2 propelled himself back to the facility sidewalk. During a concurrent observation and interview on 10/3/17, at 2 p.m., in the parking lot entrance driveway with Licensed Staff E, looking at the location where Resident 2 stayed alone, Licensed Staff E stated, Oh, No. It is not safe. Licensed Staff E stated cars or trucks driving in and out the parking lot could have, run over him (Resident 2). Licensed Staff E stated she would have to talk to Resident 2. During a concurrent interview and record review on 10/3/17, at 2:06 p.m., the Assistant DON stated Resident 2 was alert and oriented. The Assistant DON stated she had seen Resident 2 alone in the parking lot where cars or trucks could have hit him. The Assistant DON stated she talked to Resident 2 and care planned it on 8/3/17. The Assistant DON stated Resident 2 was non-compliant to instructions or care. The Assistant DON provided a IDT (Interdisciplinary Team) Note and a care plan dated 8/3/17, which indicated Resident 2 enjoyed going outside. Resident 2 was encouraged to notify the staff when going outside and stay within visual sight of vehicles. During an interview on 10/5/17, at 11:40 a.m., the Assistant DON stated Resident 2 was his own responsible party, so he did not have to sign out when going out of the facility. The Assistant DON stated they educated Resident 2 for safety in the parking lot but did not have the documentation. When asked how the facility would ensure Resident 2 stayed in a safe area outside the facility building, the Assistant DON stated that was the care plan, dated 8/3/17, to encourage Resident 2 to notify staff and stay within the visual sight of the vehicles. The Assistant DON stated the facility had not had an IDT Conference with Resident 2. When asked how the facility would ensure Resident 2 was outside staying in a safe area, the Assistant DON stated there was no Physician order for [REDACTED]. She stated they did not assign staff to be responsible for the check. Upon request for facility policy regarding resident safety or accidents, the facility provided a policy titled, Fall Evaluation (Morse Scale/Medication Fall Risk Score) and Management, which did not address safety or accidents other than falls.

Based on observations, staff interviews, and document review, the facility failed to prevent 1 of 16 sampled residents (Resident 2) from harm when the facility did not identify nor provide a need for adequate supervision for Resident 2, resulting in elopement from the facility. The resident fell , while in her wheel chair after leaving the facility, which resulted in a fractured hip. Findings: Review of Resident 2's Face Sheet in the resident's clinical record revealed the resident was a [AGE] year old woman with [DIAGNOSES REDACTED]. Review of Resident 2's Minimum Data Set (an assessment tool), dated 8/14/15, indicated that Resident 2 had short and long term memory problems, with moderately impaired cognitive skills for making daily decisions, had disorganized thinking, inattention, and exhibited wandering behavior 4-6 days over a course of seven days. Resident 2's clinical record contained an Elopement/Exit - Seeking Evaluation form. The evaluations were performed on 1/12/15, 5/18/15, and 8/26/15. All evaluations indicated the resident was at risk for elopement. The resident's Physician order [REDACTED]. The order further indicated CODE ALERT BRACELET TO ALERT STAFF OF ATTEMPTS TO ELOPE. CHECK FOR PLACEMENT AND FUNCTION Q SHIFT. PLACED ON LEFT ARM. During an interview on 11/18/15 at 4:25 p.m., with Unlicensed Staff AD, she stated that on 11/16/15 at 6:09 a.m., she was in the staff break room when she heard the Wanderguard alarm (a Wanderguard is an alarmed monitoring system often used for residents with dementia to alert staff when a resident attempts to exit a door) sounded in Hall 4. She stated she went outside the exit door and found two nurses attending to Resident 2. During an interview on 11/19/15 at 7:40 a.m., Unlicensed Staff AF was asked how frequently residents with Wanderguards open the exit doors triggering the alarm. Unlicensed Staff AF stated it could be three times a day or once a week. During an interview on 11/19/15 at 7:41 a.m., Unlicensed Staff AG was asked how frequently residents with Wanderguards open the exit doors triggering the alarm. Unlicensed Staff AG stated approximately once per shift. During an interview on 11/19/15 at 7:50 a.m., Management Staff I was asked how frequently residents with Wanderguards open the exit doors triggering the alarm. Management Staff I stated one to two times per week. During an observation and concurrent interview with Administrative Staff A on 11/19/15 at 10:45 a.m., the area outside the exit door at the end of Hall 4 revealed a groove in the soil to the right of the sloped concrete walkway. When asked if Resident 2 went off the curb into the driveway, Administrative Staff A stated: I believe she did. He also corroborated the sloped concrete pathway leading from the exit door. During an interview on 11/19/15 at 4pm, licensed Staff AC stated that on 11/16/15 at approximately 6am, she was standing at the Nurses Station near Hall 4 when she heard the Wanderguard alarm sound. She looked at the central alarm monitor at the Nurses Station and saw that the exit door at the end of Hall 4 had been breached/opened. Licensed Staff AC stated that Resident 2 was a night owl and saw her open the exit door and go out the door in her wheelchair. Licensed Staff AC stated she could not reach Resident 2 in time and by the time she got to the exit door, the door had closed and Resident 2 was outside. Licensed Staff AC stated the concrete path leading from the exit door to the outside was inclined and by the time she reached Resident 2, the resident, in the wheelchair, was found tipped on its side in the driveway. Licensed Staff AC stated one of the wheelchair's wheels went off the pathway into the dirt which caused the wheelchair to tip onto its side. Licensed Staff AC added it was very dark outside still and staff had a flashlight. After righting the resident and wheelchair, Licensed Staff AC stated she assessed Resident 2 who was found to have an abrasion on her forehead. Once inside, Licensed Staff AC stated she saw some blood on Resident 2's left foot. Review of the nurse notes dated 11/16/15 at 8:15 a.m, in Resident 2's clinical record, indicated that Resident 2 was found with w/c (wheelchair) tipped over with skin tear on the right temple, abrasion right second toe, abrasion right knee, left inner foot abrasion, C/O (complaining of) pain to left lower extremity . Res (resident) with c/o increased pain to left lower extremity r/t (related to) fall at 0600AM. MD notified of increased pain, MD in facility at 0700, res assessment done by (Medical Director). Received d/o (discharge order) to transfer to SLH (hospital) . Review of a letter summarizing Resident 2's elopement incident on 11/16/15 addressed to the Department, dated 11/20/15, and signed by Administrative Staff A, indicated Dr. (name) was in the facility at the time so he looked at her (Resident 2) and advised to send her to (local acute care facility) ER (emergency room ) for X-ray. We were later notified by the hospital the resident had sustained a hip fracture and that she (Resident 2) would be having surgery the following morning. The resident has not returned to us as of 11/20/15 0800 but is anticipated to return to facility when ready. Resident 2's clinical record contained two Elopement/Wandering Seeking care plans. The initiation date on the handwritten care plan titled, Wandering and Exit-Seeking was 11/16/13 and was dated through 8/14/15. The Goal indicated: Resident will be easily redirected to other areas in the facility as needed daily. Approaches included: 1. Evaluate and treat for any pain, 2. Redirect to activities, 3. Approach resident calmly, 4. Keeps resident's photo at nursing station and front office in a wanderes log, 5. Offer snacks throughout the day, 6 Encourage resident to participate in exercises, 7. Frequent assurance with each contact, 8. Rummage box, and 9. Encourage resident to attend musical programs. The second care plan titled, Wandering, was initiated on 5/18/15 through 8/14/15. Checked Behaviors/Symptoms included: Repeated entering other people's rooms (walking or wheelchair) and Roam through unit. Casual Factors included: Changes taking place in brain. Goals included: I will have meaningful relationships. Interventions included: Frequent assurance with each contact and Offer snacks throughout the day. Neither care plan addressed Resident 2's night owl behavior, appropriate night-time interventions or appropriate supervision of the resident to prevent elopement incidents. The care plan lacked any interventions related to the type and frequency of supervision, based on the individual resident's assessed needs, and identified hazards in the resident's environment. The generalized care plan indicated an intervention Scheduled visual check for location in Center, however the intervention was not checked.

The facility violated the regulation by failing to provide adequate supervision to prevent Resident 2 from emotional harm when the facility allowed Resident 1 to strike Resident 2's arm as she was exiting the common dining room. As a result, this failure caused emotional harm to Resident 2 and occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to Resident 2. Resident 1's Annual MDS (Minimum Data Set) Assessment, dated 1/13/2010, indicated Resident 1 has short and long term memory problems, some difficulty in new situations secondary to impaired cognitive skills for daily decision making, and behavioral symptoms which included being verbally abusive and resistive to care. Resident 2's Admission MDS (Minimum Data Set) Assessment, dated 6/7/2010, indicated Resident 2 has short and long term memory problems, but is able to remember staff names and faces. During an interview on 6/25/10 at 4:30 p.m., Resident 2 stated on 6/15/10 Resident 1 was exiting the dining room as she was entering the dining room. Resident 2 stated "I guess I got a little too close to his wheel chair and he struck me with his right fist and arm. He hit my left arm (Resident 2 pointed to her upper left arm). I'm afraid of him now! It hurt me when it happened, and I was very afraid. I still am afraid of him". Review of Nurses Notes for Resident 2 on 6/15/10 indicated, at 7:30 a.m. patient was in a wheel chair heading into the dining room. Another patient (Resident 1) was heading out of the dining room. A CNA heard her (Resident 2) say "don't hit". They (Resident 1 and 2) were immediately separated. "Nobody seen (sic) it but when I talked to (the) patient she said the other resident did hit her on the upper left arm". Review of Social Services note dated 6/15/10 indicated "(Resident 2 named) accused the resident in room (room number for Resident 1 indicated) of hitting her this morning in the left arm. A CNA heard her (Resident 2) say 'don't hit me', but did not see anything". During an interview on 9/23/10, when Licensed Nurse A was asked about the resident to resident altercation between Resident 1 and Resident 2 she stated " Which one? He's had so many of them! I do remember, though I didn't see the incident happen. I did hear (Resident 2 named) say 'Don't hit!'". Review of Nurses Notes for Resident 1 dated 6/15/10 indicated Resident (1) was reported to have struck another resident on the arm when they encountered each other at the entrance to the main dining room. Review of Resident 1's Interdisciplinary Care Plan for Behavior/Mood State dated 3/11/09 and reviewed in May 2009, July 2009, and August 2009 indicated Resident 2 displayed persisten anger toward others, refuses care on occasion and will strike out at caregivers. Review of Resident 1's Interdisciplinary Care Plan dated 6/15/10 indicated " Alleged Resident to resident altercation (aggressor)". The approach plan indicated: 1. MD notified 2. Family notified 3. Monitor behaviors for 72 hours. During an interview on 9/23/10 at 11:33 a.m., Resident 1 stated he remembered the incident with Resident 2 and affirmed that he hit Resident 2 in the upper left arm. No explanation offered as to why he struck out. During an interview on 9/23/10 at 11:35 a.m., CNA B stated that is how he (Resident 1) reacts if someone invades his space. During an interview on 11/1/10 at 1:16 p.m., Resident 2 stated "I was coming out of the dining room and he (Resident 1) was going in and he hit me on the left arm." During an interview on 11/1/10 at 1:23 p.m., Resident 3 stated "He (Resident 1) didn't feel like he had enough room. He's like that. We just stay out of his way." The facility violated the regulation by failing to provide adequate supervision to prevent Resident 2 from emotional harm when the facility allowed Resident 1 to strike Resident 2's arm as she was exiting the common dining room. As a result, this failure caused emotional harm to Resident 2 and occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to Resident 2. The violation of this regulation had a direct relationship to the health, safety, or security of patients.